Consolidated Healthcare Informatics Initiative

Consolidated Health Informatics Initiative
Final Recommendation Information Sheet

Domain Title and Team Lead

History and Physical: Linda Nugent and Viet Nguyen, VA Co-Leads

Scope

This domain is defined as the terminology that is used to identify, classify, and name the components incorporated into a patient’s medical history and the physical exam process performed by a practitioner.

Domain/Sub-domain	In-Scope (Y/N)
Document Components and Data Domains
Demographics	N*
History of Present Illness	Y
Review of Systems	Y
Past Medical/Surgical History	Y
Family History	Y
Social History	Y
Medications	N*
Immunization	N*
Non-Medication Allergies	Y
Vital Signs	Y
Physical Exam Observations	Y
Physical Exam Findings	Y
Laboratory Findings	N*
Interventions and Procedures	N*
Diagnoses and Problems	N*

*Coverage by other CHI domains.

Final Recommendation

Recommendation to defer this domain to the next phase of CHI as:

There is considerable variability, in the format and content of a History & Physical. It is presently not standardized and is typically dependant upon the clinical judgment of the practitioner.
This recommendation to defer the work on standardizing the History & Physical format will give us time to align our efforts with the efforts of other Standards Development Organizations. For instance, the HL7 Electronic Health Record [EHR] SIG recently voted to defer work on developing standard formats for History and Physicals in their current efforts. [See: "Public Response to HL7 Ballot 1 Electronic Health Record”, August 29, 2003].
Additionally, by moving the effort to a later date, the H&P group would be better able to align its recommendations for the components of an H&P with the accepted/recommended terminologies for each component, that have been approved by the CHI Council

Conditions: NA

Consolidated Health Informatics Initiative Final Recommendation Information Sheet

Consolidated Health Informatics Initiative
Final Recommendation Information Sheet