Left: | Physical Exam Section (http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection) |
Right: | Physical Exam Section (http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection) |
Error | StructureDefinition.version | Values for version differ: '3.0.0' vs '4.0.0-ballot' |
Information | StructureDefinition.date | Values for date differ: '2024-05-18T00:16:25-05:00' vs '2024-11-21T20:34:36+00:00' |
Name | Value | Comments | |
---|---|---|---|
abstract | false | ||
baseDefinition | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
copyright | |||
date | 2024-05-18T00:16:25-05:00 | 2024-11-21T20:34:36+00:00 |
|
description | 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. | ||
experimental | |||
fhirVersion | 5.0.0 | ||
jurisdiction | |||
jurisdiction[0] | urn:iso:std:iso:3166#US | ||
kind | logical | ||
name | PhysicalExamSection | ||
publisher | Health Level Seven | ||
purpose | |||
status | draft | ||
title | Physical Exam Section | ||
type | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
url | http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection | ||
version | 3.0.0 | 4.0.0-ballot |
|
Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments |
---|---|---|---|---|---|---|---|---|---|
Section | 1..1 | Section | Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | 1..1 | Section | Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | 0..1 | ?? | Binding: ?? (required) | |||
realmCode | 0..* | CS | 0..* | CS | |||||
typeId | 0..1 | II | 0..1 | II | |||||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | 0..1 | ?? | Binding: ?? (required) | |||
assigningAuthorityName | 0..1 | ?? | 0..1 | ?? | |||||
displayable | 0..1 | ?? | 0..1 | ?? | |||||
root | 1..1 | ??, ??, ?? | Fixed Value: 2.16.840.1.113883.1.3 | 1..1 | ??, ??, ?? | Fixed Value: 2.16.840.1.113883.1.3 | |||
st-simple | 1..1 | string | Primitive Type string URL: http://hl7.org/cda/stds/core/StructureDefinition/st-simple | 1..1 | string | Primitive Type string URL: http://hl7.org/cda/stds/core/StructureDefinition/st-simple | |||
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |||
ID | 0..1 | ?? | 0..1 | ?? | |||||
classCode | 0..1 | ?? | Binding: ?? (required) Fixed Value: DOCSECT | 0..1 | ?? | Binding: ?? (required) Fixed Value: DOCSECT | |||
moodCode | 0..1 | ?? | Binding: ?? (required) Fixed Value: EVN | 0..1 | ?? | Binding: ?? (required) Fixed Value: EVN | |||
id | 0..1 | II | 0..1 | II | |||||
code | 1..1 | CE | Physical findings Narrative Binding: ?? (example) | 1..1 | CE | Physical findings Narrative Binding: ?? (example) | |||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | 0..1 | ?? | Binding: ?? (required) | |||
code | 1..1 | ?? | Required Pattern: 29545-1 | 1..1 | ?? | Required Pattern: 29545-1 | |||
codeSystem | 1..1 | ??, ??, ?? | Required Pattern: 2.16.840.1.113883.6.1 | 1..1 | ??, ??, ?? | Required Pattern: 2.16.840.1.113883.6.1 | |||
codeSystemName | 0..1 | ?? | 0..1 | ?? | |||||
codeSystemVersion | 0..1 | ?? | 0..1 | ?? | |||||
displayName | 0..1 | ?? | 0..1 | ?? | |||||
sdtcValueSet | 0..1 | ?? | XML: valueSet (urn:hl7-org:sdtc) | 0..1 | ?? | XML: valueSet (urn:hl7-org:sdtc) | |||
sdtcValueSetVersion | 0..1 | ?? | XML: valueSetVersion (urn:hl7-org:sdtc) | 0..1 | ?? | XML: valueSetVersion (urn:hl7-org:sdtc) | |||
originalText | 0..1 | ED | 0..1 | ED | |||||
qualifier | 0..0 | 0..0 | |||||||
translation | 0..* | CD | 0..* | CD | |||||
title | 1..1 | ST | 1..1 | ST | |||||
text | 1..1 | xhtml | 1..1 | xhtml | |||||
confidentialityCode | 0..1 | CE | 0..1 | CE | |||||
languageCode | 0..1 | CS | Binding: ?? (required) | 0..1 | CS | Binding: ?? (required) | |||
subject | 0..1 | Subject | 0..1 | Subject | |||||
author | 0..* | Author | 0..* | Author | |||||
informant | 0..* | Informant | 0..* | Informant | |||||
