Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build United States of America flag

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section CDAR2.SectionXML 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..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1csRequired Pattern: 29545-1
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by type:$this
.... entry:longCareWound 0..*Entry
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... Slices for component 0..*InfrastructureRootSlice: Unordered, Open by value:section
.... component:component1 0..*InfrastructureRoot
..... section 1..1Section
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ST
...... text 1..1xhtml

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Section.component:component1.section.codepreferredPhysical Exam Type
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML 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..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by type:$this
.... entry:longCareWound 0..*Entry
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... Slices for component 0..*InfrastructureRootSlice: Unordered, Open by value:section
.... component:All Slices Content/Rules for all slices
..... section 1..1Section
.... component:component1 0..*InfrastructureRoot
..... section 1..1Section
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ST
...... text S1..1xhtml

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeextensibleDocumentSectionType
Section.component:component1.section.codepreferredPhysical Exam Type

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML 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..1xs:ID
... @nullFlavor 0..1csBinding: NullFlavor (required)
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntrySlice: Unordered, Open by type:$this
.... entry:longCareWound 0..*Entry
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... Slices for component 0..*InfrastructureRootSlice: Unordered, Open by value:section
.... component:All Slices Content/Rules for all slices
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csFixed Value: COMP
..... @contextConductionInd 0..1blFixed Value: true
..... section 1..1Section
.... component:component1 0..*InfrastructureRoot
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csFixed Value: COMP
..... @contextConductionInd 0..1blFixed Value: true
..... section 1..1Section
...... @ID 0..1xs:ID
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
...... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..1II
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ST
...... text S1..1xhtml
...... confidentialityCode 0..1CE
...... languageCode 0..1CSBinding: HumanLanguage (required)
...... subject 0..1Subject
...... author 0..*Author
...... informant 0..*Informant
...... entry 0..*Entry
...... component 0..*InfrastructureRoot
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section 1..1Section

doco Documentation for this format

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 (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.entry:longCareWound.nullFlavorrequiredNullFlavor
Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredNullFlavor
Section.component:component1.nullFlavorrequiredNullFlavor
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 (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.component:component1.section.component.nullFlavorrequiredNullFlavor

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section CDAR2.SectionXML 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..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1csRequired Pattern: 29545-1
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by type:$this
.... entry:longCareWound 0..*Entry
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... Slices for component 0..*InfrastructureRootSlice: Unordered, Open by value:section
.... component:component1 0..*InfrastructureRoot
..... section 1..1Section
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ST
...... text 1..1xhtml

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Section.component:component1.section.codepreferredPhysical Exam Type

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML 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..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by type:$this
.... entry:longCareWound 0..*Entry
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
... Slices for component 0..*InfrastructureRootSlice: Unordered, Open by value:section
.... component:All Slices Content/Rules for all slices
..... section 1..1Section
.... component:component1 0..*InfrastructureRoot
..... section 1..1Section
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ST
...... text S1..1xhtml

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeextensibleDocumentSectionType
Section.component:component1.section.codepreferredPhysical Exam Type

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML 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..1xs:ID
... @nullFlavor 0..1csBinding: NullFlavor (required)
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.2.10
..... @extension 1..1stRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 29545-1
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntrySlice: Unordered, Open by type:$this
.... entry:longCareWound 0..*Entry
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1LongitudinalCareWoundObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... Slices for component 0..*InfrastructureRootSlice: Unordered, Open by value:section
.... component:All Slices Content/Rules for all slices
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csFixed Value: COMP
..... @contextConductionInd 0..1blFixed Value: true
..... section 1..1Section
.... component:component1 0..*InfrastructureRoot
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csFixed Value: COMP
..... @contextConductionInd 0..1blFixed Value: true
..... section 1..1Section
...... @ID 0..1xs:ID
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
...... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 0..1II
...... code 1..1CEBinding: Physical Exam Type (preferred)
...... title 1..1ST
...... text S1..1xhtml
...... confidentialityCode 0..1CE
...... languageCode 0..1CSBinding: HumanLanguage (required)
...... subject 0..1Subject
...... author 0..*Author
...... informant 0..*Informant
...... entry 0..*Entry
...... component 0..*InfrastructureRoot
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... realmCode 0..*CS
....... typeId 0..1II
....... templateId 0..*II
....... @typeCode 0..1csFixed Value: COMP
....... @contextConductionInd 0..1blFixed Value: true
....... section 1..1Section

doco Documentation for this format

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 (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.entry:longCareWound.nullFlavorrequiredNullFlavor
Section.entry:longCareWound.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredNullFlavor
Section.component:component1.nullFlavorrequiredNullFlavor
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 (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.component:component1.section.component.nullFlavorrequiredNullFlavor

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll 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