"Physical Exam, Performed"
Data elements that meet criteria using this datatype should document the completion of the physical exam indicated by the QDM category and its corresponding value set.
Timing: The Relevant Period addresses:
- startTime – the time the physical examination activity begins
- stopTime – the time the physical examination activity ends
NOTE - timing refers to a single instance of a physical examination activity. If a measure seeks to evaluate multiple physical examination activities over a period of time, the measure developer should use CQL logic to represent the query request.
Physical Exam
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.