Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build

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:

- Use this Logical Model: Consultation Note, History and Physical, Procedure Note, Progress Note... Show 2 more, Referral Note and Transfer Summary

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

- Differential Table
- Key Elements Table
- Snapshot Table
- Statistics/References
- All

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)

Path | Conformance | ValueSet
Section.component:component1.section.code | preferred | Physical Exam Type

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

Path | Conformance | ValueSet
Section.code | extensible | DocumentSectionType
Section.component:component1.section.code | preferred | Physical Exam Type

#### 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:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: 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

Path | Conformance | ValueSet / Code
Section.nullFlavor | required | NullFlavor
Section.classCode | required | Fixed Value: DOCSECT
Section.moodCode | required | Fixed Value: EVN
Section.templateId:primary.nullFlavor | required | NullFlavor
Section.code | extensible | DocumentSectionType
Section.code.nullFlavor | required | NullFlavor
Section.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Section.entry:longCareWound.nullFlavor | required | NullFlavor
Section.entry:longCareWound.typeCode | required | XActRelationshipEntry
Section.component.nullFlavor | required | NullFlavor
Section.component:component1.nullFlavor | required | NullFlavor
Section.component:component1.section.nullFlavor | required | NullFlavor
Section.component:component1.section.classCode | required | Fixed Value: DOCSECT
Section.component:component1.section.moodCode | required | Fixed Value: EVN
Section.component:component1.section.code | preferred | Physical Exam Type
Section.component:component1.section.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Section.component:component1.section.component.nullFlavor | required | NullFlavor

#### 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:

- Longitudinal Care Wound Observation (http://hl7.org/cda/us/ccda/StructureDefinition/LongitudinalCareWoundObservation)

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)

Path | Conformance | ValueSet
Section.component:component1.section.code | preferred | Physical Exam Type

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

Path | Conformance | ValueSet
Section.code | extensible | DocumentSectionType
Section.component:component1.section.code | preferred | Physical Exam Type

#### 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:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: 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

Path | Conformance | ValueSet / Code
Section.nullFlavor | required | NullFlavor
Section.classCode | required | Fixed Value: DOCSECT
Section.moodCode | required | Fixed Value: EVN
Section.templateId:primary.nullFlavor | required | NullFlavor
Section.code | extensible | DocumentSectionType
Section.code.nullFlavor | required | NullFlavor
Section.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Section.entry:longCareWound.nullFlavor | required | NullFlavor
Section.entry:longCareWound.typeCode | required | XActRelationshipEntry
Section.component.nullFlavor | required | NullFlavor
Section.component:component1.nullFlavor | required | NullFlavor
Section.component:component1.section.nullFlavor | required | NullFlavor
Section.component:component1.section.classCode | required | Fixed Value: DOCSECT
Section.component:component1.section.moodCode | required | Fixed Value: EVN
Section.component:component1.section.code | preferred | Physical Exam Type
Section.component:component1.section.languageCode | required | HumanLanguage (a valid code from `http://terminology.hl7.org/CodeSystem/ietf3066`)
Section.component:component1.section.component.nullFlavor | required | NullFlavor

#### 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:

- Longitudinal Care Wound Observation (http://hl7.org/cda/us/ccda/StructureDefinition/LongitudinalCareWoundObservation)

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