This page is part of the CCDA: Consolidated CDA Release (v4.0.0: CCDA 4.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version. For a full list of available versions, see the Directory of published versions
Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicalGeneralHistorySection | Version: 4.0.0 | |||
Draft as of 2025-06-20 | Computable Name: MedicalGeneralHistorySection | |||
Other Identifiers: OID:2.16.840.1.113883.10.20.22.2.39 |
The Medical History Section describes all aspects of the 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. The history may 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, Social History.
Usages:
Changes since version 3.0.0:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
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0..0 | |||
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1..1 | CE | Medical (General) History | |
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1..1 | cs | Required Pattern: 11329-0 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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1..1 | ST | ||
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1..1 | xhtml | ||
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Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
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1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | Constraints: II-1 |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
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0..1 | xs:ID | ||
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0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
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0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
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0..1 | II | ||
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1..1 | CE | Medical (General) History | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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1..1 | cs | Required Pattern: 11329-0 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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0..1 | st | ||
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0..1 | st | ||
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0..1 | st | ||
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0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
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0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
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0..1 | ED | ||
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0..* | CD | ||
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1..1 | ST | ||
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1..1 | xhtml | ||
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0..1 | CE | ||
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0..1 | CS | Binding: AllLanguages (required) | |
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0..1 | Subject | ||
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0..* | Author | ||
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0..* | Informant | ||
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0..* | Entry | ||
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0..* | InfrastructureRoot | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | Constraints: II-1 |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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0..* | II | ||
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0..1 | cs | Fixed Value: COMP | |
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0..1 | bl | Fixed Value: true | |
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1..1 | Section | ||
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Path | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages From the FHIR Standard | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() |
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | Constraints: II-1 |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
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0..1 | xs:ID | ||
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0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
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0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
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0..1 | II | ||
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1..1 | CE | Medical (General) History | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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1..1 | cs | Required Pattern: 11329-0 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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0..1 | st | ||
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0..1 | st | ||
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0..1 | st | ||
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0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
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0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
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0..1 | ED | ||
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0..* | CD | ||
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1..1 | ST | ||
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1..1 | xhtml | ||
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0..1 | CE | ||
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0..1 | CS | Binding: AllLanguages (required) | |
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0..1 | Subject | ||
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0..* | Author | ||
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0..* | Informant | ||
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0..* | Entry | ||
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0..* | InfrastructureRoot | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | Constraints: II-1 |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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0..* | II | ||
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0..1 | cs | Fixed Value: COMP | |
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0..1 | bl | Fixed Value: true | |
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1..1 | Section | ||
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Path | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages From the FHIR Standard | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() |
Differential View
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
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0..0 | |||
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1..1 | CE | Medical (General) History | |
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1..1 | cs | Required Pattern: 11329-0 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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1..1 | ST | ||
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1..1 | xhtml | ||
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Key Elements View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
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1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | Constraints: II-1 |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
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0..1 | xs:ID | ||
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0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
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0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
![]() ![]() ![]() |
0..1 | II | ||
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1..1 | CE | Medical (General) History | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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1..1 | cs | Required Pattern: 11329-0 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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0..1 | st | ||
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0..1 | st | ||
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0..1 | st | ||
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0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
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0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
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0..1 | ED | ||
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0..* | CD | ||
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1..1 | ST | ||
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1..1 | xhtml | ||
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0..1 | CE | ||
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0..1 | CS | Binding: AllLanguages (required) | |
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0..1 | Subject | ||
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0..* | Author | ||
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0..* | Informant | ||
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0..* | Entry | ||
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0..* | InfrastructureRoot | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | Constraints: II-1 |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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0..* | II | ||
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0..1 | cs | Fixed Value: COMP | |
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0..1 | bl | Fixed Value: true | |
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1..1 | Section | ||
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Path | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages From the FHIR Standard | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | Constraints: II-1 |
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0..1 | cs | Binding: CDANullFlavor (required) | |
![]() ![]() ![]() ![]() |
0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
![]() ![]() ![]() ![]() |
1..1 | st | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
![]() ![]() ![]() ![]() ![]() |
0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
![]() ![]() ![]() |
0..1 | xs:ID | ||
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0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
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0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
![]() ![]() ![]() |
0..1 | II | ||
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1..1 | CE | Medical (General) History | |
![]() ![]() ![]() ![]() |
0..1 | cs | Binding: CDANullFlavor (required) | |
![]() ![]() ![]() ![]() |
1..1 | cs | Required Pattern: 11329-0 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() ![]() ![]() |
0..1 | st | ||
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0..1 | st | ||
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0..1 | st | ||
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0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
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0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
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0..1 | ED | ||
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0..* | CD | ||
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1..1 | ST | ||
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1..1 | xhtml | ||
![]() ![]() ![]() |
0..1 | CE | ||
![]() ![]() ![]() |
0..1 | CS | Binding: AllLanguages (required) | |
![]() ![]() ![]() |
0..1 | Subject | ||
![]() ![]() ![]() |
0..* | Author | ||
![]() ![]() ![]() |
0..* | Informant | ||
![]() ![]() ![]() |
0..* | Entry | ||
![]() ![]() ![]() |
0..* | InfrastructureRoot | ||
![]() ![]() ![]() ![]() |
0..1 | cs | Binding: CDANullFlavor (required) | |
![]() ![]() ![]() ![]() |
0..* | CS | ||
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C | 0..1 | II | Constraints: II-1 |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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0..* | II | ||
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0..1 | cs | Fixed Value: COMP | |
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0..1 | bl | Fixed Value: true | |
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1..1 | Section | ||
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Path | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages From the FHIR Standard | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() |