History of Present Illness Section_1.

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SDWG Supported Sample from Implementation Guide

The initial load of this repository in January 2021 includes all examples (figures) from the June 2019 Errata published PDF of C-CDA 2.1 and 2019 release of C-CDA Companion Guide.

These examples were reviewed through the HL7 ballot process. They have not been formally reviewed/approved by the examples task force.


History of Present Illness Section


Example: download example view on GitHub

  <templateId root=""/>
  <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" 
        displayName="HISTORY OF PRESENT ILLNESS"/>
    <paragraph>This patient was only recently discharged for a recurrent 
        GI bleed as described below.</paragraph>
    <paragraph>He presented to the ER today c/o a dark stool yesterday 
        but a normal brown stool today. On exam he was hypotensive in the 
        80s resolved after .... .... .... </paragraph>
    <paragraph>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, 
        electrolytes normal. H. pylori antibody pending. Admission 
        hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet 
        count 256,000. Urinalysis normal. Urine culture: No growth. INR 
        1.1, PTT 40.</paragraph>
    <paragraph>He was transfused with 6 units of packed red blood cells 
        with .... .... ....</paragraph>
    <paragraph>GI evaluation 12 September: Colonoscopy showed single red 
       clot in .... .... ....</paragraph>
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