Template 2.16.840.1.113883.10.20.2.10 Physical Exam Section

2012‑01‑12

Template 2.16.840.1.113883.10.20.2.10 - PhysicalExamSection
Id 2.16.840.1.113883.10.20.2.10
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.2.10
Label conf‑672
Version valid from 2012‑01‑12 status draft
Description The Physical Exam section includes direct observations made by the clinician. The examination may include the use of simple instruments and may also describe simple maneuvers performed directly on the patient’s body. This section includes only observations made by the examining clinician using 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: Vital Signs, General Status, and those listed in the Additional Physical Examination Subsections appendix.
Used in 1 template:

Id Name as of
2.16.840.1.113883.10.20.22.1.4 ConsultationNote  Consultation Note 2012‑01‑12
Item DT Card Conf Desc Label
cda:section
conf-672
treetree cda:templateId
II 1..1 M conf‑7806
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.2.10
treetree cda:code
CE 1..1 M conf‑7807
treeblank treetree @code
1..1 F 29545-1
treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.6.1
treeblank treetree @displayName
1..1 F Physical Findings
treetree cda:title
ST 1..1 M conf‑7808
treetree cda:text
ED 1..1 M conf‑7809