1.3.6.1.4.1.19376.1.5.3.1.3.24: Difference between revisions

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{{CDA Section|Physical Exam|1.3.6.1.4.1.19376.1.5.3.1.3.24|Draft|The physical exam section shall contain a narrative description of the patient’s physical findings.
{{CDA Section|Physical Exam|1.3.6.1.4.1.19376.1.5.3.1.3.24|Trial|The physical exam section shall contain a narrative description of the patient’s physical findings.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.3.24|PHYSICAL EXAM.TOTAL|R|22029-3}}
|LOINC=29545-1|LOINCName=PHYSICAL EXAMINATION
}}
 
{{CDA Section|Physical Exam|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Draft|The physical exam section shall contain only the required and optional subsections performed.
|Parent=1.3.6.1.4.1.19376.1.5.3.1.3.24|ParentName=1.3.6.1.4.1.19376.1.5.3.1.3.24
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|PHYSICAL EXAM.TOTAL|R|22029-3}}
|Subsections=
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Vital Signs|R|1.3.6.1.4.1.19376.1.5.3.1.3.49}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|General Appearance|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.16}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Visible Implanted Medical Devices|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.48}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Integumentary System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.17}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Head|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.18}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Eyes|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.19}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Ears, Nose, Mouth and Throat|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.20}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Ears|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.21}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Nose|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.22}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Mouth, Throat, and Teeth|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.23}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Neck|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.24}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Endocrine System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.25}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Thorax and Lungs|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.26}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Chest Wall|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.27}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Breasts|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.28}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Heart|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.29}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Respiratory System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.30}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Abdomen|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.31}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Lymphatic System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.32}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Vessels|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.33}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Musculoskeletal System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.34}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Neurologic System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.35}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Genitalia|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.36}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|Rectum|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.37}}
}}
 
{{CDA Section|Hospital Discharge Physical Exam|1.3.6.1.4.1.19376.1.5.3.1.3.26|Draft|The hospital discharge physical exam section shall contain a narrative description of the patient’s physical findings at discharge from a hospital facility.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.3.26|HOSPITAL DISCHARGE PHYSICAL|R|10184-0}}
}}
 
{{CDA Section|Vital Signs|1.3.6.1.4.1.19376.1.5.3.1.3.25|Draft|The vital signs section shall contain a narrative description of the measurement results of a patient’s vital signs.
|Parent=2.16.840.1.113883.10.20.1.16|ParentName=CCD 3.12
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.3.25|VITAL SIGNS|R|8716-3}}
}}
 
{{CDA Section|Vital Signs|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|Draft|The vital signs section contains coded measurement results of a patient’s vital signs.
|Parent=1.3.6.1.4.1.19376.1.5.3.1.3.25|ParentName=Vital Signs
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|VITAL SIGNS|R|8716-3}}
|Entry=
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|Vital Signs Organizer|R|1.3.6.1.4.1.19376.1.5.3.1.4.13.1}}
}}
 
{{CDA Section|General Appearance|1.3.6.1.4.1.19376.1.5.3.1.1.9.16|Draft|The general appearance section shall contain a description of the overall, visibly-apparent condition of the patient.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.16|GENERAL STATUS|R|10210-3}}
}}
 
{{CDA Section|Visible Implanted Medical Devices|1.3.6.1.4.1.19376.1.5.3.1.1.9.48|Draft|The visible implanted medical devices section shall contain a description of the medical devices apparent on physical exam that have been inserted into the patient, whether internal or partially external.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.48|GENERAL STATUS|R|10210-3}}
}}
 
{{CDA Section|Integumentary System|1.3.6.1.4.1.19376.1.5.3.1.1.9.17|Draft|The integumentary system section shall contain a description of any type of integumentary system exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.17|INTEGUMENTARY SYSTEM|R|29302-7}}
}}
 
{{CDA Section|Head|1.3.6.1.4.1.19376.1.5.3.1.1.9.18|Draft|The head section shall contain a description of any type of head exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.18|HEAD|R|10199-8}}
}}
 
{{CDA Section|Eyes|1.3.6.1.4.1.19376.1.5.3.1.1.9.19|Draft|The eyes section shall contain a description of any type of eye exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.19|EYE|R|10197-2}}
}}
 
{{CDA Section|Ears, Nose, Mouth and Throat|1.3.6.1.4.1.19376.1.5.3.1.1.9.20|Draft|The ears, nose, mouth, and throat section shall contain a description of any type of ears, nose, mouth, or throat exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.20|EARS & NOSE & MOUTH & THROAT|R|11393-6}}
}}
 
{{CDA Section|Ears, Nose, Mouth and Throat|1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1|Draft|The ears, nose, mouth, and throat section shall contain a description of any type of ears, nose, mouth, or throat exam. It shall contain sub-sections on ears, nose, mouth, throat, and teeth.
|Parent=1.3.6.1.4.1.19376.1.5.3.1.1.9.20|ParentName=Ears, Nose, Mouth and Throat
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1|EARS & NOSE & MOUTH & THROAT|R|11393-6}}
|Subsections=
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1|Ears|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.21}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1|Nose|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.22}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1|Mouth, Throat, and Teeth|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.23}}
}}
 
