TransferSummaryV2

Template Transfer Summary (V2) 2015‑08‑01

2.16.840.1.113883.10.20.22.1.13

Effective Date

2015‑08‑01

Status

Draft

Version Label

2.1

Name

TransferSummaryV2

Display Name

Transfer Summary (V2)

Description

This 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.

Context

Pathname //

Classification

CDA Document Level Template

Open/Closed

Open (other than defined elements are allowed)

Used by / Uses

Used by 1 transaction and 0 templates, Uses 29 templates

Used by	as	Name	Version
2.16.840.1.113883.3.1937.99.3.4.31	Transaction	Transfer Summary (V2)	2015‑08‑01
Uses	as	Name	Version
1.3.6.1.4.1.19376.1.5.3.1.3.1	Containment	Reason for Referral Section (V2) (2.1)	2014‑06‑09
1.3.6.1.4.1.19376.1.5.3.1.3.4	Containment	History of Present Illness Section (2.1)	2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.18	Containment	Review of Systems Section (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.2.5	Containment	General Status Section (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.2.10	Containment	Physical Exam Section (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.1.1	Containment	Medications Section (entries required) (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.2.2	Containment	Immunizations Section (entries optional) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.3.1	Containment	Results Section (entries required) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.4.1	Containment	Vital Signs Section (entries required) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.5.1	Containment	Problem Section (entries required) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.6.1	Containment	Allergies and Intolerances Section (entries required) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.7.1	Containment	Procedures Section (entries required) (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.2.8	Containment	Assessment Section (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.2.9	Containment	Assessment and Plan Section (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.2.10	Containment	Plan of Treatment Section (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.2.14	Containment	Functional Status Section (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.2.15	Containment	Family History Section (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.17	Containment	Social History Section (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.18	Containment	Payers Section (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.20	Containment	Past Medical History (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.21.1	Containment	Advance Directives Section (entries required) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.22.1	Containment	Encounters Section (entries required) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.23	Containment	Medical Equipment Section (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.2.24	Containment	Discharge Diagnosis Section (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.43	Containment	Admission Diagnosis Section (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.44	Containment	Admission Medications Section (entries optional) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.56	Containment	Mental Status Section (V2) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.57	Containment	Nutrition Section (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.2.64	Containment	Course of Care Section (2.1)	2015‑08‑13

Relationship

Specialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)

ref

ad1bbr-

Specialization: template 2.16.840.1.113883.10.20.22.1.1 US Realm Header (V3) (2015‑08‑01)
Version: template 2.16.840.1.113883.10.20.22.1.13 Transfer Summary (V2) (DYNAMIC)

Item

Card

Conf

Description

Label

cda:ClinicalDocument

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).

TranryV2

cda:templateId

1 … 1

C-CDA R1.1 templateId root without an extension

CONF2936

@root

uid

1 … 1

2.16.840.1.113883.10.20.22.1.13

cda:templateId

1 … 1

SHALL contain exactly one [1..1] templateId (CONF:1198-28239) such that it

CONF8239

@root

uid

1 … 1

2.16.840.1.113883.10.20.22.1.13

CONF8240

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.13" (CONF:1198-28240).

@extension

1 … 1

2015-08-01

CONF2907

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32907).

cda:code

1 … 1

SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet TransferDocumentType urn:oid:2.16.840.1.113883.1.11.20.2.4 DYNAMIC (CONF:1198-28243).

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).

CONF8243

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20.2.4 TransferDocumentType (DYNAMIC)

cda:title

1 … 1

SHALL contain exactly one [1..1] title (CONF:1198-29838).

CONF9838

cda:participant

0 … *

SHOULD contain zero or more [0..*] participant (CONF:1198-31599) such that it

CONF1599

where [@typeCode='IND']

@typeCode

1 … 1

IND

CONF1872

SHALL contain exactly one [1..1] @typeCode="IND" indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-31872).

cda:associatedEntity

1 … 1

SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31600).

CONF1600

@classCode

1 … 1

This associatedEntity SHALL contain exactly one [1..1] @classCode, which SHALL be selected from ValueSet INDRoleclassCodes urn:oid:2.16.840.1.113883.11.20.9.33 DYNAMIC (CONF:1198-31873).

CONF1873

CONF

The value of @classCode shall be drawn from value set 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes (DYNAMIC)

cda:associatedPerson

1 … 1

This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31601).

CONF1601

cda:name

1 … *

This associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31602).

