description: A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.  \n\nThe first portion of the report is a current collection of organized information unique to an individual. This is typically supplied by the patient or the caregiver, concerning the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members.\nThe next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.\n \nThe report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues.\n \nA History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P note.
package_name: hl7.fhir.us.ccda
derivation: constraint
name: HistoryAndPhysical
type: Composition
elements:
  type:
    label: History and Physical
    short: History and Physical
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.1.11.20.22'}
    index: 0
  section:
    index: 1
    slicing:
      rules: open
      discriminator:
      - {path: code, type: value}
      min: null
      slices:
        allergies_and_intolerances_section:
          match:
            code:
              coding:
              - {code: 48765-2, system: 'http://loinc.org'}
          schema:
            label: Allergies and Intolerances Section
            short: Allergies and Intolerances Section
            _required: true
            index: 2
            elements:
              title: {short: title, mustSupport: true, index: 3}
              code:
                label: Allergies, adverse reactions, alerts
                short: Allergies, adverse reactions, alerts
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 48765-2, system: 'http://loinc.org'}
                index: 4
              text: {short: text, mustSupport: true, index: 5}
              entry:
                short: entry
                index: 6
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    allergies_and_intolerances_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance']
                        index: 7
            required: [text, title, code]
        chief_complaint_section:
          match:
            code:
              coding:
              - {code: 10154-3, system: 'http://loinc.org'}
          schema:
            label: Chief Complaint Section
            short: Chief Complaint Section
            mustSupport: true
            index: 76
            elements:
              title: {short: title, mustSupport: true, index: 77}
              code:
                label: Chief Complaint
                short: Chief Complaint
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10154-3, system: 'http://loinc.org'}
                index: 78
              text: {short: This section contains only human readable content, mustSupport: true, index: 79}
            required: [text, title, code]
        general_status_section:
          match:
            code:
              coding:
              - {code: 10210-3, system: 'http://loinc.org'}
          schema:
            label: General Status Section
            short: General Status Section
            mustSupport: true
            _required: true
            index: 14
            elements:
              title: {short: title, mustSupport: true, index: 15}
              code:
                label: General Status
                short: General Status
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10210-3, system: 'http://loinc.org'}
                index: 16
              text: {short: This section contains only human readable content, mustSupport: true, index: 17}
            required: [text, title, code]
        assessment_and_plan_section:
          match:
            code:
              coding:
              - {code: 51847-2, system: 'http://loinc.org'}
          schema:
            label: Assessment and Plan Section
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            mustSupport: true
            index: 62
            elements:
              title: {short: title, mustSupport: true, index: 63}
              code:
                label: Assessment and Plan
                short: Assessment and Plan
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                pattern:
                  type: CodeableConcept
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                index: 64
              text: {short: text, mustSupport: true, index: 65}
              entry:
                index: 66
                slicing:
                  rules: open
                  discriminator:
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                  min: null
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                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/Observation', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 67
            required: [text, title, code]
        reason_for_visit_section:
          match:
            code:
              coding:
              - {code: 29299-5, system: 'http://loinc.org'}
          schema:
            label: Reason for Visit Section
            short: Reason for Visit Section
            mustSupport: true
            index: 104
            elements:
              title: {short: title, mustSupport: true, index: 105}
              code:
                label: Reason for Visit
                short: Reason for Visit
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 29299-5, system: 'http://loinc.org'}
                index: 106
              text: {short: This section contains only human readable content, mustSupport: true, index: 107}
            required: [text, title, code]
        immunizations_section:
          match:
            code:
              coding:
              - {code: 11369-6, system: 'http://loinc.org'}
          schema:
            label: Immunizations Section
            short: Immunizations Section
            mustSupport: true
            index: 80
            elements:
              title: {short: title, mustSupport: true, index: 81}
              code:
                label: Immunizations
                short: Immunizations
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 11369-6, system: 'http://loinc.org'}
                index: 82
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                  slices:
                    immunizations_entry:
                      match: {}
                      schema:
                        type: Reference
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization']
                        index: 85
            required: [text, title, code]
        past_medical_history_section:
          match:
            code:
              coding:
              - {code: 11348-0, system: 'http://loinc.org'}
          schema:
            label: Past Medical History Section
            short: Past Medical History Section
            mustSupport: true
            index: 24
            elements:
              title: {short: title, mustSupport: true, index: 25}
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                short: code
                mustSupport: true
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                  slices:
