StructureDefinition-2.16.840.1.113883.10.20.22.1.13

Sourcehl7.cda.us.ccdar2dot2#current:Consolidated CDA Release 2.1 StructureDefinition Publication (v5.0.0)
resourceTypeStructureDefinition
id2.16.840.1.113883.10.20.22.1.13
canonicalhttp://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.13
version2.2
statusactive
publisherHealth Level Seven
nameTransferSummary
titleTransfer Summary
date2021-11-24T17:43:01+00:00
descriptionThis document describes constraints on the Clinical Document Architecture (CDA) header and body elements for a Transfer Summary. The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between health care settings. Standardization of information used in this form will promote interoperability; create information suitable for reuse in quality measurement, public health, research, and for reimbursement.
jurisdictionsus
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeClinicalDocument
derivationconstraint
basehttp://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.1
Usages(none)
Name Flags Card. Type Description & Constraints doco
. . ClinicalDocument USRealmHeader
. . . Slices for templateId Slice: Unordered, Open by value:root, value:extension
. . . . templateId:primary C 1..1 1198-32946: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32946).
. . . . . root 1..1 Required Pattern: 2.16.840.1.113883.10.20.22.1.13
. . . . . extension 1..1 Required Pattern: 2015-08-01
. . . code 1..1 The Transfer Summary recommends use of the document type code 18761-7 "Provider Unspecified Transfer Summary", 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 Transfer Summary note would not be authored by a Pediatric Cardiologist. Pre-coordinated codes are those that indicate the specialty or service provided in the LOINC Long Common Name (Print Name in the TransferDocumentType valueSet table). When using a generic type of code such as 18761-7 (Provider - Unspecified Transfer Summary), the types of services involved in the care are handled in documentationOf/serviceEvent with the use of serviceEvent/code (e.g., use a SNOMED CT procedure code such as 69031006 (Excision of breast tissue) while performers/providers involved in the care can be identified using the functionCode (bound to Healthcare Provider Taxonomy role codes).
Binding: todo ( required )
. . . title 1..1
. . . Slices for participant Slice: Unordered, Open by value:typeCode
. . . . participant:participant1 0..*
. . . . . typeCode 1..1 Required Pattern: IND
. . . . . associatedEntity 1..1
. . . . . . classCode 1..1 Binding: INDRoleclassCodes ( required )
. . . . . . associatedPerson 1..1
. . . . . . . name 1..*
. . . . participant:participant2 0..*
. . . . . typeCode 1..1 Required Pattern: CALLBCK
. . . . . associatedEntity 1..1
. . . . . . classCode 1..1 Required Pattern: ASSIGNED
. . . . . . id 1..*
. . . . . . addr 0..*
. . . . . . telecom 1..*
. . . . . . associatedPerson 1..1
. . . . . . . name 1..*
. . . . . . scopingOrganization 0..1
. . . documentationOf 1..1
. . . . serviceEvent 1..1 The serviceEvent in a Transfer Note contains the representation of providers who are wholly or partially responsible for the safety and well-being of a subject of care.
. . . . . classCode 1..1 Required Pattern: PCPR
. . . . . code 0..1 Use serviceEvent/code when using a generic document type code such as 18761-7 (Provider-Unspecified Transfer Summary) to represent the service.
. . . . . Slices for performer Slice: Unordered, Open by value:typeCode
. . . . . . performer:performer1 1..*
. . . . . . . typeCode 1..1 Required Pattern: PRF
. . . . . . . functionCode 0..1 Use performer/functionCode when using a generic document type code such as 18761-7 (Provider-Unspecified Transfer Summary) to represent the provider.
Binding: Healthcare Provider Taxonomy ( preferred )
. . . component 1..1
. . . . structuredBody C 1..1 1198-31582: 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:1198-31582).
1198-31583: 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:1198-31583).
. . . . . Slices for component 0 .. 1 Slice: Unordered, Open by value:section.code
. . . . . . component:advanceDirectives 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:allergiesAndIntolerances 1..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:physicalExam 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:encounters 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:familyHistory 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:functionalStatus 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:dischargeDiagnosis 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:immunizations 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:medicalEquip 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:medications 1..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:payers 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:planOfTreatment 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:problem 1..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:procedures 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:results 1..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:socialHistory 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:vitalSigns 1..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:mentalStatus 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:generalStatus 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:reviewOfSystems 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:nutrition 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:reasonForReferral 1..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:pastMedicalHistory 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:historyOfPresentIllness 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:assessmentAndPlan 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:assessment 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:admissionMedications 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:admissionDiagnosis 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:courseOfCare 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section

doco Documentation for this format

Produced 08 Sep 2023