Domain
EHR, ICD-10, LOINC, SNOMED CT, patient care and clinical documentation
16,101 clinical terms
Calendar date on which a physical examination record was most recently updated in the clinical system. Used in audit logging, data governance, and change tracking workflows to identify when examination findings were altered and ensure the integrity of longitudinal patient records.
Timestamp indicating the precise time of day when a physical examination record was last modified. Used alongside the modified date field in clinical audit trails to provide a complete chronological record of changes to examination findings and support data integrity and compliance requirements.
Display label representing the name or title of a physical examination finding, assessment component, or examination type. Used in clinical interfaces and reports to present examination data in a readable format, supporting clinician documentation, patient chart review, and clinical summary generation.
Free-text annotation recorded by a clinician in association with a physical examination finding. Used to capture nuanced observations, clinical context, or follow-up considerations that supplement structured examination data within patient encounter records and clinical documentation workflows.
Unique numeric identifier assigned to a physical examination record within clinical systems. Used to distinguish individual physical exam encounters across EHR, billing, and clinical data platforms, enabling accurate tracking and cross-system reconciliation of examination records.
The date on which symptoms or conditions documented during a physical examination first appeared. Captured in clinical records to establish disease timeline, support diagnostic coding, and inform treatment planning based on condition duration prior to the exam encounter.
The peripheral oxygen saturation percentage measured via pulse oximetry during a physical examination. This vital sign reflects the proportion of oxygenated hemoglobin in the blood and is used to assess respiratory function and detect hypoxemia in clinical settings.
The dollar amount reimbursed or paid by a payer for services rendered during a physical examination encounter. Captured in claims and billing systems to reconcile payment against billed charges and track financial settlement for preventive or diagnostic exam services.
The date on which payment was issued by a payer for a physical examination claim. Recorded in claims adjudication and revenue cycle systems to track reimbursement timelines, reconcile accounts receivable, and monitor payer payment performance for exam services.
The higher-level record or entity to which a physical examination finding is hierarchically linked. Used in clinical data structures to associate subordinate exam components or observations with their originating encounter, episode of care, or parent diagnostic record.
A proportional value expressed as a percentage within a physical examination record, such as percentage of body surface affected, range of motion percentage, or functional capacity. Used in clinical documentation to quantify findings relative to a defined baseline or normal reference value.
The defined time interval associated with a physical examination, such as the coverage period for a required annual exam or the duration over which episodic symptoms were evaluated. Used in member health management and preventive care tracking to ensure compliance with examination schedules.
The telephone contact number associated with a physical examination record, typically belonging to the patient, ordering provider, or facility. Used in clinical administration and care coordination workflows to facilitate follow-up communication related to physical exam results or scheduling.
The preferred display label or alias associated with a physical examination type or finding, used to present clinical data in a human-readable format within EHR and reporting interfaces. Supports standardized naming conventions across clinical documentation and health data systems.
The billed or contracted cost associated with a physical examination service. Captured in claims and fee schedule systems to reflect the charge submitted by a provider for performing the exam, used in cost analysis, contract compliance, and healthcare cost benchmarking workflows.
A flag designating whether a physical examination finding or record is the primary focus of a clinical encounter. Used in diagnostic coding and clinical documentation to distinguish principal findings from secondary observations, supporting accurate ICD coding and claims prioritization.
A ranking value indicating the urgency or clinical importance assigned to a physical examination finding or follow-up action. Used in care management workflows to sequence clinical responses, triage abnormal results, and allocate resources based on the severity of examination outcomes.
The date on which a procedure identified or performed during a physical examination was carried out. Recorded in clinical and claims systems to establish the service date for procedural billing, care timeline construction, and compliance with preventive care scheduling requirements.
The heart rate in beats per minute measured during a physical examination, representing a core vital sign. Documented in clinical records to assess cardiovascular function, detect arrhythmias or hemodynamic instability, and establish baseline health status for the patient encounter.
The numeric count or measured volume associated with a physical examination finding, such as the number of lesions identified, units of a substance measured, or frequency of an observed event. Used in clinical documentation to quantify examination results for diagnostic and reporting purposes.