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.  \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. \nThe report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues. \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.\n\n#### Document Sections\nAlthough document templates may contain any section, the following sections are specifically called out by this template:\n\n**Required Sections**\n- [ChiefComplaintandReasonforVisitSection](StructureDefinition-ChiefComplaintandReasonforVisitSection.html) or both [ChiefComplaintSection](StructureDefinition-ChiefComplaintSection.html) and [ReasonforVisitSection](StructureDefinition-ReasonforVisitSection.html)\n- [AssessmentandPlanSection](StructureDefinition-AssessmentandPlanSection.html) or both [AssessmentSection](StructureDefinition-AssessmentSection.html) and [PlanofTreatmentSection](StructureDefinition-PlanofTreatmentSection.html)\n- [AllergiesAndIntolerancesSection](StructureDefinition-AllergiesAndIntolerancesSection.html)\n- [FamilyHistorySection](StructureDefinition-FamilyHistorySection.html)\n- [GeneralStatusSection](StructureDefinition-GeneralStatusSection.html)\n- [PastMedicalHistory](StructureDefinition-PastMedicalHistory.html)\n- [MedicationsSection](StructureDefinition-MedicationsSection.html)\n- [PhysicalExamSection](StructureDefinition-PhysicalExamSection.html)\n- [ResultsSection](StructureDefinition-ResultsSection.html)\n- [ReviewofSystemsSection](StructureDefinition-ReviewofSystemsSection.html)\n- [SocialHistorySection](StructureDefinition-SocialHistorySection.html)\n- [VitalSignsSection](StructureDefinition-VitalSignsSection.html)\n\n**Recommended Sections**\n- [HistoryofPresentIllnessSection](StructureDefinition-HistoryofPresentIllnessSection.html)\n\n**Additional Sections**\n- [ImmunizationsSection](StructureDefinition-ImmunizationsSection.html)\n- [InstructionsSection](StructureDefinition-InstructionsSection.html)\n- [ProblemSection](StructureDefinition-ProblemSection.html)\n- [ProceduresSection](StructureDefinition-ProceduresSection.html)\n- [AdvanceDirectivesSection](StructureDefinition-AdvanceDirectivesSection.html)
package_name: hl7.cda.us.ccda
derivation: constraint
name: HistoryandPhysical
type: http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument
elements:
  templateId:
    array: true
    min: 2
    index: 0
    slicing:
      slices:
        history-physical:
          match: {}
          schema:
            _required: true
            index: 1
            elements:
              root:
                pattern: {type: String, value: 2.16.840.1.113883.10.20.22.1.3}
                index: 2
              extension:
                pattern: {type: String, value: '2024-05-01'}
                index: 3
            required: [root, extension]
            extensions: {}
  code:
    short: The H&P Note recommends use of a single document type code, 34117-2 "History and physical note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
    binding: {strength: required, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.20.22'}
    index: 4
  informationRecipient:
    index: 5
    elements:
      intendedRecipient: {index: 6}
  participant:
    short: The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations.
    constraint:
      1198-8333:
        human: |-
          When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *STATIC* 2011-09-30 (CONF:1198-8333).
          A special class of participant is the supporting person or organization:  an individual or an organization that has a relationship to the patient, including  parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded.
        source: http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical
        severity: warning
    index: 7
  inFulfillmentOf: {short: 'inFulfillmentOf elements describe the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and the H&P Note may be in partial fulfillment of that referral.', index: 8}
  componentOf:
    short: The H&P Note is always associated with an encounter.
    index: 9
    elements:
      encompassingEncounter:
        index: 10
        elements:
          id: {index: 11}
          effectiveTime: {short: The effectiveTime represents the time interval or point in time in which the encounter took place., index: 12}
          responsibleParty:
            short: The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care.
            constraint:
              1198-8348: {human: 'The responsibleParty element, if present, **SHALL** contain an assignedEntity element, which **SHALL** contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8348).', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical', severity: error, expression: assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists()}
            index: 13
          encounterParticipant:
            short: The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care.
            constraint:
              1198-8343: {human: 'An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both (CONF:1198-8343).', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical', severity: error, expression: assignedEntity.assignedPerson.exists() or assignedEntity.representedOrganization.exists()}
            index: 14
          location: {index: 15}
  component:
    index: 16
    elements:
      structuredBody:
        short: In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional.
        constraint:
          ccrfv-or-cc-or-rfv: {human: This structuredBody **SHALL** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12)., source: 'http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical', severity: error, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection'').exists() or section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection'').exists() or section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection'').exists()).exists()'}
          ap-or-a-and-p: {human: '**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical', severity: error, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection'')).exists() or (component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection'') or section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection'')).count() = 2)'}
          ap-combo: {human: 'This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical', severity: error, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection'')).exists() implies component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection'') or section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection'')).empty()'}
          cc-rfv-combo: {human: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present., source: 'http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical', severity: error, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection'')).exists() implies component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection'') or section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection'')).empty()'}
          should-section-hpi: {human: SHOULD contain a History of Present Illness Section, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical', severity: warning, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/HistoryofPresentIllnessSection''))'}
        index: 17
        elements:
          component:
            array: true
            min: 12
            index: 18
            slicing:
              rules: open
              discriminator:
              - {path: section, type: profile}
              min: 12
              slices:
                pastMedicalHistory:
                  match: {}
                  schema:
                    _required: true
                    index: 35
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 36}
                problems:
                  match: {}
                  schema:
                    index: 47
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 48}
                socialHistory:
                  match: {}
                  schema:
                    _required: true
                    index: 57
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 58}
                instructions:
                  match: {}
                  schema:
                    index: 41
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 42}
                chiefComplaintRFV:
                  match: {}
                  schema:
                    index: 29
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 30}
                medications:
                  match: {}
                  schema:
                    _required: true
                    index: 43
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 44}
                familyHistory:
                  match: {}
                  schema:
                    _required: true
                    index: 31
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 32}
                chiefComplaint:
                  match: {}
                  schema:
                    index: 27
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 28}
                assessment:
                  match: {}
                  schema:
                    index: 21
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 22}
                assessmentAndPlan:
                  match: {}
                  schema:
                    index: 25
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 26}
                planOfTreatment:
                  match: {}
                  schema:
                    index: 23
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 24}
                vitalSigns:
                  match: {}
                  schema:
                    _required: true
                    index: 59
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 60}
                immunizations:
                  match: {}
                  schema:
                    index: 39
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 40}
                physicalExam:
                  match: {}
                  schema:
                    _required: true
                    index: 45
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 46}
                historyPresentIllness:
                  match: {}
                  schema:
                    index: 37
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 38}
                advDirectives:
                  match: {}
                  schema:
                    index: 61
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 62}
                reasonForVisit:
                  match: {}
                  schema:
                    index: 51
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 52}
                procedures:
                  match: {}
                  schema:
                    index: 49
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 50}
                generalStatus:
                  match: {}
                  schema:
                    _required: true
                    index: 33
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 34}
                allergies:
                  match: {}
                  schema:
                    _required: true
                    index: 19
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 20}
                reviewOfSystems:
                  match: {}
                  schema:
                    _required: true
                    index: 55
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 56}
                results:
                  match: {}
                  schema:
                    _required: true
                    index: 53
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 54}
    required: [structuredBody]
package_version: 3.0.0
class: logical
kind: logical
url: http://hl7.org/cda/us/ccda/StructureDefinition/HistoryandPhysical
base: http://hl7.org/cda/us/ccda/StructureDefinition/USRealmHeader
version: 3.0.0
required: [componentOf]