1.3.6.1.4.1.19376.1.5.3.1.1.3

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Referral Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.3

The use case is described fully in PCC TF-1: 3.2.1. Briefly, it involves a "collaborative" transfer of care for the referral of a patient from a primary care provider (PCP) to a specialist. The important document data elements identified by physicians and nurses for this use case are listed in the table below under the column "Data Elements". These were then mapped to the categories given HL7 Care Record Summary Implementation Guide, and HL7 CDA Release 2.0. These mappings are provided in the next two columns.

A referral summary is a type of Medical Summary, and incorporates the constraints defined for a Medical Summary(1.3.6.1.4.1.19376.1.5.3.1.1.2) above. This section defines additional constraints for Medical Summary Content used in a Referral summary. These tables present the Categories, as defined in Section 3 of CRS. In no case are these IHE requirements less strict than those defined by CRS.

Standards

CDAR2	Clinical Document Architecture, Release 2.0, 2005, HL7
CRS	Implementation Guide for CDA Release 2 – Level 1 and 2 – Care Record Summary (US realm), 2006, HL7.
CCD	ASTM/HL7 Continuity of Care Document

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 Diagnostic 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
Plan of Care (new meds labs, or x-rays ordered)	Care Plan	TREATMENT PLAN
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

-->>Data<<--

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 Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports (Lab, Imaging, EKG's, etc.) including links.	R2	1.3.6.1.4.1.19376.1.5.3.1.3.27
Plan of Care (new meds, labs, or x-rays ordered)	R2	1.3.6.1.4.1.19376.1.5.3.1.3.31
Advance Directives	R2	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	[[Category:Templates using {{{4}}}]]
Data needed for state and local referral forms, if different than above	R2	These are handed by including additional sections within the summary.

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.

Sample Referral Summary 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'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Referral Summary</title> <effectiveTime value='20240715012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/> : <component><structuredBody>     </structuredBody></component> </ClinicalDocument>

 

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Referral Summary 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>