Section Code |
LOINC: 10157-6 (HISTORY OF FAMILY MEMBER DISEASES) |
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Description |
The family medical history section is used to convey the patient's family medical history as either unstructured (CDA Level 2) text or discrete entries via Organizers per each family member. |
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CDA Level |
Level 2 or Level 3 |
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Template IDs |
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Level / Spec |
Template ID |
Standards Reference |
3 / CCD |
2.16.840.1.113883.10.20.1.4 |
CCD 3.6 |
2 / IHE |
1.3.6.1.4.1.19376.1.5.3.1.3.14 |
IHE PCC TF-2: 6.3.3.2.12 |
3 / IHE |
1.3.6.1.4.1.19376.1.5.3.1.3.15 |
IHE PCC TF-2: 6.3.3.2.13 |
Expected Entries / Sub-Sections |
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Entry |
Template ID |
Reference |
Family History Organizer |
2.16.840.1.113883.10.20.1.23
1.3.6.1.4.1.19376.1.5.3.1.4.15 |
3.4.2.9 |
OpenSHR Implementation Notes |
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Data Model |
Obs |
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Code File |
FamilyMedicalHistorySectionProcessor.java |
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Additional Constraints |
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Notes |
The OpenSHR CDA processor will use the CCD template only when generating an on-demand document section for family history. Content creators should send the IHE PCC template identifiers. |
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Specification |
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<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<!-- CCD Family History Template -->
<templateId root="2.16.840.1.113883.10.20.1.4"/>
<!-- IHE PCC Family History Template -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.14" />
<!-- IHE PCC Coded Family History Template -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.15" />
<!-- 1..1 Section Code -->
<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="HISTORY OF FAMILY MEMBER DISEASES"/>
<title>Family history</title>
<text>
...
</text>
<!-- 0..n Family History Organizers for each family member -->
<entry typeCode="DRIV">
<organizer moodCode="EVN" classCode="CLUSTER">
...
</organizer>
</entry>
</section>
</component> |
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Example |
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The following example illustrates a family medical history containing information indicating a father born 1912 who died of a heart attack at age 57 and was diagnosed with hypertension at age 40. |
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<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.4"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.14" />
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.15" />
<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="HISTORY OF FAMILY MEMBER DISEASES"/>
<title>Family history</title>
<text>
...
</text>
<entry typeCode="DRIV">
<!-- Organizer for the Father's Medical History -->
<organizer moodCode="EVN" classCode="CLUSTER">
<templateId root="2.16.840.1.113883.10.20.1.23"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.15"/>
<statusCode code="completed"/>
<!-- Father Record -->
<subject>
<relatedSubject classCode="PRS">
<code code="FTH" codeSystem="2.16.840.1.113883.5.111" displayName="Biological father"/>
<subject>
<sdtc:id xmlns:sdtc="urn:hl7-org:sdtc" root="1.2.3.4.5" extension="12304"/>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>
<birthTime value="1912"/>
</subject>
</relatedSubject>
</subject>
<!-- Component observation representing a heart attack -->
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.42"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.3"/>
<id root="d42ebf70-5c89-11db-b0de-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="22298006" codeSystem="2.16.840.1.113883.6.96" displayName="MI"
codeSystemName="SNOMED-CT"/>
<!-- Entry relationship identifying the observation as cause of death -->
<entryRelationship typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<id root="6898fae0-5c8a-11db-b0de-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="419099009" codeSystem="2.16.840.1.113883.6.96" displayName="Dead"
codeSystemName="SNOMED-CT"/>
</observation>
</entryRelationship>
<!-- Inverted entry relationship observation identifying the age at which the condition occurred -->
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.38"/>
<code code="397659008" codeSystem="2.16.840.1.113883.6.96" displayName="Age"/>
<statusCode code="completed"/>
<value xsi:type="INT" value="57"/>
</observation>
</entryRelationship>
</observation>
</component>
<!-- Observation identifying condition of hypertension -->
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.22"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.3"/>
<id root="5bfe3ec0-5c8b-11db-b0de-0800200c9a66"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="59621000" codeSystem="2.16.840.1.113883.6.96" displayName="HTN"/>
<!-- Age observation -->
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.38"/>
<code code="397659008" codeSystem="2.16.840.1.113883.6.96" displayName="Age"/>
<statusCode code="completed"/>
<value xsi:type="INT" value="40"/>
</observation>
</entryRelationship>
</observation>
</component>
</organizer>
</entry>
</section>
</component> |
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