DER Reference Model Version 1.0.0
qdm.dataelement

Physical Exam

QDM Definition:

Physical Exam represents the evaluation of the patient's body and/or mental status exam to determine its state of health. The techniques of examination can include palpation (feeling with the hands or fingers), percussion (tapping with the fingers), auscultation (listening), visual inspection or observation, inquisition and smell. Measurements may include vital signs (blood pressure, pulse, respiration) as well as other clinical measures (such as expiratory flow rate and size of lesion). Physical exam includes psychiatric examinations.

Based On: Observation

A statement that asserts the value of a property (observable) of the subject. The subject is often the patient, but may be a condition, a physical structure, or another clinical statement. For example, an interpretation is a finding about an observation.

Direct Descendants: