Id2.16.840.1.113883.3.1818.10.1.7.1Effective Date2016‑12‑01 21:39:19
Statusrejected RejectedVersion Label
NameCDAClinicalDocumentConsultReportDisplay NameBC CDA ClinicalDocumentStructuredConsultReport
Description
The Generic Consult Report Document is a constrained version of the Generic Episodic Document and is designed to specifically support the communication of a report that is a consequence of a consultation encounter.  The Generic Consult Report Document may be used as a basis for more constrained consultation report such as one relevant to a specific specialty. The section requirements for the Generic Consult Report have been informed by the Nanaimo eReferral CDA Message Specification Version 2.0.   
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 15 templates
Uses as NameVersion
2.16.840.1.113883.3.51.60.1.3Includedraft BC CDA recordTargetDYNAMIC
2.16.840.1.113883.3.51.60.1.4Includedraft BC CDA authorDYNAMIC
2.16.840.1.113883.3.51.60.1.5Includedraft BC CDA informationRecipientDYNAMIC
2.16.840.1.113883.3.51.60.1.6Includedraft BC CDA custodianDYNAMIC
2.16.840.1.113883.3.51.60.1.11Includedraft BC CDA componentOfDYNAMIC
2.16.840.1.113883.10.12.103Includeactive CDA dataEntererDYNAMIC
2.16.840.1.113883.10.12.106Includeactive CDA legalAuthenticatorDYNAMIC
2.16.840.1.113883.10.12.107Includeactive CDA authenticatorDYNAMIC
2.16.840.1.113883.10.12.108Includeactive CDA participantDYNAMIC
2.16.840.1.113883.10.12.109Includeactive CDA inFulfillmentOfDYNAMIC
2.16.840.1.113883.10.12.110Includeactive CDA documentationOfDYNAMIC
2.16.840.1.113883.10.12.111Includeactive CDA relatedDocumentDYNAMIC
2.16.840.1.113883.10.12.113Includeactive CDA componentOfDYNAMIC
2.16.840.1.113883.10.12.114Includeactive CDA AuthorizationDYNAMIC
2.16.840.1.113883.10.12.154Includeactive CDA InformantDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
MCONF:2, CONF:2.8
@classCode
cs1 … 1FDOCCLINCONF:6
@moodCode
cs1 … 1FEVNCONF:7
 ConstraintSHALL be a ClinicalDocument element from the urn:hl7-org:v3 namespace
hl7:realmCode
CS1 … 1MCONF:4
@code
CONF1 … 1FCA-BC
@codeSystem
1 … 1F2.16.840.1.113883.5.1124
@displayName
1 … 1FCanada (British Columbia)
hl7:typeId
II1 … 1MCONF:2, CONF:2.8
@root
uid1 … 1F2.16.840.1.113883.1.3CONF:3.10
@extension
st1 … 1FPOCD_HD000040CONF:3.11
hl7:templateId
II1 … 1MCONF:5
@root
uid1 … 1F2.16.840.1.113883.3.1818.10.7.1
hl7:templateId
II2 … 2MCONF:5.78
@root
uid1 … 1F2.16.840.1.113883.3.1818.10.1.7.1
hl7:id
II1 … 1MCONF:8, CONF:8.29
hl7:code
CE1 … 1MCONF:4566
@code
CONF1 … 1F11488-4
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@displayName
1 … 1FConsult Report
@codeSystemName
1 … 1FLOINC
hl7:title
ST0 … 1CONF:2, CONF:2.8
hl7:effectiveTime
TS1 … 1RCONF:2, CONF:2.8
hl7:confidentialityCode
CE1 … 1RCONF:2, CONF:2.8
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
hl7:languageCode
CS0 … 1CONF:2, CONF:2.8
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:setId
II0 … 1CONF:2, CONF:2.8
hl7:versionNumber
INT0 … 1CONF:2, CONF:2.8
Included1 … *R from 2.16.840.1.113883.3.51.60.1.3 BC CDA recordTarget (DYNAMIC)
hl7:recordTarget
1 … *RCONFdots0047
@typeCode
cs1 … 1FRCTCONFdots0507
@contextControlCode
cs1 … 1FOP
hl7:patientRole
1 … 1MCONFdots0047
@classCode
cs1 … 1FPATCONFdots0508
hl7:id
II1 … *RCONFdots0048
hl7:addr
AD.CA0 … *CONFdots0051
hl7:telecom
TEL.CA.PHONE0 … *CONFdots0052
hl7:patient
1 … 1MCONFdots0053
@classCode
cs1 … 1FPSNCONFdots0509
@determinerCode
cs1 … 1FINSTANCE
hl7:name
PN.CA1 … *MCONFdots0054
hl7:administrativeGenderCode
CE (required)1 … 1MCONFdots0055
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)
hl7:birthTime
TS1 … 1MCONFdots0056
hl7:languageCommunication
0 … *CONFdots0057
hl7:languageCode
CS0 … 1CONFdots0057
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:modeCode
CE0 … 1CONFdots0057
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12249 LanguageAbilityMode (DYNAMIC)
hl7:proficiencyLevelCode
CE0 … 1CONFdots0057
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12199 LanguageAbilityProficiency (DYNAMIC)
hl7:preferenceInd
BL0 … 1CONFdots0057
Included1 … *R from 2.16.840.1.113883.3.51.60.1.4 BC CDA author (DYNAMIC)
hl7:author
1 … *MCONFdots0058
@typeCode
cs1 … 1FAUTCONFdots0510
@contextControlCode
cs1 … 1FOPCONFdots0510
hl7:time
TS1 … 1MCONF‑BC0059, CONF‑BC0060
 ConstraintThe author/time.valueSHALL be precise to the day and SHOULD be precise to the minute. If more precise than the day, SHALL include a time zone offset.  This represents the date/time that the clinical document was dictated by the assignedPerson.  In instances where the clinical document is authored by an assignedAuthoringDevice , this date/time represents the time that the document was created by the device. (e.g. ECG auto-interpretation)
hl7:assignedAuthor
1 … 1MCONFdots0061
@classCode
cs1 … 1FASSIGNEDCONFdots0511
hl7:id
II1 … *MCONF‑BC0062, CONF‑BC0063, CONF‑BC0064
 ConstraintIf the author is a Provider, the id elements SHALL conform to section 4.2.1.3.

