This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. The current version which supersedes this version is 4.0.0. For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection | Version: 3.0.0 | |||
| Draft as of 2024-05-18 | Computable Name: PhysicalExamSection | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#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:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints  | 
|---|---|---|---|---|
|   Section | Section | XML 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
|    Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
|     templateId:section | 1..1 | II | ||
|      @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.2.10 | |
|      @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
|    code | 1..1 | CE | Physical findings Narrative | |
|     @code | 1..1 | cs | Required Pattern: 29545-1 | |
|     @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
|    title | 1..1 | ST | ||
|    text | 1..1 | xhtml | ||
|    Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation | |
|     entry:longCareWound | 0..* | Entry | ||
|      observation | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources | |
|    component | 0..* | InfrastructureRoot | ||
|     section | 1..1 | Section | ||
|      code | 1..1 | CE | Binding: Physical Exam Type  (preferred) | |
|      title | 1..1 | ST | ||
|      text | 1..1 | xhtml | ||
|  Documentation for this format | ||||
| Path | Conformance | ValueSet | URI | 
| Section.component.section.code | preferred | PhysicalExamType  http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 | 
| Name | Flags | Card. | Type | Description & Constraints  | 
|---|---|---|---|---|
|   Section | 1..1 | Section | XML 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
|    Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
|     templateId:section | 1..1 | II | ||
|      @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.2.10 | |
|      @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
|    code | 1..1 | CE | Physical findings Narrative Binding: DocumentSectionType (example) | |
|     @code | 1..1 | cs | Required Pattern: 29545-1 | |
|     @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
|    title | 1..1 | ST | ||
|    text | 1..1 | xhtml | ||
|    Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation | |
|     entry:longCareWound | 0..* | Entry | ||
|      observation | C | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | 
|    component | 0..* | InfrastructureRoot | ||
|     section | 1..1 | Section | ||
|      code | 1..1 | CE | Binding: Physical Exam Type  (preferred) | |
|      title | 1..1 | ST | ||
|      text | 1..1 | xhtml | ||
|  Documentation for this format | ||||
| Path | Conformance | ValueSet | URI | 
| Section.code | example | DocumentSectionType http://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.component.section.code | preferred | PhysicalExamType  http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 | 
| Id | Grade | Path(s) | Details | Requirements | 
| should-author | warning | Section.entry:longCareWound.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Section.entry:longCareWound.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | 
| Path | Conformance | ValueSet / Code | URI | 
| Section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECT http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionType http://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguages http://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:longCareWound.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:longCareWound.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:longCareWound.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.component.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.section.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.section.classCode | required | Fixed Value: DOCSECT http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.component.section.moodCode | required | Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.component.section.code | preferred | PhysicalExamType  http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 | |
| Section.component.section.languageCode | required | AllLanguages http://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.component.section.component.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.section.component.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | 
| Id | Grade | Path(s) | Details | Requirements | 
| should-author | warning | Section.entry:longCareWound.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Section.entry:longCareWound.observation | SHOULD 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:
Differential View
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints  | 
|---|---|---|---|---|
|   Section | Section | XML 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
|    Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
|     templateId:section | 1..1 | II | ||
|      @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.2.10 | |
|      @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
|    code | 1..1 | CE | Physical findings Narrative | |
|     @code | 1..1 | cs | Required Pattern: 29545-1 | |
|     @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
|    title | 1..1 | ST | ||
|    text | 1..1 | xhtml | ||
|    Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation | |
|     entry:longCareWound | 0..* | Entry | ||
|      observation | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources | |
|    component | 0..* | InfrastructureRoot | ||
|     section | 1..1 | Section | ||
|      code | 1..1 | CE | Binding: Physical Exam Type  (preferred) | |
|      title | 1..1 | ST | ||
|      text | 1..1 | xhtml | ||
|  Documentation for this format | ||||
| Path | Conformance | ValueSet | URI | 
| Section.component.section.code | preferred | PhysicalExamType  http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 | 
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints  | 
|---|---|---|---|---|
|   Section | 1..1 | Section | XML 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
|    Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
|     templateId:section | 1..1 | II | ||
|      @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.2.10 | |
|      @extension | 1..1 | st | Required Pattern: 2015-08-01 | |
|    code | 1..1 | CE | Physical findings Narrative Binding: DocumentSectionType (example) | |
|     @code | 1..1 | cs | Required Pattern: 29545-1 | |
|     @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
|    title | 1..1 | ST | ||
|    text | 1..1 | xhtml | ||
|    Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation | |
|     entry:longCareWound | 0..* | Entry | ||
|      observation | C | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author | 
|    component | 0..* | InfrastructureRoot | ||
|     section | 1..1 | Section | ||
|      code | 1..1 | CE | Binding: Physical Exam Type  (preferred) | |
|      title | 1..1 | ST | ||
|      text | 1..1 | xhtml | ||
|  Documentation for this format | ||||
| Path | Conformance | ValueSet | URI | 
| Section.code | example | DocumentSectionType http://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.component.section.code | preferred | PhysicalExamType  http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 | 
| Id | Grade | Path(s) | Details | Requirements | 
| should-author | warning | Section.entry:longCareWound.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Section.entry:longCareWound.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | 
Snapshot View
| Path | Conformance | ValueSet / Code | URI | 
| Section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECT http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionType http://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguages http://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.entry:longCareWound.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:longCareWound.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.entry:longCareWound.typeCode | required | XActRelationshipEntry http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
| Section.component.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.section.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.section.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.section.classCode | required | Fixed Value: DOCSECT http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.component.section.moodCode | required | Fixed Value: EVN http://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.component.section.code | preferred | PhysicalExamType  http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 | |
| Section.component.section.languageCode | required | AllLanguages http://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.component.section.component.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.section.component.typeId.nullFlavor | required | CDANullFlavor http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | 
| Id | Grade | Path(s) | Details | Requirements | 
| should-author | warning | Section.entry:longCareWound.observation | SHOULD contain author : author.exists() | |
| should-text-ref-value | warning | Section.entry:longCareWound.observation | SHOULD 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: