Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions
Logical Model:
Physical Exam Section
Official URL : http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection
Version :
2.1
Draft
as of 2023-09-29
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 CDAR2.Section
Name Flags Card. Type Description & Constraints Section CDAR2.Section XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @ID , @nullFlavor , @classCode , @moodCode , templateId , id , code , title , text , confidentialityCode , languageCode , subject , author , informant , entry , component
Slices for templateId 1 .. * II Slice: Unordered, Open by value:root, value:extension
templateId:primary 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
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 type:$this
entry:longCareWound 0..* Entry
observation 1..1 LongitudinalCareWoundObservation Base for all types and resources
Slices for component 0 .. * InfrastructureRoot Slice: Unordered, Open by value:section
component:component1 0..* InfrastructureRoot
section 1 .. 1 Section
code 1..1 CE Binding: Physical Exam Type (preferred )
title 1..1 ST
text 1..1 xhtml
Documentation for this format
Terminology Bindings (Differential)
Name Flags Card. Type Description & Constraints Section 1..1 CDAR2.Section XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @ID , @nullFlavor , @classCode , @moodCode , templateId , id , code , title , text , confidentialityCode , languageCode , subject , author , informant , entry , component Base for all types and resources
Slices for templateId 1 .. * II Slice: Unordered, Open by value:root, value:extension
templateId:primary 1..1 II
@root 1..1 oid , uuid , ruid Required Pattern: 2.16.840.1.113883.10.20.2.10
@extension 1..1 st Required Pattern: 2015-08-01
code 1..1 CE Binding: DocumentSectionType (extensible )
@code 1..1 cs Required Pattern: 29545-1
@codeSystem 1..1 oid , uuid , ruid Required Pattern: 2.16.840.1.113883.6.1
title 1..1 ST
text S 1..1 xhtml
Slices for entry 0 .. * Entry Slice: Unordered, Open by type:$this
entry:longCareWound 0..* Entry
observation 1..1 LongitudinalCareWoundObservation Base for all types and resources
Slices for component 0 .. * InfrastructureRoot Slice: Unordered, Open by value:section
component:All Slices Content/Rules for all slices
section 1..1 Section
component:component1 0..* InfrastructureRoot
section 1..1 Section
code 1..1 CE Binding: Physical Exam Type (preferred )
title 1..1 ST
text S 1..1 xhtml
Documentation for this format
Terminology Bindings
Constraints
Id Grade Path(s) Details Requirements
ele-1 error **ALL** elements All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
Name Flags Card. Type Description & Constraints Section 1..1 CDAR2.Section XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @ID , @nullFlavor , @classCode , @moodCode , templateId , id , code , title , text , confidentialityCode , languageCode , subject , author , informant , entry , component Base for all types and resources
@ID 0..1 xs:ID
@nullFlavor 0..1 cs Binding: NullFlavor (required )
@classCode 0..1 cs Binding: ActClassRecordOrganizer (required )Fixed Value: DOCSECT
@moodCode 0..1 cs Binding: ActMood (required )Fixed Value: EVN
Slices for templateId 1 .. * II Slice: Unordered, Open by value:root, value:extension
templateId:primary 1..1 II
@nullFlavor 0..1 cs Binding: NullFlavor (required )
@assigningAuthorityName 0..1 st
@displayable 0..1 bl
@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
id 0..1 II
code 1..1 CE Binding: DocumentSectionType (extensible )
@nullFlavor 0..1 cs Binding: NullFlavor (required )
@code 1..1 cs Required Pattern: 29545-1
@codeSystem 1..1 oid , uuid , ruid Required Pattern: 2.16.840.1.113883.6.1
@codeSystemName 0..1 st
@codeSystemVersion 0..1 st
@displayName 0..1 st
@sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtcXML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtcXML: valueSetVersion (urn:hl7-org:sdtc)
originalText 0..1 ED
translation 0..* CD
title 1..1 ST
text S 1..1 xhtml
confidentialityCode 0..1 CE
languageCode 0..1 CS Binding: HumanLanguage (required )
subject 0..1 Subject
author 0..* Author
informant 0..* Informant
Slices for entry 0 .. * Entry Slice: Unordered, Open by type:$this
entry:longCareWound 0..* Entry
@nullFlavor 0..1 cs Binding: NullFlavor (required )
realmCode 0..* CS
typeId 0..1 II
templateId 0..* II
@typeCode 0..1 cs Binding: x_ActRelationshipEntry (required )
@contextConductionInd 0..1 bl Fixed Value: true
act 0..1 Act
encounter 0..1 Encounter
observation 1..1 LongitudinalCareWoundObservation Base for all types and resources
observationMedia 0..1 ObservationMedia
organizer 0..1 Organizer
procedure 0..1 Procedure
regionOfInterest 0..1 RegionOfInterest
substanceAdministration 0..1 SubstanceAdministration
supply 0..1 Supply
Slices for component 0 .. * InfrastructureRoot Slice: Unordered, Open by value:section
component:All Slices Content/Rules for all slices
@nullFlavor 0..1 cs Binding: NullFlavor (required )
realmCode 0..* CS
typeId 0..1 II
templateId 0..* II
@typeCode 0..1 cs Fixed Value: COMP
@contextConductionInd 0..1 bl Fixed Value: true
section 1..1 Section
component:component1 0..* InfrastructureRoot
@nullFlavor 0..1 cs Binding: NullFlavor (required )
realmCode 0..* CS
typeId 0..1 II
templateId 0..* II
@typeCode 0..1 cs Fixed Value: COMP
@contextConductionInd 0..1 bl Fixed Value: true
section 1..1 Section
@ID 0..1 xs:ID
@nullFlavor 0..1 cs Binding: NullFlavor (required )
@classCode 0..1 cs Binding: ActClassRecordOrganizer (required )Fixed Value: DOCSECT
@moodCode 0..1 cs Binding: ActMood (required )Fixed Value: EVN
templateId 0..* II
id 0..1 II
code 1..1 CE Binding: Physical Exam Type (preferred )
title 1..1 ST
text S 1..1 xhtml
confidentialityCode 0..1 CE
languageCode 0..1 CS Binding: HumanLanguage (required )
subject 0..1 Subject
author 0..* Author
informant 0..* Informant
entry 0..* Entry
component 0..* InfrastructureRoot
@nullFlavor 0..1 cs Binding: NullFlavor (required )
realmCode 0..* CS
typeId 0..1 II
templateId 0..* II
@typeCode 0..1 cs Fixed Value: COMP
@contextConductionInd 0..1 bl Fixed Value: true
section 1..1 Section
Documentation for this format
Terminology Bindings
Constraints
Id Grade Path(s) Details Requirements
ele-1 error **ALL** elements All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
This structure is derived from CDAR2.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 type:$this
The element Section.component is sliced based on the value of value:section
Differential View
This structure is derived from CDAR2.Section
Name Flags Card. Type Description & Constraints Section CDAR2.Section XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @ID , @nullFlavor , @classCode , @moodCode , templateId , id , code , title , text , confidentialityCode , languageCode , subject , author , informant , entry , component
Slices for templateId 1 .. * II Slice: Unordered, Open by value:root, value:extension
templateId:primary 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
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 type:$this
entry:longCareWound 0..* Entry
observation 1..1 LongitudinalCareWoundObservation Base for all types and resources
Slices for component 0 .. * InfrastructureRoot Slice: Unordered, Open by value:section
component:component1 0..* InfrastructureRoot
section 1 .. 1 Section
code 1..1 CE Binding: Physical Exam Type (preferred )
title 1..1 ST
text 1..1 xhtml
Documentation for this format
Terminology Bindings (Differential)
Key Elements View
Name Flags Card. Type Description & Constraints Section 1..1 CDAR2.Section XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @ID , @nullFlavor , @classCode , @moodCode , templateId , id , code , title , text , confidentialityCode , languageCode , subject , author , informant , entry , component Base for all types and resources
Slices for templateId 1 .. * II Slice: Unordered, Open by value:root, value:extension
templateId:primary 1..1 II
@root 1..1 oid , uuid , ruid Required Pattern: 2.16.840.1.113883.10.20.2.10
@extension 1..1 st Required Pattern: 2015-08-01
code 1..1 CE Binding: DocumentSectionType (extensible )
@code 1..1 cs Required Pattern: 29545-1
@codeSystem 1..1 oid , uuid , ruid Required Pattern: 2.16.840.1.113883.6.1
title 1..1 ST
text S 1..1 xhtml
Slices for entry 0 .. * Entry Slice: Unordered, Open by type:$this
entry:longCareWound 0..* Entry
observation 1..1 LongitudinalCareWoundObservation Base for all types and resources
Slices for component 0 .. * InfrastructureRoot Slice: Unordered, Open by value:section
component:All Slices Content/Rules for all slices
section 1..1 Section
component:component1 0..* InfrastructureRoot
section 1..1 Section
code 1..1 CE Binding: Physical Exam Type (preferred )
title 1..1 ST
text S 1..1 xhtml
Documentation for this format
Terminology Bindings
Constraints
Id Grade Path(s) Details Requirements
ele-1 error **ALL** elements All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
Snapshot View
Name Flags Card. Type Description & Constraints Section 1..1 CDAR2.Section XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @ID , @nullFlavor , @classCode , @moodCode , templateId , id , code , title , text , confidentialityCode , languageCode , subject , author , informant , entry , component Base for all types and resources
@ID 0..1 xs:ID
@nullFlavor 0..1 cs Binding: NullFlavor (required )
@classCode 0..1 cs Binding: ActClassRecordOrganizer (required )Fixed Value: DOCSECT
@moodCode 0..1 cs Binding: ActMood (required )Fixed Value: EVN
Slices for templateId 1 .. * II Slice: Unordered, Open by value:root, value:extension
templateId:primary 1..1 II
@nullFlavor 0..1 cs Binding: NullFlavor (required )
@assigningAuthorityName 0..1 st
@displayable 0..1 bl
@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
id 0..1 II
code 1..1 CE Binding: DocumentSectionType (extensible )
@nullFlavor 0..1 cs Binding: NullFlavor (required )
@code 1..1 cs Required Pattern: 29545-1
@codeSystem 1..1 oid , uuid , ruid Required Pattern: 2.16.840.1.113883.6.1
@codeSystemName 0..1 st
@codeSystemVersion 0..1 st
@displayName 0..1 st
@sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtcXML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtcXML: valueSetVersion (urn:hl7-org:sdtc)
originalText 0..1 ED
translation 0..* CD
title 1..1 ST
text S 1..1 xhtml
confidentialityCode 0..1 CE
languageCode 0..1 CS Binding: HumanLanguage (required )
subject 0..1 Subject
author 0..* Author
informant 0..* Informant
Slices for entry 0 .. * Entry Slice: Unordered, Open by type:$this
entry:longCareWound 0..* Entry
@nullFlavor 0..1 cs Binding: NullFlavor (required )
realmCode 0..* CS
typeId 0..1 II
templateId 0..* II
@typeCode 0..1 cs Binding: x_ActRelationshipEntry (required )
@contextConductionInd 0..1 bl Fixed Value: true
act 0..1 Act
encounter 0..1 Encounter
observation 1..1 LongitudinalCareWoundObservation Base for all types and resources
observationMedia 0..1 ObservationMedia
organizer 0..1 Organizer
procedure 0..1 Procedure
regionOfInterest 0..1 RegionOfInterest
substanceAdministration 0..1 SubstanceAdministration
supply 0..1 Supply
Slices for component 0 .. * InfrastructureRoot Slice: Unordered, Open by value:section
component:All Slices Content/Rules for all slices
@nullFlavor 0..1 cs Binding: NullFlavor (required )
realmCode 0..* CS
typeId 0..1 II
templateId 0..* II
@typeCode 0..1 cs Fixed Value: COMP
@contextConductionInd 0..1 bl Fixed Value: true
section 1..1 Section
component:component1 0..* InfrastructureRoot
@nullFlavor 0..1 cs Binding: NullFlavor (required )
realmCode 0..* CS
typeId 0..1 II
templateId 0..* II
@typeCode 0..1 cs Fixed Value: COMP
@contextConductionInd 0..1 bl Fixed Value: true
section 1..1 Section
@ID 0..1 xs:ID
@nullFlavor 0..1 cs Binding: NullFlavor (required )
@classCode 0..1 cs Binding: ActClassRecordOrganizer (required )Fixed Value: DOCSECT
@moodCode 0..1 cs Binding: ActMood (required )Fixed Value: EVN
templateId 0..* II
id 0..1 II
code 1..1 CE Binding: Physical Exam Type (preferred )
title 1..1 ST
text S 1..1 xhtml
confidentialityCode 0..1 CE
languageCode 0..1 CS Binding: HumanLanguage (required )
subject 0..1 Subject
author 0..* Author
informant 0..* Informant
entry 0..* Entry
component 0..* InfrastructureRoot
@nullFlavor 0..1 cs Binding: NullFlavor (required )
realmCode 0..* CS
typeId 0..1 II
templateId 0..* II
@typeCode 0..1 cs Fixed Value: COMP
@contextConductionInd 0..1 bl Fixed Value: true
section 1..1 Section
Documentation for this format
Terminology Bindings
Constraints
Id Grade Path(s) Details Requirements
ele-1 error **ALL** elements All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
This structure is derived from CDAR2.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 type:$this
The element Section.component is sliced based on the value of value:section
Other representations of profile: CSV , Excel