If the author is a not a Provider, assignedAuthor/id  MAY be a locally assigned identifier
hl7:code
CE0 … 1CONFdots0061
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111
hl7:addr
AD.CA0 … *CONFdots0061
hl7:telecom
TEL.CA.PHONE0 … *CONFdots0061
Choice0 … 1Elements to choose from:
  • hl7:assignedPerson
  • hl7:assignedAuthoringDevice
hl7:assignedPerson
0 … 1RCONFdots0065
Included from 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC)
@classCode
cs1 … 1FPSNCONFdots0519
@determinerCode
cs1 … 1FINSTANCECONFdots0519
hl7:name
PN.CA1 … *MCONFdots0100
 ConstraintassignedEntity/assignedPerson.name element SHALL conform to the constraints in the common section on names
hl7:assignedAuthoringDevice
0 … 1RCONFdots0065
Included from 2.16.840.1.113883.3.51.60.1.21 BC CDA Device (DYNAMIC)
@classCode
cs1 … 1FDEV
@determinerCode
cs1 … 1FINSTANCE
hl7:code
CE0 … 1BCCDdotsvice
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16040 EntityCode (DYNAMIC)
hl7:manufacturerModelName
SC0 … 1BCCDdotsvice
hl7:softwareName
SC0 … 1BCCDdotsvice
Included0 … 1 from 2.16.840.1.113883.10.12.103 CDA dataEnterer (DYNAMIC)
hl7:dataEnterer
0 … 1CDAddotserer
@typeCode
cs0 … 1FENT
@contextControlCode
cs0 … 1FOP
hl7:time
TS0 … 1CDAddotserer
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAddotserer
Included0 … * from 2.16.840.1.113883.10.12.154 CDA Informant (DYNAMIC)
hl7:informant
0 … *CDAidotsmant
@typeCode
cs0 … 1FINF
@contextControlCode
cs0 … 1FOP
Choice1 … 1Elements to choose from:
hl7:assignedEntity
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAidotsmant
hl7:relatedEntity
Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC)CDAidotsmant
Included1 … 1R from 2.16.840.1.113883.3.51.60.1.6 BC CDA custodian (DYNAMIC)
hl7:custodian
1 … 1MCONFdots0082
@typeCode
cs1 … 1FCSTCONFdots0083
hl7:assignedCustodian
1 … 1MCONFdots0084
@classCode
cs1 … 1FASSIGNEDCONFdots0514
hl7:representedCustodianOrganization
1 … 1MCONFdots0085
@classCode
cs1 … 1FORGCONFdots0515
@determinerCode
cs1 … 1FINSTANCECONFdots0515
hl7:id
II1 … 1MCONFdots0086
 Constraint

a.If the clinical document is generated from a Health Authority, this id SHALL contain the root OID of the Health Authority, and the facility id shall be used as the extension. 

b.If the clinical document is generated from an EMR, this id SHALL NOT contain the root OID of a Health Authority or of the BC Ministry of Health.

hl7:name
ON0 … 1CONFdots0087
Included1 … *M from 2.16.840.1.113883.3.51.60.1.5 BC CDA informationRecipient (DYNAMIC)
hl7:informationRecipient
1 … *MCONF‑BC0070, CONF‑BC0071
@typeCode
cs1 … 1R
 ConstraintinformationRecipientSHALL have the attribute typeCode whichSHALL be either “PRCP” (primary recipient) or “TRC” (secondary recipient),  from HL7 Value Set x_InformationRecipient.   

