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Template Consultation Note (V3) 2015‑08‑01

Id2.16.840.1.113883.10.20.22.1.4Effective Date2015‑08‑01
Statusdraft DraftVersion Label2.1
NameConsultationNoteV3Display NameConsultation Note (V3)
Description
The 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).
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 26 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal Consultation Note (V3)2015‑08‑01
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1Containmentdraft Chief Complaint Section (2.1)2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.4Containmentdraft History of Present Illness Section (2.1)2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.18Containmentdraft Review of Systems Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.2.5Containmentdraft General Status Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.2.10Containmentdraft Physical Exam Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.1.1Containmentdraft Medications Section (entries required) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.2Containmentdraft Immunizations Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.3.1Containmentdraft Results Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.4.1Containmentdraft Vital Signs Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.5.1Containmentdraft Problem Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6.1Containmentdraft Allergies and Intolerances Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.7Containmentdraft Procedures Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.8Containmentdraft Assessment Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.9Containmentdraft Assessment and Plan Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Treatment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.12Containmentdraft Reason for Visit Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.13Containmentdraft Chief Complaint and Reason for Visit Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.14Containmentdraft Functional Status Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.15Containmentdraft Family History Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.17Containmentdraft Social History Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.20Containmentdraft Past Medical History (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.21Containmentdraft Advance Directives Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.23Containmentdraft Medical Equipment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.56Containmentdraft Mental Status Section (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.57Containmentdraft Nutrition Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.5.3Containmentdraft US Realm Date and Time (DT.US.FIELDED) (2.1)2015‑08‑13
RelationshipSpecialization: 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 2.16.840.1.113883.10.20.22.1.4 Consultation Note (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
RWhen 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:1198-32935).
ConsdotsteV3
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.4
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1198-8375) such that itCONFdots8375
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.4CONFdots0040
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.4" (CONF:1198-10040).
@extension
st1 … 1F2015-08-01CONFdots2502
 SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32502).
cda:code
1 … 1SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet ConsultDocumentType urn:oid:2.16.840.1.113883.11.20.9.31 DYNAMIC (CONF:1198-17176).

The Consultation Note recommends use of the document type code 11488-4 "Consult 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.		CONFdots7176
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.31 ConsultDocumentType (DYNAMIC)
cda:participant
0 … *RSHOULD contain zero or more [0..*] participant (CONF:1198-31656) such that itCONFdots1656
@typeCode
cs1 … 1FCALLBCKCONFdots1657
 SHALL contain exactly one [1..1] @typeCode="CALLBCK" call back contact (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 DYNAMIC) (CONF:1198-31657).
cda:associatedEntity
1 … 1MSHALL contain exactly one [1..1] associatedEntity (CONF:1198-31658).CONFdots1658
@classCode
cs1 … 1FASSIGNEDCONFdots1659
 This associatedEntity SHALL contain exactly one [1..1] @classCode="ASSIGNED" assigned entity (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110 DYNAMIC) (CONF:1198-31659).
cda:id
II1 … *This associatedEntity SHALL contain at least one [1..*] id (CONF:1198-31660).CONFdots1660
cda:addr
AD0 … *RThis associatedEntity SHOULD contain zero or more [0..*] addr (CONF:1198-31661).CONFdots1661
cda:telecom
TEL1 … *This associatedEntity SHALL contain at least one [1..*] telecom (CONF:1198-31662).CONFdots1662
cda:associatedPerson
1 … 1MThis associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-31663).CONFdots1663
cda:name
1 … *RThis associatedPerson SHALL contain at least one [1..*] name (CONF:1198-31664).CONFdots1664
cda:scopingOrganization
0 … 1This associatedEntity MAY contain zero or one [0..1] scopingOrganization (CONF:1198-31665).CONFdots1665
cda:inFulfillmentOf
1 … *MSHALL contain at least one [1..*] inFulfillmentOf (CONF:1198-8382).

The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note.		CONFdots8382
cda:order
1 … 1MSuch inFulfillmentOfs SHALL contain exactly one [1..1] order (CONF:1198-29923).CONFdots9923
cda:id
II1 … *This order SHALL contain at least one [1..*] id (CONF:1198-29924).

Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template.		CONFdots9924
cda:componentOf
1 … 1MSHALL contain exactly one [1..1] componentOf (CONF:1198-8386).

A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter. 		CONFdots8386
cda:encompassingEncounter
1 … 1MContains 2.16.840.1.113883.10.20.22.5.3 US Realm Date and Time (DT.US.FIELDED) (2015‑08‑13)CONFdots8387
cda:id
II1 … *This encompassingEncounter SHALL contain at least one [1..*] id (CONF:1198-8388).CONFdots8388
cda:responsibleParty
0 … 1This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:1198-8391).CONFdots8391
cda:assignedEntity
1 … 1MThe responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32904).CONFdots2904
 Schematron assertrolered error 
 testcda:assignedPerson | cda:representedOrganization 
 MessageThis assignedEntity SHALL contain an assignedPerson or a representedOrganization or both 
cda:encounterParticipant
0 … *This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:1198-8392).

The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.		CONFdots8392
cda:assignedEntity
1 … 1MThe encounterParticipant, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32902).CONFdots2902
 Schematron assertrolered error 
 testcda:assignedPerson | cda:representedOrganization 
 MessageThis assignedEntity SHALL contain an assignedPerson or a representedOrganization or both 
cda:component
1 … 1MSHALL contain exactly one [1..1] component (CONF:1198-8397).CONFdots8397
cda:structuredBody
1 … 1MThis component SHALL contain exactly one [1..1] structuredBody (CONF:1198-28895).CONFdots8895
 ConstraintThis structuredBody *SHALL NOT* contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13)CONFdots8896
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09)CONFdots8898
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09)CONFdots8900
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2015‑08‑13)CONFdots8904
cda:component
1 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2015‑08‑13)CONFdots8906
cda:component
0 … 1RContains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01)CONFdots8908
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.6.1 Allergies and Intolerances Section (entries required) (V3) (2015‑08‑01)CONFdots8910
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2015‑08‑13)CONFdots8912
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2015‑08‑13)CONFdots8915
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01)CONFdots8917
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2015‑08‑13)CONFdots8919
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01)CONFdots8921
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (2015‑08‑01)CONFdots8923
cda:component
0 … 1RContains 2.16.840.1.113883.10.20.22.2.1.1 Medications Section (entries required) (V2) (2014‑06‑09)CONFdots8925
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.5.1 Problem Section (entries required) (V3) (2015‑08‑01)CONFdots8928
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2014‑06‑09)CONFdots8930
cda:component
0 … 1RContains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (V3) (2015‑08‑01)CONFdots8932
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01)CONFdots8934
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.4.1 Vital Signs Section (entries required) (V3) (2015‑08‑01)CONFdots8936
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.21 Advance Directives Section (entries optional) (V3) (2015‑08‑01)CONFdots8942
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09)CONFdots8944
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2015‑08‑13)CONFdots0237
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.23 Medical Equipment Section (V2) (2014‑06‑09)CONFdots0904
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.56 Mental Status Section (V2) (2015‑08‑01)CONFdots0906
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13)CONFdots0909
 Schematron assertrolered error 
 test//cda:section/cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.1' or //cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12' 
 Message*SHALL* include a Reason for Referral or Reason for Visit section 
 Schematron assertrolered 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']) 
 MessageSHALL 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 assertrolered error 
 testnot(//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']) ) 
 MessageSHALL 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