Source | hl7.fhir.us.ccda#current:C-CDA on FHIR (v4.0.1) |
resourceType | StructureDefinition |
id | Transfer-Summary |
canonical | http://hl7.org/fhir/us/ccda/StructureDefinition/Transfer-Summary |
version | 1.2.0-ballot |
status | active |
publisher | HL7 Structured Documents Working Group |
name | TransferSummary |
title | Transfer Summary |
date | 2023-03-27T20:25:00+00:00 |
description | This profile describes constraints 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. |
jurisdictions | us |
fhirVersion | 4.0.1 |
kind | resource |
abstract | false |
sdTtype | Composition |
derivation | constraint |
base | http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header |
Usages |
|
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | USRealmHeader | |||
type | S |
Transfer Summary Binding: TransferDocumentType ( required ) |
||
event | S | 1..1 | event | |
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: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.. |
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 | 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:results_section | S | 1..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:vital_signs_section | S | 1..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 ) | ||
section:reason_for_referral_section | S | 1..1 | Reason for Referral Section | |
title | S | 1.. | title | |
code | S |
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.. | text | |
Slices for entry |
entry
Slice: Unordered, Open by profile:resolve() |
|||
entry:reason_for_referral_entry | S | Reference ( ServiceRequest ) | 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:discharge_diagnosis_section | S | 1..1 | Discharge Diagnosis Section | |
title | S | 1.. | title | |
code | S | 1.. |
Hospital discharge diagnosis 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: 11535-2 |
|
text | S | 1.. | text | |
Slices for entry | S |
entry
Slice: Unordered, Open by profile:resolve() |
||
entry:discharge_diagnosis_entry | S | Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition) | ||
section:social_history_section | S | 1..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: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: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:mental_status_section | S | ..1 | Mental Status Section | |
title | S | 1.. | title | |
code | S | 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 | 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:history_of_present_illness_section | S | 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:functional_status_section | S | ..1 | Functional Status Section | |
title | S | 1.. | title | |
code | S | 1.. |
Functional status assessment 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:assessment_section | S | 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:admission_medications_section | S | ..1 | Admission Medications Section | |
title | S | 1.. | title | |
code | S | 1.. |
Medications on admission 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: 42346-7 |
|
text | S | 1.. | text | |
Slices for entry |
entry
Slice: Unordered, Open by profile:resolve() |
|||
entry:admission_medications_entry | S | Reference ( MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | ||
section:encounters_section | S | ..1 | Encounters Section | |
title | S | 1.. | title | |
code | S | 1.. |
Encounters 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: 46240-8 |
|
text | S | 1.. | text | |
Slices for entry |
entry
Slice: Unordered, Open by profile:resolve() |
|||
entry:encounters_entry | S | Reference (US Core Encounter Profile) | 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 | 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: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:past_medical_history_section | S | ..1 | Past Medical History 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: 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:payers_section | S | Payers 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: 48768-6 |
|
text | S | 1.. | text | |
Slices for entry |
entry
Slice: Unordered, Open by profile:resolve() |
|||
entry:payers_entry | S | Reference ( Coverage ) | 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: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:admission_diagnosis_section | S | Admission Diagnosis 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: 46241-6 |
|
text | S | 1.. | text | |
Slices for entry |
entry
Slice: Unordered, Open by profile:resolve() |
|||
entry:admission_diagnosis_entry | S | Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition) | ||
section:assessment_and_plan_section | S | ..1 | Assessment and Plan Section. This section represents the clinicianâs 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.. |
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: 51847-2 |
|
text | S | 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. | |
Documentation for this format |
Produced 06 Apr 2023