StructureDefinition-2.16.840.1.113883.10.20.22.1.14

Sourcehl7.cda.us.ccda#current:Consolidated CDA Release 2.1 StructureDefinition Publication (v5.0.0)
resourceTypeStructureDefinition
id2.16.840.1.113883.10.20.22.1.14
canonicalhttp://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.14
version2.1
statusactive
publisherHealth Level Seven
nameReferralNote
titleReferral Note
date2023-08-24T14:33:15+00:00
descriptionA Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery. Examples of referral situations are when a patient is referred from a family physician to a cardiologist for cardiac evaluation or when patient is sent by a cardiologist to an emergency department for angina or when a patient is referred by a nurse practitioner to an audiologist for hearing screening or when a patient is referred by a hospitalist to social services.
jurisdictionsus
fhirVersion5.0.0
kindlogical
abstractfalse
sdTtypehttp://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument
derivationconstraint
basehttp://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.1
Usages(none)
Name Flags Card. Type Description & Constraints doco
. . ClinicalDocument USRealmHeaderV4 XML Namespace: urn:hl7-org:v3
This logical model cannot be the target of a reference
. . . Slices for templateId 1 .. Slice: Unordered, Open by value:root, value:extension
. . . . templateId:primary 1..1
. . . . . root 1..1 Required Pattern: 2.16.840.1.113883.10.20.22.1.14
. . . . . extension 1..1 Required Pattern: 2015-08-01
. . . code 1..1 The Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType ( required )
. . . informationRecipient 1..1
. . . . intendedRecipient 1..1
. . . . . addr 0..*
. . . . . telecom 0..*
. . . . . informationRecipient 1..1
. . . . . . name 1..* http://hl7.org/cda/stds/core/StructureDefinition/PN
. . . Slices for participant This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
Slice: Unordered, Open by value:typeCode
. . . . participant:participant1 0..*
. . . . . typeCode 1..1 Fixed Value: IND
. . . . . associatedEntity 1..1
. . . . . . classCode 1..1 Binding: INDRoleclassCodes ( required )
. . . . . . associatedPerson 1..1
. . . . . . . name 1..* http://hl7.org/cda/stds/core/StructureDefinition/PN
. . . . participant:participant2 0..*
. . . . . typeCode 1..1 Fixed Value: CALLBCK
. . . . . associatedEntity 1..1
. . . . . . classCode 1..1 Fixed Value: ASSIGNED
. . . . . . id 1..*
. . . . . . addr 0..*
. . . . . . telecom 1..*
. . . . . . associatedPerson 1..1
. . . . . . . name 1..*
. . . . . . scopingOrganization 0..1
. . . component 1 .. 1 Slice: Unordered, Open by value:section.code
. . . . component:All Slices Content/Rules for all slices
. . . . . structuredBody C 1..1 1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
1198-29103: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
. . . . . . Slices for component 1 .. 1 Slice: Unordered, Open by value:section.code
. . . . . . . component:planOfTreatment 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:advanceDirectives 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:historyOfPresentIllness 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:familyHistory 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:immunizations 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:problem 1..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:procedures 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:results 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:reviewOfSystems 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:socialHistory 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:vitalSigns 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:functionalStatus 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:physicalExam 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:nutrition 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:mentalStatus 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:medicalEquip 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:allergiesAndIntolerances 1..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:assessment 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:assessmentAndPlan 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:medicalHistory 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:generalStatus 0..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:medications 1..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:reasonForReferral 1..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section
. . . . . . . component:payers 1..1
. . . . . . . . section 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Section

doco Documentation for this format

Produced 08 Sep 2023