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