Slices for entry | 0..* | Entry | Slice: Unordered, Open by profile:observation | 0..* | Entry | Slice: Unordered, Open by profile:observation | |||
component | 0..* | InfrastructureRoot | 0..* | InfrastructureRoot | |||||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | 0..1 | ?? | Binding: ?? (required) | |||
realmCode | 0..* | CS | 0..* | CS | |||||
typeId | 0..1 | II | 0..1 | II | |||||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | 0..1 | ?? | Binding: ?? (required) | |||
assigningAuthorityName | 0..1 | ?? | 0..1 | ?? | |||||
displayable | 0..1 | ?? | 0..1 | ?? | |||||
root | 1..1 | ??, ??, ?? | Fixed Value: 2.16.840.1.113883.1.3 | 1..1 | ??, ??, ?? | Fixed Value: 2.16.840.1.113883.1.3 | |||
st-simple | 1..1 | string | Primitive Type string URL: http://hl7.org/cda/stds/core/StructureDefinition/st-simple | 1..1 | string | Primitive Type string URL: http://hl7.org/cda/stds/core/StructureDefinition/st-simple | |||
templateId | 0..* | II | 0..* | II | |||||
typeCode | 0..1 | ?? | Fixed Value: COMP | 0..1 | ?? | Fixed Value: COMP | |||
contextConductionInd | 0..1 | ?? | Fixed Value: true | 0..1 | ?? | Fixed Value: true | |||
section | 1..1 | Section | 1..1 | Section | |||||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | 0..1 | ?? | Binding: ?? (required) | |||
realmCode | 0..* | CS | 0..* | CS | |||||
typeId | 0..1 | II | 0..1 | II | |||||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | 0..1 | ?? | Binding: ?? (required) | |||
assigningAuthorityName | 0..1 | ?? | 0..1 | ?? | |||||
displayable | 0..1 | ?? | 0..1 | ?? | |||||
root | 1..1 | ??, ??, ?? | Fixed Value: 2.16.840.1.113883.1.3 | 1..1 | ??, ??, ?? | Fixed Value: 2.16.840.1.113883.1.3 | |||
st-simple | 1..1 | string | Primitive Type string URL: http://hl7.org/cda/stds/core/StructureDefinition/st-simple | 1..1 | string | Primitive Type string URL: http://hl7.org/cda/stds/core/StructureDefinition/st-simple | |||
templateId | 0..* | II | 0..* | II | |||||
ID | 0..1 | ?? | 0..1 | ?? | |||||
classCode | 0..1 | ?? | Binding: ?? (required) Fixed Value: DOCSECT | 0..1 | ?? | Binding: ?? (required) Fixed Value: DOCSECT | |||
moodCode | 0..1 | ?? | Binding: ?? (required) Fixed Value: EVN | 0..1 | ?? | Binding: ?? (required) Fixed Value: EVN | |||
id | 0..1 | II | 0..1 | II | |||||
code | 1..1 | CE | Binding: ?? (preferred) | 1..1 | CE | Binding: ?? (preferred) | |||
title | 1..1 | ST | 1..1 | ST | |||||
text | 1..1 | xhtml | 1..1 | xhtml | |||||
confidentialityCode | 0..1 | CE | 0..1 | CE | |||||
languageCode | 0..1 | CS | Binding: ?? (required) | 0..1 | CS | Binding: ?? (required) | |||
subject | 0..1 | Subject | 0..1 | Subject | |||||
author | 0..* | Author | 0..* | Author | |||||
informant | 0..* | Informant | 0..* | Informant | |||||
entry | 0..* | Entry | 0..* | Entry | |||||
component | 0..* | InfrastructureRoot | 0..* | InfrastructureRoot | |||||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | 0..1 | ?? | Binding: ?? (required) | |||
realmCode | 0..* | CS | 0..* | CS | |||||
typeId | 0..1 | II | 0..1 | II | |||||
nullFlavor | 0..1 | ?? | Binding: ?? (required) | 0..1 | ?? | Binding: ?? (required) | |||
assigningAuthorityName | 0..1 | ?? | 0..1 | ?? | |||||
displayable | 0..1 | ?? | 0..1 | ?? | |||||
root | 1..1 | ??, ??, ?? | Fixed Value: 2.16.840.1.113883.1.3 | 1..1 | ??, ??, ?? | Fixed Value: 2.16.840.1.113883.1.3 | |||
st-simple | 1..1 | string | Primitive Type string URL: http://hl7.org/cda/stds/core/StructureDefinition/st-simple | 1..1 | string | Primitive Type string URL: http://hl7.org/cda/stds/core/StructureDefinition/st-simple | |||
templateId | 0..* | II | 0..* | II | |||||
typeCode | 0..1 | ?? | Fixed Value: COMP | 0..1 | ?? | Fixed Value: COMP | |||
contextConductionInd | 0..1 | ?? | Fixed Value: true | 0..1 | ?? | Fixed Value: true | |||
section | 1..1 | Section | 1..1 | Section | |||||
Documentation for this format |