DICOM PS3.20 2016c - Imaging Reports using HL7 Clinical Document Architecture

9.8.3 Medical (General) History
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### 9.8.3 Medical (General) History

Template ID | 2.16.840.1.113883.​10.20.22.2.39
Name | Medical (General) History
Effective Date | 2012-07
Version Label | DICOM-20150324
Status | Active
Description | History general describes all aspects of medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. It may also be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections, including Past Medical History and Social History.
Classification | CDA Section Level
Relationships | Included in 9.2 Clinical Information
Context | parent node
Open/Closed | Open
Revision History | From Consolidated CDA r1.1 DICOM-20150324: Addition of optional entries; C-CDA templateID retained

Business Name | Nest Level | Element/​Attribute | Card | Elem/Attr Conf | Data Type | Value Conf | Value | Subsidiary Template
--- | --- | --- | --- | --- | --- | --- | --- | ---
History |  | section | 1..1 | SHALL |  |  |  |
| > | template​Id | 1..1 | SHALL | II |  |  |
| >@ | @root | 1..1 | SHALL | UID | SHALL | 2.16.840.1.113883.​10.20.22.2.39 |
| > | id | 1..* | SHALL | II |  |  |
| > | code | 1..1 | SHALL | CD | SHALL | (11329-0, LOINC, "History General") |
Title | > | title | 1..1 | SHALL | ST |  |  |
Text | > | text | 1..1 | COND | ED |  |  | 9.1.1 Section Text 1.2.840.10008.9.19
| > |  | 0..1 | MAY |  |  |  | 9.1.2 General Section Entries 1.2.840.10008.9.23

#### 9.8.3.1 section/text

In the context of an Imaging Report, the section/text should document any contraindications to contrast administration or other procedure techniques that affected the selection or performance of the protocol.

Example 9.8.3.1-1. Medical (General) History section example

    <section classCode="DOCSECT" moodCode="EVN">
        <templateId root="2.16.840.1.113883.10.20.22.2.39"/>
        <id root="1.2.840.10213.2.62.7044785528.114289875"/>
        <code code="11329-0"
            codeSystem="2.16.840.1.113883.6.1"
            codeSystemName="LOINC"
            displayName="History General"/>
        <title>Relevant Medical History</title>
        <text>
            <list>
                <item>Patient reported adverse reaction to iodine.</item>
                <item>Patient is smoker (1 pack daily).</item>
            </list>
        </text>
    </section>

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9.8.2 Procedure Indications | Home | 9.8.4 Complications

DICOM PS3.20 2016c - Imaging Reports using HL7 Clinical Document Architecture