Id2.16.840.1.113883.10.20.2.10Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NamePhysicalExamSectionDisplay NamePhysical Exam Section
Description
The Physical Exam section includes direct observations made by the clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patient’s body. This section includes only observations made by the examining clinician using 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: Vital Signs, General Status, and those listed in the Additional Physical Examination Subsections appendix.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.2.10
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 4 transactions and 4 templates, Uses 3 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.4Transactionfinal Progress Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.5Transactionfinal Procedure Note (US Realm – Release 1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.2Transactionfinal Consultation Notes (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.7Transactionfinal History and Physical (H and P) (Release 1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.3Containmentdraft History and Physical (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.4Containmentdraft Consultation Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.6Containmentdraft Procedure Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.9Containmentdraft Progress Note (1.1)2013‑01‑31
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.70Containmentdraft Pressure Ulcer Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.76Containmentdraft Number of Pressure Ulcers Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.77Containmentdraft Highest Pressure Ulcer Stage (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:section
Physdotstion
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CONF1 … 1F29545-1
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1 … 1F2.16.840.1.113883.6.1
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0 … *Contains 2.16.840.1.113883.10.20.22.4.77 Highest Pressure Ulcer Stage (2013‑01‑31)confdots7098