1.3.6.1.4.1.19376.1.5.3.1.1.3
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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
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/XDS-MS#Use_Case_1:_Ambulatory_Specialist_Referral. 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 |
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 Handled by the Medical Documents Content Profile by reference to constraints in HL7 CRS. |
R | |
Pertinent Insurance Information Refer to Appropriate Payers Section -- TBD |
R2 | |
Data needed for state and local referral forms, if different than above These are handed by including additional sections within the summary.
|
R2 |
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.
<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='20240814012005'/> <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> |
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.3'> <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.3"]'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='../cda:ClinicalDocument'> Error: The Referral Summary can only be used on Clinical Documents. </assert> <!-- 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> <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 Referral Summary Document must contain a(n) Reason for Referral Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document must contain a(n) History Present Illness Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document must contain a(n) Active Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document must contain a(n) Current Meds Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document must contain a(n) Allergies Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document should contain a(n) Resolved Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document should contain a(n) List of Surgeries Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document should contain a(n) Immunizations Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document should contain a(n) Family History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document should contain a(n) Social History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document does not contain a(n) Pertinent Review of Systems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document should contain a(n) Vital Signs Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document should contain a(n) Physical Exam Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document should contain a(n) Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </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 Referral Summary Document should contain a(n) Plan of Care (new meds, labs, or x-rays ordered) Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> <!-- Alert on any missing required if known elements --> Warning: The Referral Summary Document should contain a(n) Advance Directives Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </assert> <assert test='.//cda:templateId[@root = ""]'> <!-- Verify that all required data elements are present --> Error: The Referral Summary Document must contain a(n) Patient Administrative Identifiers Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </assert> <assert test='.//cda:templateId[@root = ""]'> <!-- Alert on any missing required if known elements --> Warning: The Referral Summary Document should contain a(n) Pertinent Insurance Information Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.3 </assert> <assert test='.//cda:templateId[@root = ""]'> <!-- Alert on any missing required if known elements --> Warning: The Referral Summary 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=1.3.6.1.4.1.19376.1.5.3.1.1.3 </assert> </rule> </pattern>
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