{{CDA Section|Ears|1.3.6.1.4.1.19376.1.5.3.1.1.9.21|Draft|The ears section shall contain a description of any type of ear exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.21|EAR|R|10195-6}}
}}
 
{{CDA Section|Nose|1.3.6.1.4.1.19376.1.5.3.1.1.9.22|Draft|The nose section shall contain a description of any type of nose exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.22|NOSE|R|10203-8}}
}}
 
{{CDA Section|Mouth, Throat and Teeth|1.3.6.1.4.1.19376.1.5.3.1.1.9.23|Draft|The mouth, throat, and teeth section shall contain a description of any type of mouth, throat, or teeth exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.23|MOUTH & THROAT & TEETH|R|10201-2}}
}}
 
{{CDA Section|Neck|1.3.6.1.4.1.19376.1.5.3.1.1.9.24|Draft|The neck section shall contain a description of any type of neck exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.24|NECK|R|11411-6}}
}}
 
{{CDA Section|Endocrine System|1.3.6.1.4.1.19376.1.5.3.1.1.9.25|Draft|The endocrine system section shall contain a description of any type of endocrine system exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.25|ENDOCRINE SYSTEM|R|29307-6}}
}}
 
{{CDA Section|Thorax and Lungs|1.3.6.1.4.1.19376.1.5.3.1.1.9.26|Draft|The thorax and lungs section shall contain a description of any type of thoracic or lung exams.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.26|THORAX+LUNGS|R|10207-9}}
}}
 
{{CDA Section|Thorax and Lungs|1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1|Draft|The thorax and lungs section shall contain a description of any type of thoracic or lung exams.
|Parent=1.3.6.1.4.1.19376.1.5.3.1.1.9.26|ParentName=Thorax and Lungs
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1|THORAX+LUNGS|R|10207-9}}
|Subsections=
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1|Chest Wall|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.27}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1|Breasts|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.28}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1|Heart|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.29}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1|Respiratory System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.30}}
}}
 
{{CDA Section|Chest Wall|1.3.6.1.4.1.19376.1.5.3.1.1.9.27|Draft|The chest wall section shall contain a description of any type of chest wall exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.27|CHEST WALL|R|11392-8}}
}}
 
{{CDA Section|Breast|1.3.6.1.4.1.19376.1.5.3.1.1.9.28|Draft|The breast section shall contain a description of any type of breast exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.28|BREASTS|R|10193-1}}
}}
 
{{CDA Section|Heart|1.3.6.1.4.1.19376.1.5.3.1.1.9.29|Draft|The heart section shall contain a description of any type of heart exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.29|HEART|R|10200-4}}
}}
 
{{CDA Section|Respiratory System|1.3.6.1.4.1.19376.1.5.3.1.1.9.30|Draft|The respiratory system section shall contain a description of any type of respiratory exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.30|RESPIRATORY SYSTEM|R|11412-4}}
}}
 
{{CDA Section|Abdomen|1.3.6.1.4.1.19376.1.5.3.1.1.9.31|Draft|The abdomen system section shall contain a description of any type of abdominal exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.31|ABDOMEN|R|10191-5}}
}}
 
{{CDA Section|Lymphatic System|1.3.6.1.4.1.19376.1.5.3.1.1.9.32|Draft|The lymphatic system section shall contain a description of any type of lymphatic exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.32|HEMATOLOGIC+LYMPHATIC+IMMUNOLOGIC SYSTEM|R|11447-0}}
}}
 
{{CDA Section|Vessels|1.3.6.1.4.1.19376.1.5.3.1.1.9.33|Draft|The vessels section shall contain a description of any type of vessels exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.33|VESSELS|R|10208-7}}
}}
 
{{CDA Section|Musculoskeletal System|1.3.6.1.4.1.19376.1.5.3.1.1.9.34|Draft|The musculoskeletal system section shall contain a description of any type of musculoskeletal exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.34|MUSCULOSKELETAL SYSTEM|R|11410-8}}
}}
 
{{CDA Section|Neurologic System|1.3.6.1.4.1.19376.1.5.3.1.1.9.35|Draft|The neurologic system section shall contain a description of any type of neurologic exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.35|NEUROLOGIC SYSTEM|R|10202-0}}
}}
 
{{CDA Section|Genitalia|1.3.6.1.4.1.19376.1.5.3.1.1.9.36|Draft|The genitalia section shall contain a description of any type of genital exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.36|GENITALIA|R|11400-9}}
}}
 
{{CDA Section|Rectum|1.3.6.1.4.1.19376.1.5.3.1.1.9.37|Draft|The rectum section shall contain a description of any type of rectal exam.
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.9.37|RECTUM|R|10205-3}}
}}
}}

Latest revision as of 14:20, 23 August 2007

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

Physical Exam Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.24
General Description The physical exam section shall contain a narrative description of the patient’s physical findings.
LOINC Code Opt Description
29545-1 R PHYSICAL EXAMINATION



Sample Physical Exam Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
    <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>  
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.24'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- 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 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> 
 </rule> 
</pattern>
Uses

See Templates using the Physical Exam Section


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