There SHALL be at least one [1..*] primary recipient (“PRCP”).
hl7:intendedRecipient
1 … 1MCONFdots0072
@classCode
cs1 … 1FASSIGNEDCONFdots0074
hl7:id
II1 … 2RCONF‑BC0073, CONF‑BC0075, CONF‑BC0076
 ConstraintIf the informationRecipient is a Provider, the id elements SHALL conform to section 4.2.1.3.

If the informationRecipient is a not a Provider, intendedRecipient/id.extension MAY be a locally assigned identifier
hl7:addr
AD.CA0 … *CONFdots0077
 ConstraintIf present, intendedRecipient/addr SHALL conform to the restrictions for the described in common elements for addresses.
hl7:telecom
TEL.CA.PHONE0 … *CONFdots0078
 ConstraintIf present, telecomSHALL conform to the restrictions for the pan-Canadian data type flavor TEL.PHONE or TEL.EMAIL
hl7:informationRecipient
1 … 1RCONFdots0072
Included0 … * from 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC)
@classCode
cs1 … 1FPSNCONFdots0519
@determinerCode
cs1 … 1FINSTANCECONFdots0519
hl7:name
PN.CA0 … *M

noticeWarning: If isMandatory=true, minimumMultiplicity shall be greater than 0.

CONFdots0100
 ConstraintassignedEntity/assignedPerson.name element SHALL conform to the constraints in the common section on names
hl7:receivedOrganization
0 … 1CONFdots0080
Included0 … * from 2.16.840.1.113883.3.51.60.1.5.1 BC CDA Organization (DYNAMIC)
@classCode
cs1 … 1FORGCONFdots0533
@determinerCode
cs1 … 1FINSTANCE
hl7:id
II0 … *M

noticeWarning: If isMandatory=true, minimumMultiplicity shall be greater than 0.

CDAOdotstion
hl7:name
ON0 … *M

noticeWarning: If isMandatory=true, minimumMultiplicity shall be greater than 0.

CONFdots0534
Included0 … 1 from 2.16.840.1.113883.10.12.106 CDA legalAuthenticator (DYNAMIC)
hl7:legalAuthenticator
0 … 1CDAldotsator
@typeCode
cs0 … 1FLA
@contextControlCode
cs0 … 1FOP
hl7:time
TS1 … 1RCDAldotsator
hl7:signatureCode
CS1 … 1RCDAldotsator
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAldotsator
Included0 … * from 2.16.840.1.113883.10.12.107 CDA authenticator (DYNAMIC)
hl7:authenticator
0 … *CDAadotsator
@typeCode
cs0 … 1FAUTHEN
hl7:time
TS1 … 1RCDAadotsator
hl7:signatureCode
CS1 … 1RCDAadotsator
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAadotsator
Included0 … * from 2.16.840.1.113883.10.12.108 CDA participant (DYNAMIC)
hl7:participant
0 … *CDApdotspant
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (DYNAMIC)
@contextControlCode
cs0 … 1FOP
hl7:functionCode
CE0 … 1CDApdotspant
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
IVL_TS0 … 1CDApdotspant
hl7:associatedEntity
1 … 1CDApdotspant
@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.19313 RoleClassAssociative (DYNAMIC)
hl7:id
II0 … *CDApdotspant
hl7:code
CE0 … 1CDApdotspant
 CONF
shall be drawn from concept domain "RoleCode"
hl7:addr
AD0 … *CDApdotspant
hl7:telecom
TEL0 … *CDApdotspant
hl7:associatedPerson
0 … 1Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)CDApdotspant
hl7:scopingOrganization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)CDApdotspant
Included0 … * from 2.16.840.1.113883.10.12.109 CDA inFulfillmentOf (DYNAMIC)
hl7:inFulfillmentOf
0 … *CDAidotsntOf
@typeCode
cs0 … 1FFLFS
hl7:order
1 … 1CDAidotsntOf
@classCode
cs0 … 1FACT
@moodCode
cs1 … 1FRQO
hl7:id
II1 … *RCDAidotsntOf
hl7:code
CE0 … 1CDAidotsntOf
 CONF
shall be drawn from concept domain "ActCode"
hl7:priorityCode
CE0 … 1CDAidotsntOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
Included0 … * from 2.16.840.1.113883.10.12.110 CDA documentationOf (DYNAMIC)
hl7:documentationOf
0 … *CDAddotsonOf
@typeCode
cs1 … 1FDOC
hl7:serviceEvent
1 … 1CDAddotsonOf
@classCode
cs1 … 1FACT
@moodCode
cs1 … 1FEVN
hl7:id
II0 … *CDAddotsonOf
hl7:code
CE0 … 1CDAddotsonOf
 CONF
shall be drawn from concept domain "ActCode"
hl7:effectiveTime
IVL_TS0 … 1CDAddotsonOf
hl7:performer
0 … *CDAddotsonOf
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC)
hl7:functionCode
CE0 … 1CDAddotsonOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
IVL_TS0 … 1CDAddotsonOf
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAddotsonOf
Included0 … * from 2.16.840.1.113883.10.12.111 CDA relatedDocument (DYNAMIC)
hl7:relatedDocument
0 … *CDArdotsment
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)
hl7:parentDocument
1 … 1CDArdotsment
@classCode
cs0 … 1FDOCCLIN
@moodCode
cs0 … 1FEVN
hl7:id
II1 … *RCDArdotsment
hl7:code
CD0 … 1CDArdotsment
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
hl7:text
ED0 … 1CDArdotsment
hl7:setId
II0 … 1CDArdotsment
hl7:versionNumber
INT0 … 1CDArdotsment
Included0 … * from 2.16.840.1.113883.10.12.114 CDA Authorization (DYNAMIC)
hl7:authorization
0 … *CDAadotstion
@typeCode
cs0 … 1FAUTH
hl7:consent
1 … 1CDAadotstion
@classCode
cs0 … 1FCONS
@moodCode
cs0 … 1FEVN
hl7:id
II0 … *CDAadotstion
hl7:code
CE0 … 1CDAadotstion
 CONF
shall be drawn from concept domain "ActCode"
hl7:statusCode
CS1 … 1RCDAadotstion
@code
CONF0 … 1Fcompleted
Included0 … 1 from 2.16.840.1.113883.10.12.113 CDA componentOf (DYNAMIC)
hl7:componentOf
0 … 1CDAcdotsntOf
@typeCode
cs0 … 1FCOMP
hl7:encompassingEncounter
1 … 1CDAcdotsntOf
@classCode
cs0 … 1FENC
@moodCode
cs0 … 1FEVN
hl7:id
II0 … *CDAcdotsntOf
hl7:code
CE0 … 1CDAcdotsntOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
hl7:effectiveTime
IVL_TS1 … 1RCDAcdotsntOf
hl7:dischargeDispositionCode
CE0 … 1CDAcdotsntOf
 CONF
shall be drawn from concept domain "EncounterDischargeDisposition"
hl7:responsibleParty
0 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAcdotsntOf
@typeCode
cs0 … 1FRESP
hl7:encounterParticipant
0 … *CDAcdotsntOf
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
hl7:time
IVL_TS0 … 1CDAcdotsntOf
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAcdotsntOf
hl7:location
0 … 1CDAcdotsntOf
@typeCode
cs0 … 1FLOC
hl7:healthCareFacility
1 … 1CDAcdotsntOf
@classCode
cs0 … 1FSDLOC
hl7:id
II0 … *CDAcdotsntOf
hl7:code
CE0 … 1CDAcdotsntOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
hl7:location
0 … 1Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)CDAcdotsntOf
hl7:serviceProviderOrganization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)CDAcdotsntOf
Included1 … 1M from 2.16.840.1.113883.3.51.60.1.11 BC CDA componentOf (DYNAMIC)
hl7:componentOf
1 … 1MCDAcdotsntOf
@typeCode
cs1 … 1FCOMPCONFdots0528
hl7:encompassingEncounter
1 … 1RCONFdots0114
@classCode
cs1 … 1FENCCONFdots0529
@moodCode
cs1 … 1FEVN
hl7:id
II0 … *CONFdots0114
hl7:effectiveTime
IVL_TS1 … 1RCONFdots0114
hl7:responsibleParty
0 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CONFdots0116
@typeCode
cs1 … 1FRESPCONFdots0530
hl7:encounterParticipant
0 … *CONFdots0115
@typeCode
cs1 … 1RCONFdots0117
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
 ConstraintMAY contain zero or more [0..*]encounterParticipantelements. If present, the encounterParticipant/assignedEntity element SHALL have at least one of assignedPerson or representedOrganization element present.
hl7:assignedEntity
1 … 1RContains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CONFdots0115