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Physical Exam, Performed

Performance/Reporting Period
2021
QDM Datatype (QDM Version 5.5 Guidance Update):

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:

  • relevant dateTime references the time the physical exam is performed when the physical exam occurs at a single point in time.
  • relevantPeriod references a start and stop time for a physical exam that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the physical exam begins.
    • stopTime - The time the physical exam ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • 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.
  • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
QDM Category (QDM Version 5.5 Guidance Update)

Physical Exam

Physical Exam represents the evaluation of the patient's body and/or mental status 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). In the context of quality measurement, the physical exam category is also used to represent calculations based upon measurements (such as body mass index [BMI]). Physical exam includes psychiatric examinations.
QDM Attributes

Anatomical Location Site

The anatomical site or structure
  • Where the diagnosis/problem manifests itself (a).
  • That is the focus of the action represented by the datatype (b).

Author dateTime

The time the data element was entered into the clinical software. Note, some datatypes include both relevant dateTime and author dateTime attributes. When both are present, author dateTime is included to accommodate negation rationale.

The author dateTime addresses when an activity is documented. Documentation can occur at the beginning, during, at the end, or subsequent to the end of the activity. The author dateTime should be used only if the relevantPeriod cannot be obtained or to represent the time negation rationale is documented.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

Components

Elements included or documented as part of evaluations or test panels.
  • Examples include: specific questions included in assesments, tests included in a laboratory test panel, observations included in a cardiac exam during a physical examination. Each assessment, diagnostic study, laboratory test, physical exam, or procedure may have one or more components.
components also reference specific details about an encounter diagnosis.
  • Examples include an "Encounter, Performed" diagnosis that is also present on admission and refers to the principal diagnosis (rank = 1)

Method

Indicates the procedure or technique used in its performance.

Negation Rationale

Indicates the reason that an action was not performed. Only QDM datatypes that represent actions (e.g., performed, recommended, communication, order, dispensed) allow the negation rationale attribute. The intent is to indicate a justification that such action did not happen as expected. This attribute specifically does not address the presence or absence of information in a clinical record (e.g., documented absence of allergies versus lack of documentation about allergies). QDM assumes a world view that absence of evidence indicates information does not exist or an action did not happen. To express such lack of evidence, an eCQM author should use the CQL expression not exists with reference to the data element rather than the QDM data model. negation rationale in QDM signifies only a reason for such absence, i.e., the reason must be present to qualify for negation rationale. The syntax in the human readable HQMF is addressed in CQL examples and in the MAT User Guide. Prior versions of QDM used the syntax, "Procedure, Performed not done." QDM versions starting with 5.3 use the syntax, "Procedure, not Performed." Section A-5 provides examples for expressing negation rationale in CQL.

A QDM Known Issue has been identified related to this attribute. To see this QDM known Issue, please click here.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

Reason

The thought process or justification for the datatype. In some measures, specific treatments are acceptable inclusion criteria only if a justified reason is present. Each of these measures uses a value set (often, but not exclusively, using SNOMED CT) to express acceptable justification reasons. Other measures specify reasons as justification for exclusions. Examples include patient, system, or medical-related reasons for declining to perform specific actions. Each of these measures also uses a value set to express acceptable justification reasons for declining to perform expected actions.

Relevant Period

Relevant Period addresses the time between the start of an action to the end of an action. Each datatype using relevant period defines specific definitions for the start and stop time for the action listed.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatyperelated actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod

Result

The final consequences or data collected from the datatype. results can be used in four ways to express:

  • That a result is present in the electronic record but any entry is acceptable
  • A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units - examples:
    • 100mg/dL for a lab test
    • 140 mmHg for blood pressure
    • as a percentage (actually as a quantity with % as units)
    • as a titer or ratio (e.g., 1:4, 1:80)
  • A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct reference code
  • A result as a dateTime ("Assessment, Performed" and components)
Last Updated: Jun 08, 2020