StructureDefinition-Referral-Note

Sourcehl7.fhir.us.ccda#current:C-CDA on FHIR (v4.0.1)
resourceTypeStructureDefinition
idReferral-Note
canonicalhttp://hl7.org/fhir/us/ccda/StructureDefinition/Referral-Note
version1.2.0-ballot
statusactive
publisherHL7 Structured Documents Working Group
nameReferralNote
titleReferral Note
date2023-03-27T20:25:00+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. * When patient is sent by a cardiologist to an emergency department for angina. * When a patient is referred by a nurse practitioner to an audiologist for hearing screening. * When a patient is referred by a hospitalist to social services.
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 type
Binding: ReferralDocumentType ( required )
. . . 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.. code
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:allergies_and_intolerances_entry S Reference (US Core AllergyIntolerance Profile)
. . . . section:medications_section S 1..1 Medications Section
. . . . . title S 1.. title
. . . . . code S 1.. code
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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:medications_entry S Reference ( MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)
. . . . section:problem_section S 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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:problem_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:reason_for_referral_section S 1..1 Reason for Referral Section
. . . . . title S 1.. title
. . . . . code S 1.. code
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: 42349-1
. . . . . text S 1.. This section contains only human readable content
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:reason_for_referral_entry S Reference ( ServiceRequest )
. . . . section:functional_status_section S ..1 Functional Status Section
. . . . . title S 1.. title
. . . . . code S 1.. code
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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:functional_status_entry S 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:mental_status_section S ..1 Mental Status Section
. . . . . title S 1.. title
. . . . . code S 1.. code
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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:mental_status_entry S 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 S ..1 Nutrition Section
. . . . . title S 1.. title
. . . . . code S 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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:nutrition_entry S 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:plan_of_treatment_section S ..1 Plan of Treatment Section
. . . . . title S 1.. title
. . . . . code S 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 S 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:results_section S 0..1 Results Section
. . . . . title S 1.. title
. . . . . code S 1.. Relevant diagnostic tests and 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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:results_entry S Reference (US Core Laboratory Result Observation Profile)
. . . . section:assessment_and_plan_section S ..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 S 1.. title
. . . . . code S 1.. Assessment 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:assessment_and_plan_entry S 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: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_section S ..1 Assessment Section
. . . . . title S 1.. title
. . . . . code S 1.. code
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 S 1.. This section contains only human readable content
. . . . section:family_history_section S ..1 Family History Section
. . . . . title S 1.. title
. . . . . code S 1.. History of family member diseases
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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:family_history_entry S 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:general_status_section S ..1 General Status Section
. . . . . title S 1.. title
. . . . . code S 1.. code
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 S 1.. This section contains only human readable content
. . . . section:past_medical_history_section S ..1 Past Medical History Section
. . . . . title 1.. title
. . . . . code S 1.. code
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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:past_medical_history_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:history_of_present_illness_section S ..1 History of Present Illness Section
. . . . . title S 1.. title
. . . . . code S 1.. code
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:immunizations_section S ..1 Immunizations Section
. . . . . title S 1.. title
. . . . . code S 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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:immunizations_entry S Reference (US Core Immunization Profile)
. . . . section:medical_equipment_section S ..1 Medical Equipment Section
. . . . . title S 1.. title
. . . . . code S 1.. Medical equipment
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 S 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:physical_exam_section S ..1 Physical Exam Section
. . . . . title S 1.. title
. . . . . code S 1.. code
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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:physical_exam_entry S 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:procedures_section S ..1 Procedures Section
. . . . . title S 1.. title
. . . . . code S 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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:procedures_entry S Reference (US Core Procedure Profile)
. . . . section:review_of_systems_section S ..1 Review of Systems Section
. . . . . title S 1.. title
. . . . . code S 1.. code
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 S 1.. This section contains only human readable content
. . . . section:social_history_section S 0..1 Social History Section
. . . . . title S 1.. title
. . . . . code S 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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:social_history_entry S Reference (US Core Smoking Status Observation Profile) Smoking status
. . . . section:vital_signs_section S 0..1 Vital Signs Section
. . . . . title S 1.. title
. . . . . code S 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 S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:vital_signs_entry S Reference ( Vital Signs Profile ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:goals_section S 0..1 Goals Section
. . . . . title S 1.. title
. . . . . code S 1.. Goals
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: 61146-7
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:goals_entry S Reference (US Core Goal Profile) entry
. . . . section:health_concerns_section S 0..1 Health Concerns Section
. . . . . title S 1.. title
. . . . . code S 1.. Health concerns section code
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: 75310-3
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:health_concerns_entry S Reference (US Core AllergyIntolerance Profile | http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition | US Core Laboratory Result Observation Profile | US Core Smoking Status Observation Profile | Vital Signs Profile | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

doco Documentation for this format

Produced 06 Apr 2023