Physical Exam
Source Object: Physical Exam
Overview and Usage: The "Physical Exam" source object is used in healthcare systems to document and manage physical examination data for patients. It includes various fields to record and categorize the examination findings. Here's a breakdown of the key components:
- LastModifiedBy: Indicates the user or healthcare professional who last modified the physical examination data.
- LastModifiedDateTime: Specifies the date and time when the physical examination data was last modified.
- PhysicalExam: Contains the primary physical examination data.
- PhysicalExam.ParagraphId: Identifies specific paragraphs within the physical exam, allowing for structured organization.
- PhysicalExam.ParagraphName: Describes the name or title of the paragraph within the physical exam.
- PhysicalExam.Sentences: Represents sentences or statements related to the physical examination.
- PhysicalExam.Sentences.SentenceId: Identifies individual sentences within the physical exam.
- PhysicalExam.Sentences.SentenceName: Describes the name or title of each sentence.
- PhysicalExam.Sentences.SentenceNote: Contains additional notes or details about each sentence.
- SectionNote: Provides notes or information specific to a section of the physical exam.
- TemplateData: Refers to data related to the use of templates in documenting the physical examination.
- Templates: Allows the use of predefined templates for consistent documentation.
This source object serves as a valuable tool for healthcare providers to maintain comprehensive and structured records of physical examinations, making it easier to monitor patient health, track changes over time, and provide well-documented care. It can be instrumental in enhancing patient care and ensuring accurate and up-to-date medical records, which are essential for informed decision-making and effective treatment planning.
Mapping Table
| Data Field | Example Value | Source Data Field Description | Source Field Data Type | Source Data Field Cardinality | Mapped FHIR++ Resource | Mapped FHIR Data Field | Augmented Mapping | Associated Coding System | Associated FHIR Data Field Extension | Mapping Context |
|---|---|---|---|---|---|---|---|---|---|---|
| lastmodifiedby | - | \n\t\t\t\tA string representing the username of the user who last modified the physical exam section.\n\t\t | String | 0..1 | Observation | extension[*].valueString | - | - | last-modified-by | Top Level |
| lastmodifieddatetime | - | The last time any information in the physical exam section was modified | String | 0..1 | Observation | extension[*].valueString | - | - | last-modified-date | Top Level |
| physicalexam | - | The structured physical exam data. It is structured as a list of paragraphs, each containing a list of sentences, each containing a list of findings. | Object | 0..* | Observation | extension.[*].valueString (the whole physical exam is stringified into a JSON ) | - | - | physical-exam/physical-exam-template | Top Level |
| physicalexam.paragraphid | - | ID of this paragraph. | Integer | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.paragraphname | - | The label for this paragraph | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences | - | Object | 0..* | Observation | - | - | - | - | Top Level | |
| physicalexam.sentences.findings | - | The list of findings | Object | 0..* | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.contradictionids | - | A string representing an array of finding IDs that contradict the current finding ID. What this means is that if this finding is selected, any findings in the CONTRADICTIONIDS should not be selected. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.findingid | - | ID of this Finding. | Integer | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findingsv.findinglastmodifiedby | - | The username of the provider that last modified the value for this finding. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.findinglastmodifieddatetime | - | The date and time that the value for this finding was last modified. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.findingname | - | The label for this finding. Note that this may contain specific answers for this finding (e.g. "wakes up 2 hours after going to sleep"). See GENERICFINDINGNAME for an example that does not contain specific answers. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.findingnote | - | The note for this finding | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.findingnotelastmodifiedby | - | The username of the provider that last modified the note for this finding. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.findingnotelastmodifieddatetime | - | The date and time that the note for this finding was last modified. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.findingshortname | - | The abbreviated label for this finding | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.findingtype | - | Describes the finding -- either NORMAL, ABNORMAL, or NEUTRAL. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.freetext | - | Freetext for this finding | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.freetextlastmodifiedby | - | The username of the provider that last modified the value of the text field sometimes associated with this finding. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.freetextlastmodifieddatetime | - | The date and time that the value of the text field sometimes associated with this finding was last modified. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.genericfindingname | - | The general label for this finding. It will not contain any specific answers for this finding (e.g. "wakes up ___ {{minutes* | hours}} after going to sleep"). | String | 0..1 | Observation | - | - | - | - |
| physicalexam.sentences.findings.medcinid | - | Where available, the matching MEDCIN ID for this clinical finding. | Integer | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.optionlists | - | An array of arrays. Each inner array contains the possible options for a dropdown list. The order of the these arrays corresponds to the ordering of dropdowns from left to right within the finding. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.selected | - | Whether the finding is selected. If templateids are not passed in, this field will not be returned. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.findings.selectedoptions | - | The options the user has chosen from any dropdowns for this finding. The order of these selections corresponds to the order of the dropdowns from left to right in the finding name. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.sentenceid | - | ID of this sentence. | Integer | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.sentencename | - | The label for this sentence | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.sentencenote | - | The note for this sentence | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.sentencenotelastmodifiedby | - | The username of the provider that last modified the note for this sentence. | String | 0..1 | Observation | - | - | - | - | Top Level |
| physicalexam.sentences.sentencenotelastmodifieddatetime | - | The date and time that the note for this sentence was last modified. | String | 0..1 | Observation | - | - | - | - | Top Level |
| sectionnote | - | The structured section-level note for the physical exam section. | String | 0..1 | Observation | extension.[*].valueString | - | - | physicalexam/section-note | Top Level |
| sectionnotelastmodifiedby | - | \n\t\t\t\tA string representing the username of a the user who last modified the physical exam section note.\n\t\t | String | 0..1 | Observation | extension.[*].valueString | - | - | physical-exam/section-note-last-modified-by | Top Level |
| sectionnotelastmodifieddatetime | - | The last time the physical exam section note was modified | String | 0..1 | Observation | extension.[*].valueString | - | - | physical--exam/section-note-last-modified-datetime | Top Level |
| summarytext | - | The unstructured summary | String | 0..1 | Observation | note.text | - | - | - | Top Level |
| templatedata | - | An array of objects each containing the name and id for physical exam templates attached to the encounter. | Object | 0..* | Observation | extension.[*].valueString ((the whole physical exam is stringified into a JSON )) | - | - | physical-exam/physical-exam-template-data | Top Level |
| templatedata.templateid | - | ID of the template. | Integer | 0..1 | Observation | extension.[*].valueString | - | - | physicalexam/template-id | Top Level |
| templatedata.templatename | - | Name of the template. | String | 0..1 | Observation | extension.[*].valueString | - | - | physicalexam/template-name | Top Level |
| templates | - | The comma separated list of selected physical exam templates used | String | 0..1 | Observation | extension.[*].valueString | - | - | physicalexam/templates | Top Level |