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Physical Exam Section

[Section: templateId 2.16.840.1.113883.10.20.2.10]

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.

  1. SHALL contain exactly one [1..1] templateId ( CONF:10465 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.2.10"
  2. SHALL contain exactly one [1..1] code (CONF:15397)/@code="29545-1" PHYSICAL EXAMINATION (CodeSystem: 2.16.840.1.113883.6.1 LOINC) (CONF:15398)
  3. SHALL contain exactly one [1..1] title (CONF:7808)
  4. SHALL contain exactly one [1..1] text (CONF:7809)
  5. MAY contain zero or more [0..*] entry (CONF:17094, CONF:17095)
    1. Contains exactly one [1..1] Pressure Ulcer Observation (templateId: 2.16.840.1.113883.10.20.22.4.70)
  6. MAY contain zero or more [0..*] entry (CONF:17096, CONF:17097)
    1. Contains exactly one [1..1] Number Of Pressure Ulcers Observation (templateId: 2.16.840.1.113883.10.20.22.4.76)
  7. MAY contain zero or more [0..*] entry (CONF:17098, CONF:17099)
    1. Contains exactly one [1..1] Highest Pressure Ulcer Stage (templateId: 2.16.840.1.113883.10.20.22.4.77)