Consolidated CDA
3.0.0-ballot - ballot United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions

Logical Model: Physical Exam Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: PhysicalExamSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.2.10:2015-08-01

The section includes direct observations made by a clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patient’s body.

It also includes observations made by the examining clinician using only inspection, palpation, auscultation, and percussion. It does not include laboratory or imaging findings.

The exam may be limited to pertinent body systems based on the patient’s chief complaint or it may include a comprehensive examination. The examination may be reported as a collection of random clinical statements or it may be reported categorically.

The Physical Exam Section may contain multiple nested subsections.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEPhysical Findings
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:observation
.... entry:longCareWound 0..*Entry
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... component 0..*InfrastructureRoot
.... section 1..1Section
..... code 1..1CEBinding: Physical Exam Type (preferred)
..... title 1..1ST
..... text 1..1xhtml

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Section.component.section.codepreferredPhysicalExamType
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEPhysical Findings
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:observation
.... entry:longCareWound 0..*Entry
..... observation C1..1LongitudinalCareWoundObservationBase for all types and resources
... component 0..*InfrastructureRoot
.... section 1..1Section
..... code 1..1CEBinding: Physical Exam Type (preferred)
..... title 1..1ST
..... text 1..1xhtml

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeexampleDocumentSectionType
Section.component.section.codepreferredPhysicalExamType

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:longCareWound.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEPhysical Findings
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:observation
.... entry:longCareWound 0..*Entry
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1LongitudinalCareWoundObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @ID 0..1xs:ID
..... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..1II
..... code 1..1CEBinding: Physical Exam Type (preferred)
..... title 1..1ST
..... text 1..1xhtml
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: AllLanguages (required)
..... subject 0..1Subject
..... author 0..*Author
..... informant 0..*Informant
..... entry 0..*Entry
..... component 0..*InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csFixed Value: COMP
...... @contextConductionInd 0..1blFixed Value: true
...... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
Section.component.section.nullFlavorrequiredCDANullFlavor
Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
Section.component.section.classCoderequiredFixed Value: DOCSECT
Section.component.section.moodCoderequiredFixed Value: EVN
Section.component.section.codepreferredPhysicalExamType
Section.component.section.languageCoderequiredAllLanguages
Section.component.section.component.nullFlavorrequiredCDANullFlavor
Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:longCareWound.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements (4 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the value of profile:observation

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEPhysical Findings
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:observation
.... entry:longCareWound 0..*Entry
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... component 0..*InfrastructureRoot
.... section 1..1Section
..... code 1..1CEBinding: Physical Exam Type (preferred)
..... title 1..1ST
..... text 1..1xhtml

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Section.component.section.codepreferredPhysicalExamType

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEPhysical Findings
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:observation
.... entry:longCareWound 0..*Entry
..... observation C1..1LongitudinalCareWoundObservationBase for all types and resources
... component 0..*InfrastructureRoot
.... section 1..1Section
..... code 1..1CEBinding: Physical Exam Type (preferred)
..... title 1..1ST
..... text 1..1xhtml

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeexampleDocumentSectionType
Section.component.section.codepreferredPhysicalExamType

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:longCareWound.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEPhysical Findings
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:observation
.... entry:longCareWound 0..*Entry
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1LongitudinalCareWoundObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @ID 0..1xs:ID
..... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
..... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
..... id 0..1II
..... code 1..1CEBinding: Physical Exam Type (preferred)
..... title 1..1ST
..... text 1..1xhtml
..... confidentialityCode 0..1CE
..... languageCode 0..1CSBinding: AllLanguages (required)
..... subject 0..1Subject
..... author 0..*Author
..... informant 0..*Informant
..... entry 0..*Entry
..... component 0..*InfrastructureRoot
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @typeCode 0..1csFixed Value: COMP
...... @contextConductionInd 0..1blFixed Value: true
...... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:longCareWound.nullFlavorrequiredCDANullFlavor
Section.entry:longCareWound.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor
Section.component.section.nullFlavorrequiredCDANullFlavor
Section.component.section.typeId.nullFlavorrequiredCDANullFlavor
Section.component.section.classCoderequiredFixed Value: DOCSECT
Section.component.section.moodCoderequiredFixed Value: EVN
Section.component.section.codepreferredPhysicalExamType
Section.component.section.languageCoderequiredAllLanguages
Section.component.section.component.nullFlavorrequiredCDANullFlavor
Section.component.section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-authorwarningSection.entry:longCareWound.observationSHOULD contain author
: author.exists()
should-text-ref-valuewarningSection.entry:longCareWound.observationSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements (4 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the value of profile:observation

 

Other representations of profile: CSV, Excel