1.3.6.1.4.1.19376.1.5.3.1.1.9.15

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Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at https://www.ihe.net/resources/technical_frameworks/#pcc

Trial.gif Physical Exam Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Parent Template 1.3.6.1.4.1.19376.1.5.3.1.3.24 (1.3.6.1.4.1.19376.1.5.3.1.3.24)
General Description The physical exam section shall contain only the required and optional subsections performed.
LOINC Code Opt Description
29545-1 R PHYSICAL EXAMINATION
Entries Opt Description
Subsections Opt Description
1.3.6.1.4.1.19376.1.5.3.1.3.25 O Vital Signs
Vital signs may be a subsection of the physical exam or they may stand alone
1.3.6.1.4.1.19376.1.5.3.1.1.9.16 O General Appearance
1.3.6.1.4.1.19376.1.5.3.1.1.9.48 O Visible Implanted Medical Devices
1.3.6.1.4.1.19376.1.5.3.1.1.9.17 O Integumentary System
1.3.6.1.4.1.19376.1.5.3.1.1.9.18 O Head
1.3.6.1.4.1.19376.1.5.3.1.1.9.19 O Eyes
1.3.6.1.4.1.19376.1.5.3.1.1.9.20 O Ears, Nose, Mouth and Throat
1.3.6.1.4.1.19376.1.5.3.1.1.9.21 O Ears
1.3.6.1.4.1.19376.1.5.3.1.1.9.22 O Nose
1.3.6.1.4.1.19376.1.5.3.1.1.9.23 O Mouth, Throat, and Teeth
1.3.6.1.4.1.19376.1.5.3.1.1.9.24 O Neck
1.3.6.1.4.1.19376.1.5.3.1.1.9.25 O Endocrine System
1.3.6.1.4.1.19376.1.5.3.1.1.9.26 O Thorax and Lungs
1.3.6.1.4.1.19376.1.5.3.1.1.9.27 O Chest Wall
1.3.6.1.4.1.19376.1.5.3.1.1.9.28 O Breasts
1.3.6.1.4.1.19376.1.5.3.1.1.9.29 O Heart
1.3.6.1.4.1.19376.1.5.3.1.1.9.30 O Respiratory System
1.3.6.1.4.1.19376.1.5.3.1.1.9.31 O Abdomen
1.3.6.1.4.1.19376.1.5.3.1.1.9.32 O Lymphatic System
1.3.6.1.4.1.19376.1.5.3.1.1.9.33 O Vessels
1.3.6.1.4.1.19376.1.5.3.1.1.9.34 O Musculoskeletal System
1.3.6.1.4.1.19376.1.5.3.1.1.9.35 O Neurologic System
1.3.6.1.4.1.19376.1.5.3.1.1.9.36 O Genitalia
1.3.6.1.4.1.19376.1.5.3.1.1.9.37 O Rectum
1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1 O Extremeties



Parent Template

The parent of this template is 1.3.6.1.4.1.19376.1.5.3.1.3.24.

Sample Physical Exam Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
    <id root=' ' extension=' '/>
    <code code='29545-1' displayName='PHYSICAL EXAMINATION'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>  
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Optional Vital Signs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.16'/>
        <!-- Optional General Appearance Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.48'/>
        <!-- Optional Visible Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.17'/>
        <!-- Optional Integumentary System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.18'/>
        <!-- Optional Head Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.19'/>
        <!-- Optional Eyes Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.20'/>
        <!-- Optional Ears, Nose, Mouth and Throat Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.21'/>
        <!-- Optional Ears Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.22'/>
        <!-- Optional Nose Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.23'/>
        <!-- Optional Mouth, Throat, and Teeth Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.24'/>
        <!-- Optional Neck Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.25'/>
        <!-- Optional Endocrine System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.26'/>
        <!-- Optional Thorax and Lungs Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.27'/>
        <!-- Optional Chest Wall Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.28'/>
        <!-- Optional Breasts Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.29'/>
        <!-- Optional Heart Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.30'/>
        <!-- Optional Respiratory System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.31'/>
        <!-- Optional Abdomen Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.32'/>
        <!-- Optional Lymphatic System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.33'/>
        <!-- Optional Vessels Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.34'/>
        <!-- Optional Musculoskeletal System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.35'/>
        <!-- Optional Neurologic System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.36'/>
        <!-- Optional Genitalia Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.37'/>
        <!-- Optional Rectum Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1'/>
        <!-- Optional Extremeties Section content -->
      </section>
    </component>

       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9.15'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Physical Exam can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     Error: The parent template identifier for Physical Exam is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "29545-1"]'> 
     Error: The section type code of a Physical Exam must be 29545-1 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.16"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) General Appearance Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.48"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Visible Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Integumentary System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Head Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.19"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Eyes Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.20"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Ears, Nose, Mouth and Throat Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.21"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Ears Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.22"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Nose Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.23"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Mouth, Throat, and Teeth Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.24"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Neck Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Endocrine System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.26"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Thorax and Lungs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.27"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Chest Wall Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.28"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Breasts Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.29"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Heart Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.30"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Respiratory System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.31"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Abdomen Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.32"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Lymphatic System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.33"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Vessels Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.34"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Musculoskeletal System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.35"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Neurologic System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.36"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Genitalia Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.37"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Rectum Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Exam Section does not contain a(n) Extremeties Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9.15
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Physical Exam Section


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