                    past_medical_history_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 29
            required: [text, title, code]
        results_section:
          match:
            code:
              coding:
              - {code: 30954-2, system: 'http://loinc.org'}
          schema:
            label: Results Section
            short: Results Section
            mustSupport: true
            _required: true
            index: 36
            elements:
              title: {short: title, mustSupport: true, index: 37}
              code:
                label: Relevant diagnostic tests and/or laboratory data
                short: Relevant diagnostic tests and/or laboratory data
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 30954-2, system: 'http://loinc.org'}
                index: 38
              text: {short: text, mustSupport: true, index: 39}
              entry:
                short: entry
                index: 40
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    results_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab']
                        index: 41
            required: [text, title, code]
        history_of_present_illness_section:
          match:
            code:
              coding:
              - {code: 10164-2, system: 'http://loinc.org'}
          schema:
            label: History of Present Illness Section
            short: History of Present Illness Section
            mustSupport: true
            index: 58
            elements:
              title: {short: title, mustSupport: true, index: 59}
              code:
                label: History of Present Illness
                short: History of Present Illness
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10164-2, system: 'http://loinc.org'}
                index: 60
              text: {short: This section contains only human readable content, mustSupport: true, index: 61}
            required: [text, title, code]
        instructions_section:
          match:
            code:
              coding:
              - {code: 69730-0, system: 'http://loinc.org'}
          schema:
            label: Instructions Section
            short: Instructions Section
            mustSupport: true
            index: 108
            elements:
              title: {short: title, mustSupport: true, index: 109}
              code:
                label: Instructions
                short: Instructions
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 69730-0, system: 'http://loinc.org'}
                index: 110
              text: {short: This section contains only human readable content, mustSupport: true, index: 111}
            required: [text, title, code]
        medications_section:
          match:
            code:
              coding:
              - {code: 10160-0, system: 'http://loinc.org'}
          schema:
            label: Medications Section
            short: Medications Section
            mustSupport: true
            _required: true
            index: 18
            elements:
              title: {short: title, mustSupport: true, index: 19}
              code:
                label: History of medication use
                short: History of medication use
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10160-0, system: 'http://loinc.org'}
                index: 20
              text: {short: text, mustSupport: true, index: 21}
              entry:
                short: entry
                index: 22
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    medications_section_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/MedicationStatement', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest']
                        index: 23
            required: [text, title, code]
        social_history_section:
          match:
            code:
              coding:
              - {code: 29762-2, system: 'http://loinc.org'}
          schema:
            label: Social History Section
            short: Social History Section
            mustSupport: true
            _required: true
            index: 46
            elements:
              title: {short: title, mustSupport: true, index: 47}
              code:
                label: Social History
                short: Social History
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
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                    - {code: 29762-2, system: 'http://loinc.org'}
                index: 48
              text: {short: text, mustSupport: true, index: 49}
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                short: entry
                index: 50
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    smoking_status_entry:
                      match: {}
                      schema:
                        type: Reference
                        short: Smoking status
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus']
                        index: 51
            required: [text, title, code]
        procedures_section:
          match:
            code:
              coding:
              - {code: 47519-4, system: 'http://loinc.org'}
          schema:
            label: Procedures Section
            short: Procedures Section
            mustSupport: true
            index: 98
            elements:
              title: {short: title, mustSupport: true, index: 99}
              code:
                label: History of Procedures
                short: History of Procedures
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 47519-4, system: 'http://loinc.org'}
                index: 100
              text: {short: text, mustSupport: true, index: 101}
              entry:
                short: entry
                index: 102
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    procedures_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure']
                        index: 103
            required: [text, title, code]
        chief_complaint_and_reason_for_visit_section:
          match:
            code:
              coding:
              - {code: 46239-0, system: 'http://loinc.org'}
          schema:
            label: Chief Complaint and Reason for Visit Section
            short: Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
            mustSupport: true
            index: 72
            elements:
              title: {short: title, mustSupport: true, index: 73}
              code:
                label: Chief Complaint and Reason for Visit
                short: Chief Complaint and Reason for Visit
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 46239-0, system: 'http://loinc.org'}
                index: 74
              text: {short: This section contains only human readable content, mustSupport: true, index: 75}
            required: [text, title, code]
        plan_of_treatment_section:
          match:
            code:
              coding:
              - {code: 18776-5, system: 'http://loinc.org'}
          schema:
            label: Plan of Treatment Section
            short: Plan of Treatment Section
            mustSupport: true
