A concise narrative from the patient’s perspective about their present health state. This is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.
Patients unable to communicate can be supported by a proxy author. The patient’s story, provided here, may be told by the patient or by a proxy.
Classification
CDA Section Level Template
Open/Closed
Open (other than defined elements are allowed)
Uses
Uses 3 templates
Uses
as
Name
Version
2.16.840.1.113883.10.22.4.14
Containment
IPS Body Author (STU1)
DYNAMIC
2.16.840.1.113883.10.12.319
Containment
CDA Informant (Body)
DYNAMIC
2.16.840.1.113883.10.22.3.15
Containment
IPS Translation Section (2021)
DYNAMIC
Item
DT
Card
Conf
Description
Label
hl7:section
1 … 1
M
(IPS...ion)
@classCode
cs
0 … 1
F
DOCSECT
hl7:templateId
II
1 … 1
M
(IPS...ion)
@root
uid
1 … 1
F
2.16.840.1.113883.10.22.3.7
hl7:id
II
0 … *
R
(IPS...ion)
hl7:code
CE.IPS
1 … 1
M
(IPS...ion)
@code
CONF
1 … 1
F
81338-6
@codeSystem
1 … 1
F
2.16.840.1.113883.6.1 (LOINC)
hl7:title
ST
1 … 1
M
History of Past Illness
(IPS...ion)
hl7:text
SD.TEXT
1 … 1
M
(IPS...ion)
hl7:author
0 … *
Contains 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)