Id2.16.840.1.113883.10.20.2.10Effective Date2015‑08‑01
Statusdraft DraftVersion Label2.1
NamePhysicalExamSectionV3Display NamePhysical Exam Section (V3)
Description
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.
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 6 transactions and 10 templates, Uses 1 template
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.29Transactionfinal Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal Consultation Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.28Transactionfinal Procedure Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transactionfinal Referral Note (V2)2015‑08‑01
1.3.6.1.4.1.19376.1.4.1.1.4Containmentpending Cardiac Procedure Note (1.0)2017‑04‑02 18:28:22
1.3.6.1.4.1.19376.1.4.1.1.4Containmentdraft Cardiac Procedure Note (Rev 2.1 – Trial Implementation)2018‑07‑26 13:54:24
2.16.840.1.113883.3.1937.99.61.28.10.3Containmentdraft CDA de Consulta (1)2017‑04‑22 23:20:01
2.16.840.1.113883.10.20.22.1.3Containmentdraft History and Physical (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.4Containmentdraft Consultation Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.6Containmentdraft Procedure Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.9Containmentdraft Progress Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.13Containmentdraft Transfer Summary (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.14Containmentdraft Referral Note (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.101Containmentdraft BC CDA Referral Note (V2) (2.1)2019‑04‑06 02:03:17
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.114Containmentdraft Longitudinal Care Wound Observation (V2) (2.1)2015‑08‑01
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.2.10 Physical Exam Section (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:section
PhysdotsonV3
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.2.10
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1198-7806) such that itCONFdots7806
@root
uid1 … 1F2.16.840.1.113883.10.20.2.10CONFdots0465
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.2.10" (CONF:1198-10465).
@extension
st1 … 1F2015-08-01CONFdots2587
 SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32587).
cda:code
CE1 … 1MSHALL contain exactly one [1..1] code (CONF:1198-15397).CONFdots5397
@code
CONF1 … 1F29545-1
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:title
ST1 … 1SHALL contain exactly one [1..1] title (CONF:1198-7808).CONFdots7808
cda:text
SD.TEXT1 … 1RSHALL contain exactly one [1..1] text (CONF:1198-7809).CONFdots7809
cda:entry
0 … *Contains 2.16.840.1.113883.10.20.22.4.114 Longitudinal Care Wound Observation (V2) (2015‑08‑01)CONFdots1926
cda:component
0 … *MAY contain zero or more [0..*] component (CONF:1198-32434) such that itCONFdots2434
cda:section
1 … 1MSHALL contain exactly one [1..1] section (CONF:1198-32435).CONFdots2435
cda:code
CE1 … 1This section SHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Physical Exam Type urn:oid:2.16.840.1.113883.11.20.9.65 DYNAMIC (CONF:1198-32436).CONFdots2436
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.65 Physical Exam Type (DYNAMIC)
cda:title
ST1 … 1This section SHALL contain exactly one [1..1] title (CONF:1198-32437).CONFdots2437
cda:text
SD.TEXT1 … 1RThis section SHALL contain exactly one [1..1] text (CONF:1198-32438).CONFdots2438