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 |
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.
<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='20240917012005'/> <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>
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- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.31
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.34
- Templates using
- Templates using These are handed by including additional sections within the summary.
- CDA Document Templates