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pending Template  Physical Exam Section

Template 2.16.840.1.113883.10.20.2.10 - PhysicalExamSection
Id 2.16.840.1.113883.10.20.2.10
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Section Level Template
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.2.10
Open/Closed Open (other than defined elements are allowed)
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 by / Uses
Used by / Uses 7 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.1.3 Containment HistoryandPhysical History and Physical 2013‑01‑31
2.16.840.1.113883.10.20.22.1.4 Containment ConsultationNote Consultation Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.6 Containment ProcedureNote Procedure Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.9 Containment ProgressNote Progress Note 2013‑01‑31
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.4.70 Containment PressureUlcerObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.76 Containment NumberofPressureUlcersObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.77 Containment HighestPressureUlcerStage DYNAMIC
Item DT Card Conf Description Label
cda:section
(PhysicalExamSection)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:7806) such that it conf‑7806
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.2.10
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:15397). conf‑15397
treeblank treetree @code
1 .. 1 F 29545-1
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
treetree cda:title
1 .. 1 M SHALL contain exactly one [1..1] title (CONF:7808). conf‑7808
treetree cda:text
1 .. 1 M SHALL contain exactly one [1..1] text (CONF:7809). conf‑7809
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.70']]
0 .. * conf‑17094
  Contains 2.16.840.1.113883.10.20.22.4.70 Pressure Ulcer Observation (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.76']]
0 .. * conf‑17096
  Contains 2.16.840.1.113883.10.20.22.4.76 Number of Pressure Ulcers Observation (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.77']]
0 .. * conf‑17098
  Contains 2.16.840.1.113883.10.20.22.4.77 Highest Pressure Ulcer Stage (DYNAMIC)