Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection | Version: 4.0.0-ballot | |||
Draft as of 2024-11-21 | Computable Name: PhysicalExamSection | |||
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#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:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:section | 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 | Physical findings Narrative | |
@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 profile:observation | |
entry:longCareWound | 0..* | Entry | ||
observation | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources | |
component | 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 |
Path | Conformance | ValueSet | URI |
Section.component.section.code | preferred | PhysicalExamType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:section | 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 | Physical findings Narrative Binding: DocumentSectionType (example) | |
@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 profile:observation | |
entry:longCareWound | 0..* | Entry | ||
observation | C | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
component | 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 |
Path | Conformance | ValueSet | URI |
Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
Section.component.section.code | preferred | PhysicalExamType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 |
Id | Grade | Path(s) | Details | Requirements |
should-author | warning | Section.entry:longCareWound.observation | SHOULD contain author : author.exists() | |
should-text-ref-value | warning | Section.entry:longCareWound.observation | SHOULD contain text/reference/@value : text.reference.value.exists() |
Path | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.entry:longCareWound.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:longCareWound.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:longCareWound.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.component.section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.component.section.code | preferred | PhysicalExamType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 | |
Section.component.section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.component.section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
should-author | warning | Section.entry:longCareWound.observation | SHOULD contain author : author.exists() | |
should-text-ref-value | warning | Section.entry:longCareWound.observation | SHOULD contain text/reference/@value : text.reference.value.exists() |
This structure is derived from Section
Summary
Mandatory: 9 elements(4 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:section | 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 | Physical findings Narrative | |
@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 profile:observation | |
entry:longCareWound | 0..* | Entry | ||
observation | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources | |
component | 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 |
Path | Conformance | ValueSet | URI |
Section.component.section.code | preferred | PhysicalExamType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:section | 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 | Physical findings Narrative Binding: DocumentSectionType (example) | |
@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 profile:observation | |
entry:longCareWound | 0..* | Entry | ||
observation | C | 1..1 | LongitudinalCareWoundObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-author: SHOULD contain author |
component | 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 |
Path | Conformance | ValueSet | URI |
Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
Section.component.section.code | preferred | PhysicalExamType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 |
Id | Grade | Path(s) | Details | Requirements |
should-author | warning | Section.entry:longCareWound.observation | SHOULD contain author : author.exists() | |
should-text-ref-value | warning | Section.entry:longCareWound.observation | SHOULD contain text/reference/@value : text.reference.value.exists() |
Snapshot View
Path | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.entry:longCareWound.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:longCareWound.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.entry:longCareWound.typeCode | required | XActRelationshipEntryhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntry | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.component.section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.component.section.code | preferred | PhysicalExamType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.65 | |
Section.component.section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.component.section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
should-author | warning | Section.entry:longCareWound.observation | SHOULD contain author : author.exists() | |
should-text-ref-value | warning | Section.entry:longCareWound.observation | SHOULD contain text/reference/@value : text.reference.value.exists() |
This structure is derived from Section
Summary
Mandatory: 9 elements(4 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices: