Gives information about the History section
Important: This specification is based on the Professional Records Standards Body's Pharmacy information flows standard which provides further information on document headings and content: https://theprsb.org/standards/pharmacyinformationflows1and2/
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.
| HISTORY | |||||
|---|---|---|---|---|---|
| Data Item | Description | Cardinality | Values | Mandatory/required/ optional | FHIR Target |
| 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 | History pertinent to the emergency supply of medicine e.g. contraindications, pregnancy, immunosupression. May be a SNOMED CT term or free text. | Required | Composition.section.text |
| Medical History | Some summary of the patient’srecent and relevant medical history. Summary only. Pharmacist will need to access SCR and not rely on this summary | Mandatory | Composition.section.text | ||
| Relevant Information | Notes from the referring organisation referral that may be relevant to the consultation. Supports the medical history | Mandatory | Composition.section.text | ||
| Other Details | Additional information relating to the referral & presenting complaint, captured by the the referring organisation initial referral. | Mandatory | Composition.section.text | ||
| Prescribed Meds Already Taken | Additional notes on Medicines already taken from the referring organisation referral that may be relevant to the consultation. Supports the medical history | Mandatory | Composition.section.text | ||
| Over the counter (OTC) RemediesToDate | Additional notes on remedies to date from the referring organisation referral that may be relevant to the consultation. Supports the medical history | Mandatory | Composition.section.text | ||
| Associated Symptoms | Additional notes on Associated symptoms from the referring organisation referral that may be relevant to the consultation. Supports the medical history | Mandatory | Composition.section.text | ||
| Other Symptoms | Additional notes on other symptoms from the referring organisation referral that may be relevant to the consultation. Supports the medical history | Mandatory | Composition.section.text |
Example History Section
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<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.
