History & Physical
HL7 Implementation Guide for CDA Release 2: History and Physical (H&P) Notes
Draft Standard for Trial Use
Published July 16, 2008
The purpose of the implementation guide is to describe constraints on the CDA Header and Body for H&P Notes. An H&P Note is a two-part medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. The information forms the basis of most treatment plans. A sample H&P Note was provided by the Military Health System and used as a test against the design of this HL7 Draft Standard for Trial Use.
The audience for this draft standard includes software developers and consultants responsible for implementation of Electronic Health Record (EHR) systems, Electronic Medical Record (EMR) systems, Personal Health Record (PHR) systems, dictation/transcription systems, document management applications, and local, regional and national health information exchange networks who wish to create and/or process HL7 Clinical Document Architecture documents created according to this specification.
The Consultation Note and History & Physical standards are referenced by the Healthcare Information Technology Standards Panel (HITSP) in document C/84, "Consult & History & Physical Note Component." They are also referenced in this regard by the Certification Commission for Healthcare Information Technology (CCHIT) in the current Health Information Exchange work group roadmap criteria, Road.HIE.157, "The HIE shall provide the ability to receive and forward a HITSP C/84 document," slated for 2011 certification.