CONF1602

cda:participant

0 … *

SHOULD contain zero or more [0..*] participant (CONF:1198-31626) such that it

CONF1626

where [@typeCode='CALLBCK']

@typeCode

1 … 1

CALLBCK

CONF1627

SHALL contain exactly one [1..1] @typeCode="CALLBCK" Call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-31627).

cda:associatedEntity

1 … 1

SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31628).

CONF1628

@classCode

1 … 1

ASSIGNED

CONF1641

This associatedEntity SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110) (CONF:1198-31641).

cda:id

1 … *

This associatedEntity SHALL contain at least one [1..*] id (CONF:1198-31629).

CONF1629

cda:addr

0 … *

This associatedEntity SHOULD contain zero or more [0..*] addr (CONF:1198-31630).

CONF1630

cda:telecom

TEL

1 … *

This associatedEntity SHALL contain at least one [1..*] telecom (CONF:1198-31631).

CONF1631

cda:associatedPerson

1 … 1

This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31632).

CONF1632

cda:name

1 … *

This associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31633).

CONF1633

cda:scopingOrganization

0 … 1

This associatedEntity MAY contain zero or one [0..1] scopingOrganization (CONF:1198-31634).

CONF1634

cda:documentationOf

1 … 1

SHALL contain exactly one [1..1] documentationOf (CONF:1198-31570).

CONF1570

cda:serviceEvent

1 … 1

This documentationOf SHALL contain exactly one [1..1] serviceEvent (CONF:1198-31571).

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.

CONF1571

@classCode

1 … 1

PCPR

CONF1572

This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" Care Provision (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-31572).

cda:code

0 … 1

This serviceEvent MAY contain zero or one [0..1] code (CONF:1198-32650).

Use serviceEvent/code when using a generic document type code such as 18761-7 (Provider-Unspecified Transfer Summary) to represent the service.

CONF2650

cda:performer

1 … *

This serviceEvent SHALL contain at least one [1..*] performer (CONF:1198-31574) such that it

CONF1574

@typeCode

1 … 1

PRF

CONF1575

SHALL contain exactly one [1..1] @typeCode="PRF" Participation of Physical Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC) (CONF:1198-31575).

cda:functionCode

0 … 1

MAY contain zero or one [0..1] functionCode, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32651).

Use performer/functionCode when using a generic document type code such as 18761-7 (Provider-Unspecified Transfer Summary) to represent the provider.

CONF2651

CONF

The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.1066 Healthcare Provider Taxonomy (DYNAMIC)

cda:component

1 … 1

SHALL contain exactly one [1..1] component (CONF:1198-28251).

CONF8251

cda:structuredBody

1 … 1

This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-28252).

CONF8252

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.21.1 Advance Directives Section (entries required) (V3) (2015‑08‑01)

CONF8253

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.6.1 Allergies and Intolerances Section (entries required) (V3) (2015‑08‑01)

CONF8255

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01)

CONF8257

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.22.1 Encounters Section (entries required) (V3) (2015‑08‑01)

CONF8261

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01)

CONF8263

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09)

CONF8265

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.24 Discharge Diagnosis Section (V3) (2015‑08‑01)

CONF8271

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (2015‑08‑01)

CONF8273

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (2014‑06‑09)

CONF8275

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (V2) (2014‑06‑09)

CONF8277

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.18 Payers Section (V3) (2015‑08‑01)

CONF8279

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09)

CONF8281

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.5.1 Problem Section (entries required) (V3) (2015‑08‑01)

CONF8283

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.7.1 Procedures Section (entries required) (V2) (2014‑06‑09)

CONF8285

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (V3) (2015‑08‑01)

CONF8287

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01)

CONF8289

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.4.1 Vital Signs Section (entries required) (V3) (2015‑08‑01)

CONF8291

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.56 Mental Status Section (V2) (2015‑08‑01)

CONF8327

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2015‑08‑13)

CONF8838

cda:component

0 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2015‑08‑13)

CONF0239

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13)

CONF0776

cda:component

1 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 Reason for Referral Section (V2) (2014‑06‑09)

CONF1342

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01)

CONF1561

cda:component

0 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2015‑08‑13)

CONF1563

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09)

CONF1565

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13)

CONF1567

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.44 Admission Medications Section (entries optional) (V3) (2015‑08‑01)

CONF2445

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.43 Admission Diagnosis Section (V3) (2015‑08‑01)

CONF2447

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.64 Course of Care Section (2015‑08‑13)

CONF2648

Schematron assert

role

error

test

//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'] or ( //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] and //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'] )

Message

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).

Schematron assert

role

error

test

not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9']) or ( not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8']) and not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) )

Message

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.

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Template

Template Transfer Summary (V2) 2015‑08‑01