["Physical Exam, Performed": "Weight"]
Data Element Scope: This value set may use a model element related to Physical Exam.
Inclusion Criteria: Includes concepts that represent a physical exam with a patient weight measurement.
Exclusion Criteria: Excludes concepts that represent an ideal body weight, estimated body weight or a body fat measurement.
Constrained to codes in the Weight value set (2.16.840.1.113883.3.464.1003.121.12.1015)
"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:
- 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.
relevantDateTime
relevantPeriod
relevantPeriod addresses the time between the start of an action to the end of an action. Each QDM datatype using relevantPeriod 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 datatype-related 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)