ࡱ> ` hbjbj .(?ZZZZZZZnr)r)r)8)$)n!i2^+^+(+++a,a,a,hhhhhhh$SkhmphZa,a,a,a,a,hZZ++hS/S/S/a,Z+Z+hS/a,hS/S/N^ZZc+R+ `r)1-`0ch0!i`+n-+n`c+nZc a,a,S/a,a,a,a,a,hh.Xa,a,a,!ia,a,a,a,nnn!r)nnnr)nnnZZZZZZ Consolidated Health Informatics Standards Adoption Recommendation History and Physical Index Part I Sub-team & Domain Scope Identification basic information defining the team and the scope of its investigation. Part II Standards Adoption Recommendation team-based advice on standard(s) to adopt. Part III Adoption & Deployment Information supporting information gathered to assist with deployment of the standard (may be partial). Summary Domain: History and Physical Standards Adoption Recommendation: NONE: Work deferred to CHI Phase II SCOPE This domain is defined as the terminology that is used to identify, classify, and name the components incorporated into a patients medical history and the physical exam process performed by a practitioner. RECOMMENDATION No recommendation. Work deferred to CHI Phase II. OWNERSHIP -NA- APPROVALS AND ACCREDITATIONS -NA- ACQUISITION AND COST -NA- Part I Team & Domain Scope Identification Target Vocabulary Domain Common name used to describe the clinical/medical domain or messaging standard requirement that has been examined. History and Physical Describe the specific purpose/primary use of this standard in the federal health care sector (100 words or less) This domain is defined as the terminology that is used to identify, classify, and name the components incorporated into a patients medical history and the physical exam process performed by a practitioner.  Sub-domains: Identify/dissect the domain into sub-domains, if any. For each, indicate if standards recommendations are or are not included in the scope of this recommendation. Domain/Sub-domainIn-Scope (Y/N)Document Components and Data DomainsDemographics N*History of Present Illness YReview of SystemsYPast Medical/Surgical History YFamily History YSocial History YMedicationsN*ImmunizationN*Non-Medication Allergies YVital Signs YPhysical Exam ObservationsYPhysical Exam Findings YLaboratory Findings N*Interventions and ProceduresN*Diagnoses and ProblemsN**These subdomains are being addressed by other CHI workgroups Information Exchange Requirements (IERs) Using the table at appendix A, list the IERs involved when using this vocabulary. -NA- Team Members Team members names and agency names with phone numbers. NameAgency/DepartmentDr. Viet Nguyen (co-lead)VALinda Nugent (co-lead)VABart HarmonDoDDr. Howard HaysHHS/IHSNancy OrvisDoDDr. Timothy MayhewHHS/IHSAlicia BradfordCMSSandy BaileyVADerek WangSSADavid TemoshokGSA Work Period Dates work began/ended. StartEndOctober 2003December 2003 Part II Standards Adoption Recommendation Recommendation Identify the solution recommended. Recommendation to defer this domain to Phase II 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  Ownership Structure Describe who owns the standard, how it is managed and controlled. -NA- Summary Basis for Recommendation Summarize the teams basis for making the recommendation (300 words or less). -NA_ Conditional Recommendation If this is a conditional recommendation, describe conditions upon which the recommendation is predicated. -NA-Approvals & Accreditations Indicate the status of various accreditations and approvals: Approvals & Accreditations Yes/Approved Applied Not ApprovedFull SDO BallotANSI Options Considered Inventory solution options considered and summarize the basis for not recommending the alternative(s). SNOMED CT must be specifically discussed.  Current Deployment Summarize the degree of market penetration today; i.e., where is this solution installed today? What number of or percentage of relevant vendors have adopted the standard? What number or percentage of healthcare institutions have adopted the standard? What number or percentage of federal agencies have adopted the standard? Is the standard used in other countries? 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