| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | phy | 0;1 | DATE-TIME | B | Date of Physical Exam. | |
| .02 | height in inches | 0;2 | NUMERIC | Patent's height in inches. | ||
| .03 | weight in pounds | 0;3 | NUMERIC | Patient's weight in pounds. | ||
| .04 | temp.(+) | 0;4 | NUMERIC | Patient's temperature (fahrenheit). | ||
| .05 | pulse(+) | 0;5 | FREE TEXT | Patient's observed pulse. | ||
| .06 | b.p.(+) | 0;6 | FREE TEXT | Patient's Blood Pressure. | ||
| .07 | resps.(+) | 0;7 | NUMERIC | Patient's observed respirations per minute. | ||
| .9 | general appearance(+) | .8;1 | FREE TEXT | Patient's general appearance. | ||
| 2 | head | .9;1 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 2.9 | head ab | 1;9 | FREE TEXT | Abnormalities observed of patient's head. | ||
| 3 | eyes | .9;2 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 3.1 | eom | 2;1 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 3.2 | pupil size | 2;2 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 3.3 | fundi | 2;3 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 3.4 | rla | 2;4 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 3.9 | eyes ab | 2;9 | FREE TEXT | Abnormalities observed of the patient's eyes. | ||
| 4 | ears | .9;3 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 4.1 | hearing | 3;1 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within mormal limits, 2=omitted, 3=abnormal. | |
| 4.2 | external meatus | 3;2 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 4.3 | drums | 3;3 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 4.9 | ears ab | 3;9 | FREE TEXT | Abnormalities observed of the patient's ears. | ||
| 5 | nose | .9;4 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 5.9 | nose ab | 4;9 | FREE TEXT | Abnormalities observed of the patient's nose. | ||
| 6 | mouth | .9;5 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 6.9 | mouth ab | 5;9 | FREE TEXT | Abnormalities observed of the patient's mouth. | ||
| 7 | neck | .9;6 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 7.9 | neck ab | 6;9 | FREE TEXT | Abnormalities observed of the patient's neck. | ||
| 8 | chest and breasts | .9;7 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 8.9 | chest ab | 7;9 | FREE TEXT | Abnormalities observed of the patient's chest and/or breast(s). | ||
| 9 | lungs | .9;8 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 9.9 | lungs ab | 8;9 | FREE TEXT | Abnormalities observed of the patient's lung(s). | ||
| 10 | heart | .9;9 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 10.9 | heart ab | 9;9 | FREE TEXT | Abnormalities observed of the patient's heart. | ||
| 11 | abdomen | .9;10 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 11.9 | abdomen ab | 10;9 | FREE TEXT | Abnormalities observed of the patient's abdomen. | ||
| 12 | genitalia | .9;11 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 12.1 | testes | 11;1 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 12.2 | epididymides | 11;2 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 12.3 | penis | 11;3 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 12.4 | prostate | 11;4 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 12.9 | genitalia ab | 11;9 | FREE TEXT | Abnormalities observed of the patient's genitalia. | ||
| 13 | pelvic | .9;12 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 13.9 | pelvic ab | 12;9 | FREE TEXT | Abnormalities observed of the patient's pelvis/pelvic area. | ||
| 14 | rectum | .9;13 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 14.9 | rectum ab | 13;9 | FREE TEXT | Abnormalities observed of the patient's rectum. | ||
| 15 | back | .9;14 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abmormal. | |
| 15.9 | back ab | 14;9 | FREE TEXT | Abnormalities observed of the patient's back. | ||
| 16 | extremities | .9;15 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 16.9 | extremities ab | 15;9 | FREE TEXT | Abnormalities observed of the patient's extremities. | ||
| 17 | neurological | .9;16 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 17.9 | neurological ab | 16;9 | FREE TEXT | Patient neurological abnormalities observed. | ||
| 18 | skin | .9;17 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 18.9 | skin ab | 17;9 | FREE TEXT | Abnormalities observed of the patient's skin. | ||
| 19 | lymph | .9;18 | SET OF CODES | 1:WITHIN NORMAL LIMITS 2:OMITTED 3:ABNORMAL | Set of Codes: 1=within normal limits, 2=omitted, 3=abnormal. | |
| 19.9 | lymph ab | 18;9 | FREE TEXT | Abnormalities observed of the patient's lymph system. | ||
| 29 | examiner(+) | 0;10 | POINTER | 200 | Enter the name of the person examining the patient. It is stored internally as a pointer value to the NEW PERSON file (#200) for the examiner. | |
| 30 | comments | 19;0 | WORD-PROCESSING | Comments relating to the physical exam. | ||
| 31 | initial impression | 20;0 | WORD-PROCESSING | Examiner's initial impression. | ||
| 32 | height in centimeters | 0;8 | NUMERIC | Patient's height in centimeters. | ||
| 33 | weight in kilograms | 0;9 | NUMERIC | Patient's weight in kilograms. | ||
| 34 | temperature centigrade | 0;11 | NUMERIC | Patient's temperature in centigrades. |
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