1.3.6.1.4.1.19376.1.5.3.1.1.10

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Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif Emergency Department Referral Specification 1.3.6.1.4.1.19376.1.5.3.1.1.10

An ED Referral is a type of Referral Summary, and incorporates the constraints defined for Referral Summaries.

This use case is described fully in the EDR Profile in PCC TF-1. Briefly, it involves a collaborative transfer of care for the referral of a patient from a care provider to an emergency department. Using this use case the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below.

Using this information from the use case, the following mappings were made to existing standards.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:edr:2007

Parent Template

This document is an instance of the Medical Summary template.


Data Element Index
Data Elements HL7 Care Record Summary CDA Release 2.0
Reason for Referral Reason for Referral REASON FOR REFERRAL
History Present Illness History of Present Illness HISTORY OF PRESENT ILLNESS
Active Problems Conditions PROBLEM LIST
Current Meds Medications HISTORY OF MEDICATION USE
Allergies Allergies and Adverse Reactions HISTORY OF ALLERGIES
Resolved Problems Conditions HISTORY OF PAST ILLNESS
List of Surgeries Past Surgical History HISTORY OF PRIOR SURGERIES
Immunizations Immunizations HISTORY OF IMMUNIZATIONS
Family History Family History HISTORY OF FAMILY ILLNESS
Social History Social History SOCIAL HISTORY
Pertinent Review of Systems Review of Systems REVIEW OF SYSTEMS
Vital Signs Physical Exam VITAL SIGNS
Physical Exam Physical Exam GENERAL STATUS, PHYSICAL FINDINGS
Relevant Surgical Procedures / Clinical Reports (including links) Studies and Reports RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links. Studies and Reports RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA
Care Plan (new meds labs, or x-rays ordered) Care Plan TREATMENT PLAN
Proposed ED Disposition ED DISPOSITION
Mode of Transport to the Emergency Department Care Plan MODE OF TRANSPORT
Estimated Time of Arrival to the ED Care Plan MODE OF TRANSPORT
Advance Directives Advance Directives ADVANCE DIRECTIVES
Patient Administrative Identifiers Header patientRole/id
Pertinent Insurance Information Participant participant[@roleCode='HLD']
Data needed for state and local referral forms, if different than above Optional Sections section
Specification
Data Element Name Opt Template ID
Reason for Referral R 1.3.6.1.4.1.19376.1.5.3.1.3.1
History Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems R 1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Meds R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Resolved Problems R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries R2 1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History R2 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
Pertinent Review of Systems O 1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs R2 1.3.6.1.4.1.19376.1.5.3.1.3.25
Physical Exam R2 1.3.6.1.4.1.19376.1.5.3.1.3.24
Relevant Diagnostic Results and/or Clinical Reports
Includes Diagnostic Surgical Procedures, Clinical Reports and Diagnostic Tests and Results (Lab, Imaging, EKG’s, etc.) including links to relevant documents.
R2 1.3.6.1.4.1.19376.1.5.3.1.3.27
Care Plan
(new meds, labs, or x-rays ordered)
R2 1.3.6.1.4.1.19376.1.5.3.1.3.31
Mode of Transport to the Emergency Department
(includes ETA)
R 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Proposed ED Disposition R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
Advance Directives
The availability of information about Advance Directives must provided. A common concern among ED providers is over situations where patients presented to the ED require extensive resuscitative efforts, only later to discover that the patient had a DNR order.
R 1.3.6.1.4.1.19376.1.5.3.1.3.34
Patient Administrative Identifiers
These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS.
R
Pertinent Insurance Information R2
Data needed for state and local referral forms, if different than above
These are handed by including additional sections within the summary.
R2

Note: Highlighted items in the table above are different from what appears in the XDS-MS profile. All other data elements have identical definitions.
Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Emergency Department Referral Document
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.3'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Emergency Department Referral</title> <effectiveTime value='20200702012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/>  : <component><structuredBody>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.1'/> <!-- Required Reason for Referral Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/> <!-- Required History Present Illness Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <!-- Required Active Problems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/> <!-- Required Current Meds Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/> <!-- Required Allergies Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/> <!-- Required if known Resolved Problems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/> <!-- Required if known List of Surgeries Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/> <!-- Required if known Immunizations Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/> <!-- Required if known Family History Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/> <!-- Required if known Social History Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/> <!-- Optional Pertinent Review of Systems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/> <!-- Required if known Vital Signs Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/> <!-- Required if known Physical Exam Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/> <!-- Required if known Relevant Diagnostic Results and/or Clinical Reports Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <!-- Required if known Care Plan Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/> <!-- Required Mode of Transport to the Emergency Department
(includes ETA) Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/> <!-- Required if known Proposed ED Disposition Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/> <!-- Required Advance Directives Section content --> </section> </component>
    </structuredBody></component> </ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.10'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.10"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Emergency Department Referral can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.3"]'>
     Error: The parent template identifier for Emergency Department Referral is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Emergency Department Referral must be {{{LOINC}}}
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Reason for Referral Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) History Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Current Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Resolved Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Emergency Department Referral Document does not contain a(n) Pertinent Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Physical Exam Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Relevant Diagnostic Results and/or Clinical Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Emergency Department Referral Document should contain a(n) Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Emergency Department Referral Document must contain a(n) Mode of Transport to the Emergency Department
(includes ETA) Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert>  <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'>  <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Proposed ED Disposition Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert>  <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'>  <!-- Verify that all required data elements are present --> Error: The Emergency Department Referral Document must contain a(n) Advance Directives Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10  </assert>  <assert test='.//cda:templateId[@root = ""]'>  <!-- Verify that all required data elements are present --> Error: The Emergency Department Referral Document must contain a(n) Patient Administrative Identifiers Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10  </assert>  <assert test='.//cda:templateId[@root = ""]'>  <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Pertinent Insurance Information Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10 </assert>  <assert test='.//cda:templateId[@root = ""]'>  <!-- Alert on any missing required if known elements --> Warning: The Emergency Department Referral Document should contain a(n) Data needed for state and local referral forms, if different than above Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.10  </assert>  </rule> </pattern>