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History Section

Gives information about the History section

History Section Content

The History section carries history related to the patient’s previous care. Elements should be rendered as subheadings in any HTML sent.

Section Description Card. MRO* FHIR Target and Guidance
History Information relating to the development of each presenting complaint, and the patient's relevant health history. 0 to 1 R Carried in the CodeableConcept of Composition.section.code FHIR element.
PRSB Element Description Card. MRO* FHIR Target and Guidance
Relevant past medical, surgical and mental health history The record of the person's significant medical, surgical and mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc (will include dental and obstetric history) 0 to 1 R History pertinent to the emergency supply of medicine e.g. contraindications, pregnancy, immunosupression. May be a SNOMED CT term or free text.
* M=Mandatory R=Required O=Optional

Example History Section

<xml>
<!--History-->
	<section>
	<title value="History"/>
		<code>
			<coding>
				<system value="http://snomed.info/sct"/>
				<code value="717121000000105"/>
				<display value="History"/>
			</coding>
		</code>
		<text>
		<status value="additional"/>
		<div xmlns="http://www.w3.org/1999/xhtml">
		<table width="100%">
			<tbody>
			<tr>
				<th>Relevant past medical, surgical and mental health history</th>
				<td>
				<p>Patient has Chronic Obstructive Pulmonary Disease (COPD). She was advised to have the flu vaccination as she is at greater risk from flu and its complications when she last attended her GP Practice.</p>
				<p>Patient requested the vaccination.</p>
				<p>No history of vaccination recorded at Pharmacy.</p>
				</td>
			</tr>
			</tbody>
		</table>
		</div>
		</text>
	</section>
</xml>

Coded Resources

This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.

Tags: fhir

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