            index: 86
            elements:
              title: {short: title, mustSupport: true, index: 87}
              code:
                label: Plan of Treatment
                short: Plan of Treatment
                mustSupport: true
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                  value:
                    coding:
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                index: 88
              text: {short: text, mustSupport: true, index: 89}
              entry:
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                index: 90
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                  discriminator:
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                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        refers: ['http://hl7.org/fhir/StructureDefinition/Appointment', 'http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/CommunicationRequest', 'http://hl7.org/fhir/StructureDefinition/DeviceRequest', 'http://hl7.org/fhir/StructureDefinition/NutritionOrder', 'http://hl7.org/fhir/StructureDefinition/RequestGroup', 'http://hl7.org/fhir/StructureDefinition/ServiceRequest', 'http://hl7.org/fhir/StructureDefinition/Task', 'http://hl7.org/fhir/StructureDefinition/VisionPrescription', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest']
                        index: 91
            required: [text, title, code]
        problem_section:
          match:
            code:
              coding:
              - {code: 11450-4, system: 'http://loinc.org'}
          schema:
            label: Problem Section
            short: Problem Section
            mustSupport: true
            index: 92
            elements:
              title: {short: title, mustSupport: true, index: 93}
              code:
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                short: Problem List
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
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                index: 94
              text: {short: text, mustSupport: true, index: 95}
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                index: 96
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                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 97
            required: [text, title, code]
        review_of_systems_section:
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            code:
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            short: Review of Systems Section
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            _required: true
            index: 42
            elements:
              title: {short: title, mustSupport: true, index: 43}
              code:
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                short: Review of Systems
                mustSupport: true
                pattern:
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                  value:
                    coding:
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                index: 44
              text: {short: This section contains only human readable content, mustSupport: true, index: 45}
            required: [text, title, code]
        vital_signs_section:
          match:
            code:
              coding:
              - {code: 8716-3, system: 'http://loinc.org'}
          schema:
            label: Vital Signs Section
            short: Vital Signs Section
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            _required: true
            index: 52
            elements:
              title: {short: title, mustSupport: true, index: 53}
              code:
                label: Vital Signs
                short: Vital Signs
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
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                index: 54
              text: {short: text, mustSupport: true, index: 55}
              entry:
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                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/vitalsigns']
                        index: 57
            required: [text, title, code]
        physical_exam_section:
          match:
            code:
              coding:
              - {code: 29545-1, system: 'http://loinc.org'}
          schema:
            label: Physical Exam Section
            short: Physical Exam Section
            _required: true
            index: 30
            elements:
              title: {short: title, mustSupport: true, index: 31}
              code:
                label: Physical Findings
                short: Physical Findings
                mustSupport: true
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                  value:
                    coding:
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                index: 32
              text: {short: text, mustSupport: true, index: 33}
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                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/Observation']
                        index: 35
            required: [text, title, code]
        family_history_section:
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            code:
              coding:
              - {code: 10157-6, system: 'http://loinc.org'}
          schema:
            label: Family History Section
            short: Family History Section
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            index: 8
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                short: Family History
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                  discriminator:
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                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance']
                        index: 13
            required: [text, title, code]
        assessment_section:
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            code:
              coding:
              - {code: 51848-0, system: 'http://loinc.org'}
          schema:
            label: Assessment Section
            short: Assessment Section
            mustSupport: true
            index: 68
            elements:
              title: {short: title, mustSupport: true, index: 69}
              code:
                label: Assessments
                short: Assessments
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                pattern:
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                  value:
                    coding:
                    - {code: 51848-0, system: 'http://loinc.org'}
                index: 70
              text: {short: This section contains only human readable content, mustSupport: true, index: 71}
            required: [text, title, code]
package_version: 2.0.0-ballot
class: profile
kind: resource
url: http://hl7.org/fhir/us/ccda/StructureDefinition/History-and-Physical
base: http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header
version: 2.0.0-ballot