ReferralNoteV2

Template Referral Note (V2) 2015‑08‑01

2.16.840.1.113883.10.20.22.1.14

Effective Date

2015‑08‑01

Status

Draft

Version Label

2.1

Name

ReferralNoteV2

Display Name

Referral Note (V2)

Description

A 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 or when patient is sent by a cardiologist to an emergency department for angina or when a patient is referred by a nurse practitioner to an audiologist for hearing screening or when a patient is referred by a hospitalist to social services.

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 25 templates

Used by	as	Name	Version
2.16.840.1.113883.3.1937.99.3.4.30	Transaction	Referral Note (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
2.16.840.1.113883.10.20.22.2.2.1	Containment	Immunizations Section (entries required) (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	Containment	Procedures Section (entries optional) (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
2.16.840.1.113883.10.20.22.2.20	Containment	Past Medical History (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.21	Containment	Advance Directives Section (entries optional) (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
2.16.840.1.113883.10.20.22.2.56	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
2.16.840.1.113883.10.20.22.5.1	Containment	US Realm Patient Name (PTN.US.FIELDED) (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.5.1.1	Containment	US Realm Person Name (PN.US.FIELDED) (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 2.16.840.1.113883.10.20.22.1.14 Referral Note (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:1198-32943).

RefeteV2

cda:templateId

1 … 1

C-CDA R1.1 templateId root without an extension

CONF2936

@root

uid

1 … 1

2.16.840.1.113883.10.20.22.1.14

cda:templateId

1 … 1

SHALL contain exactly one [1..1] templateId (CONF:1198-28947) such that it

CONF8947

@root

uid

1 … 1

2.16.840.1.113883.10.20.22.1.14

CONF8948

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.14" (CONF:1198-28948).

@extension

1 … 1

2015-08-01

CONF2911

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32911).

cda:code

1 … 1

SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet ReferralDocumentType urn:oid:2.16.840.1.113883.1.11.20.2.3 DYNAMIC (CONF:1198-28949).

The Referral Note recommends use of the document type code 57133-1 "Referral Note", 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 Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).

CONF8949

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20.2.3 ReferralDocumentType (DYNAMIC)

cda:informationRecipient

1 … 1

SHALL contain exactly one [1..1] informationRecipient (CONF:1198-31589).

CONF1589

cda:intendedRecipient

1 … 1

This informationRecipient SHALL contain exactly one [1..1] intendedRecipient (CONF:1198-31590).

CONF1590

cda:addr

0 … *

This intendedRecipient SHOULD contain zero or more [0..*] addr (CONF:1198-31591).

CONF1591

cda:telecom

TEL

0 … *

This intendedRecipient SHOULD contain zero or more [0..*] telecom (CONF:1198-31592).

CONF1592

cda:informationRecipient

1 … 1

Contains 2.16.840.1.113883.10.20.22.5.1.1 US Realm Person Name (PN.US.FIELDED) (2015‑08‑13)

CONF1593

cda:participant

0 … *

SHOULD contain zero or more [0..*] participant (CONF:1198-31642) such that it

CONF1642

where [@typeCode='IND']

@typeCode

1 … 1

IND

CONF1924

SHALL contain exactly one [1..1] @typeCode="IND" Indirect (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-31924).

cda:associatedEntity

1 … 1

SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31643).

CONF1643

@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:1198-31925).

CONF1925

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

Contains 2.16.840.1.113883.10.20.22.5.1 US Realm Patient Name (PTN.US.FIELDED) (2015‑08‑13)

CONF1644

cda:participant

0 … *

SHOULD contain zero or more [0..*] participant (CONF:1198-31647) such that it

This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.

CONF1647

where [@typeCode='CALLBCK']

@typeCode

1 … 1

CALLBCK

CONF1648

SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC) (CONF:1198-31648).

cda:associatedEntity

1 … 1

SHALL contain exactly one [1..1] associatedEntity (CONF:1198-31649).

CONF1649

@classCode

1 … 1

ASSIGNED

CONF2419

This associatedEntity SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110) (CONF:1198-32419).

cda:id

1 … *

This associatedEntity SHALL contain at least one [1..*] id (CONF:1198-31650).

CONF1650

cda:addr

0 … *

This associatedEntity SHOULD contain zero or more [0..*] addr (CONF:1198-31651).

CONF1651

cda:telecom

TEL

1 … *

This associatedEntity SHALL contain at least one [1..*] telecom (CONF:1198-31652).

CONF1652

cda:associatedPerson

1 … 1

This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31653).

CONF1653

cda:name

1 … *

This associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31654).

CONF1654

cda:scopingOrganization

0 … 1

This associatedEntity MAY contain zero or one [0..1] scopingOrganization (CONF:1198-31655).

CONF1655

cda:component

1 … 1

SHALL contain exactly one [1..1] component (CONF:1198-29062).

CONF9062

cda:structuredBody

1 … 1

This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-29063).

CONF9063

cda:component

0 … 1

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

CONF9066

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.21 Advance Directives Section (entries optional) (V3) (2015‑08‑01)

CONF9068

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)

CONF9074

cda:component

0 … 1

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

CONF9076

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.2.1 Immunizations Section (entries required) (V3) (2015‑08‑01)

CONF9082

cda:component

1 … 1

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

CONF9086

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2014‑06‑09)

CONF9088

cda:component

0 … 1

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

CONF9090

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)

CONF9092

cda:component

0 … 1

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

CONF9094

cda:component

0 … 1

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

CONF9096

cda:component

0 … 1

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

CONF9098

cda:component

0 … 1

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

CONF9100

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13)

CONF0780

cda:component

0 … 1

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

CONF0796

cda:component

0 … 1

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

CONF0798

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)

CONF0911

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13)

CONF0913

cda:component

0 … 1

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

CONF0915

cda:component

0 … 1

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

CONF0917

cda:component

0 … 1

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

CONF0919

cda:component

1 … 1

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

CONF0922

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)

CONF0924

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

SHALL include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan Section (2.16.840.1.113883.10.20.22.2.10).

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

SHALL NOT include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9) when an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Care Section (2.16.840.1.113883.10.20.22.2.10) are present

Template
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Template

Template Referral Note (V2) 2015‑08‑01