StructureDefinition-Consultation-Note

Sourcehl7.fhir.us.ccda#current:C-CDA on FHIR (v4.0.1)
resourceTypeStructureDefinition
idConsultation-Note
canonicalhttp://hl7.org/fhir/us/ccda/StructureDefinition/Consultation-Note
version1.2.0-ballot
statusactive
publisherHL7 Structured Documents Working Group
nameConsultationNote
titleConsultation Note
date2023-03-27T20:25:00+00:00
descriptionThe Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter. A Consultation Note includes the reason for the referral, history of present illness, physical examination, and decision-making components (Assessment and Plan).
jurisdictionsus
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeComposition
derivationconstraint
basehttp://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header
Usages
Name Flags Card. Type Description & Constraints doco
. . Composition USRealmHeader
. . . type S Consultation Note
Binding: ConsultDocumentType ( required )
. . . encounter S 1.. encompassingEncounter
. . . Slices for section Slice: Unordered, Open by value:code
. . . . section:allergies_and_intolerances_section S 1..1 Allergies and Intolerances Section
. . . . . title S 1.. title
. . . . . code S 1.. Allergies and adverse reactions
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:allergy_intolerance_entry S Reference (US Core AllergyIntolerance Profile)
. . . . section:history_of_present_illness_section S 1..1 History of Present Illness Section
. . . . . title S 1.. title
. . . . . code S 1.. History of present illness
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
. . . . . text S 1.. This section contains only human readable content
. . . . section:problem_section 1..1 Problem Section
. . . . . title S 1.. title
. . . . . code S 1.. Problem list
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
. . . . . text 1.. Narrative text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:problem_section_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:medications_section ..1 Medications Section
. . . . . title 1.. title
. . . . . code 1.. History of medication use
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference ( MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)
. . . . section:physical_exam_section ..1 Physical Exam Section
. . . . . title 1.. title
. . . . . code 1.. Physical findings
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference ( Observation ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:results_section ..1 Results Section
. . . . . title 1.. title
. . . . . code 1.. Relevant diagnostic tests/laboratory data
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (US Core Laboratory Result Observation Profile)
. . . . section:advance_directives_section S ..1 Advance Directives Section
. . . . . title S 1.. title
. . . . . code S 1.. Advance directives
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 42348-3
. . . . . text S 1.. text
. . . . . Slices for entry Slice: Unordered, Open by profile:resolve()
. . . . . . entry:advance_directive_entry S Reference ( Consent )
. . . . section:assessment_and_plan_section ..1 Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
. . . . . title 1.. title
. . . . . code 1.. Assessment (evaluation) and plan
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51847-2
. . . . . text 1.. text
. . . . . Slices for entry Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition | Observation | Communication ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:assessment_section ..1 Assessment Section
. . . . . title 1.. title
. . . . . code 1.. Assessments (evaluation)
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51848-0
. . . . . text 1.. This section contains only human readable content
. . . . section:chief_complaint_and_reason_for_visit_section ..1 Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
. . . . . title 1.. title
. . . . . code 1.. Chief complaint and reason for visit
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46239-0
. . . . . text 1.. This section contains only human readable content
. . . . section:chief_complaint_section ..1 Chief Complaint Section
. . . . . title 1.. title
. . . . . code 1.. Chief complaint
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
. . . . . text 1.. This section contains only human readable content
. . . . section:family_history_section ..1 Family History Section
. . . . . title 1.. title
. . . . . code 1.. Family history
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference ( FamilyMemberHistory ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:functional_status_section ..1 Functional Status Section
. . . . . title 1.. title
. . . . . code 1.. Functional status
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47420-5
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference ( Observation ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:general_status_section ..1 General Status Section
. . . . . title 1.. title
. . . . . code 1.. Physical findings of General status
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10210-3
. . . . . text 1.. This section contains only human readable content
. . . . section:past_medical_history_section ..1 Past Medical History Section
. . . . . title 1.. title
. . . . . code 1.. Past Medical History
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:immunizations_section ..1 Immunizations Section
. . . . . title 1.. title
. . . . . code 1.. History of immunization
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (US Core Immunization Profile)
. . . . section:medical_equipment_section ..1 Medical Equipment Section
. . . . . title 1.. title
. . . . . code 1.. History of medical device use
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46264-8
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:medical_equipment_entry S Reference ( Device | US Core Procedure Profile) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:mental_status_section ..1 Mental Status Section
. . . . . title 1.. title
. . . . . code 1.. Mental status
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10190-7
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference ( Observation ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:nutrition_section ..1 Nutrition Section
. . . . . title 1.. title
. . . . . code 1.. Diet and nutrition
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 61144-2
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference ( NutritionOrder | ClinicalImpression ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:plan_of_treatment_section ..1 Plan of Treatment Section
. . . . . title 1.. title
. . . . . code 1.. Plan of treatment
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:procedures_section ..1 Procedures Section
. . . . . title 1.. title
. . . . . code 1.. History of Procedures
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (US Core Procedure Profile)
. . . . section:reason_for_visit_section ..1 Reason for Visit Section
. . . . . title 1.. title
. . . . . code 1.. Reason for visit
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29299-5
. . . . . text 1.. This section contains only human readable content
. . . . section:review_of_systems_section ..1 Review of Systems Section
. . . . . title 1.. title
. . . . . code 1.. Review of systems
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
. . . . . text 1.. This section contains only human readable content
. . . . section:social_history_section ..1 Social History Section
. . . . . title 1.. title
. . . . . code 1.. Social history
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (US Core Smoking Status Observation Profile) Smoking status
. . . . section:vital_signs_section ..1 Vital Signs Section
. . . . . title 1.. title
. . . . . code 1.. Vital signs
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8716-3
. . . . . text 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference ( Vital Signs Profile )

doco Documentation for this format

Produced 06 Apr 2023