1.3.6.1.4.1.19376.1.5.3.1.1.9.15
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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.
<component> <section> |
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>
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