Consolidated CDA Release 2.2
2.2 - CI Build United States of America flag

Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions

Resource Profile: Physical Exam Section

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.2.10 Version: 2.2
Active as of 2022-05-13 Computable Name: PhysicalExamSection
Other Identifiers: : 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 patients 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 patients 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 CDAR2.Section

Summary

Mandatory: 8 elements (5 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 value:observation
  • The element Section.component is sliced based on the value of value:section

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1stringRequired Pattern: 29545-1
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... Slices for entry 0..*ElementSlice: Unordered, Open by value:observation
.... entry:longCareWound 0..*Element
..... observation 1..1LongitudinalCareWoundObservation
... Slices for component 0..*ElementSlice: Unordered, Open by value:section
.... component:component1 0..*Element
..... section 1..1Section
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ED
...... text 1..1xhtml

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 29545-1
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry I0..*ElementSlice: Unordered, Open by value:observation
.... entry:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entry:longCareWound I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1LongitudinalCareWoundObservation
... Slices for component 0..*ElementSlice: Unordered, Open by value:section
.... component:All Slices Content/Rules for all slices
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
.... component:component1 0..*Element
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
...... ID 0..1string
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..1II
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ED
...... text S1..1xhtml
...... confidentialityCode 0..1CE
...... languageCode 0..1CSBinding: HumanLanguage (required)
...... subject 0..1Element
....... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
....... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
....... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
....... relatedSubject 1..1RelatedSubject
...... author 0..*Author
...... informant 0..*Element
....... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
....... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
....... assignedEntity 0..1AssignedEntity
....... relatedEntity 0..1RelatedEntity
...... entry I0..*Element
....... typeCode 1..1code
....... contextConductionInd 1..1boolean
....... (Choice of one) 1..1
........ observation 0..1Observation
........ regionOfInterest 0..1RegionOfInterest
........ observationMedia 0..1ObservationMedia
........ substanceAdministration 0..1SubstanceAdministration
........ supply 0..1Supply
........ procedure 0..1Procedure
........ encounter 0..1Encounter
........ organizer 0..1Organizer
........ act 0..1Act
...... component 0..*Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1Section

doco Documentation for this format

This structure is derived from CDAR2.Section

Summary

Mandatory: 8 elements (5 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 value:observation
  • The element Section.component is sliced based on the value of value:section

Differential View

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1stringRequired Pattern: 29545-1
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... Slices for entry 0..*ElementSlice: Unordered, Open by value:observation
.... entry:longCareWound 0..*Element
..... observation 1..1LongitudinalCareWoundObservation
... Slices for component 0..*ElementSlice: Unordered, Open by value:section
.... component:component1 0..*Element
..... section 1..1Section
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ED
...... text 1..1xhtml

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 29545-1
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry I0..*ElementSlice: Unordered, Open by value:observation
.... entry:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entry:longCareWound I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1LongitudinalCareWoundObservation
... Slices for component 0..*ElementSlice: Unordered, Open by value:section
.... component:All Slices Content/Rules for all slices
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
.... component:component1 0..*Element
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... section 1..1Section
...... ID 0..1string
...... nullFlavor 0..1codeBinding: NullFlavor (required)
...... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
...... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..1II
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ED
...... text S1..1xhtml
...... confidentialityCode 0..1CE
...... languageCode 0..1CSBinding: HumanLanguage (required)
...... subject 0..1Element
....... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
....... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
....... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
....... relatedSubject 1..1RelatedSubject
...... author 0..*Author
...... informant 0..*Element
....... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
....... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
....... assignedEntity 0..1AssignedEntity
....... relatedEntity 0..1RelatedEntity
...... entry I0..*Element
....... typeCode 1..1code
....... contextConductionInd 1..1boolean
....... (Choice of one) 1..1
........ observation 0..1Observation
........ regionOfInterest 0..1RegionOfInterest
........ observationMedia 0..1ObservationMedia
........ substanceAdministration 0..1SubstanceAdministration
........ supply 0..1Supply
........ procedure 0..1Procedure
........ encounter 0..1Encounter
........ organizer 0..1Organizer
........ act 0..1Act
...... component 0..*Element
....... typeCode 1..1codeFixed Value: COMP
....... contextConductionInd 1..1boolean
....... section 1..1Section

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredNullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP
Section.component:component1.section.nullFlavorrequiredNullFlavor
Section.component:component1.section.classCoderequiredFixed Value: DOCSECT
Section.component:component1.section.moodCoderequiredFixed Value: EVN
Section.component:component1.section.codepreferredPhysical Exam Type
Section.component:component1.section.languageCoderequiredHumanLanguage
Section.component:component1.section.subject.typeCoderequiredFixed Value: SBJ
Section.component:component1.section.subject.contextControlCoderequiredFixed Value: OP
Section.component:component1.section.subject.awarenessCodeextensibleTargetAwareness
Section.component:component1.section.informant.typeCoderequiredFixed Value: INF
Section.component:component1.section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePathDetailsRequirements
only-one-statementerrorSection.entrySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:longCareWoundSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.component:component1.section.entrySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1