1.3.6.1.4.1.19376.1.5.3.1.1.10

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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(1.3.6.1.4.1.19376.1.5.3.1.1.3) .

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 Emergency Department Referral Document

<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Emergency Department Referral</title> <effectiveTime value='20260408012005'/> <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 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>

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 below in Figure 5.4 4. Note that an ED Referral is a Referral Summary, and so includes that <templateId> element as well.

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.10"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.3"/>
    :

A CDA Document may conform to more than one template, and can therefore have more that one <templateId> element. Both of the <templateId> elements shown above must be present in the document.

This use case is described fully in Link TBD. 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 under the column “Use Case Documentation Section”.

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

|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
Plan of Care (new meds labs, or x-rays ordered)	Care Plan	TREATMENT PLAN
Proposed disposition	Care Plan	TREATMENT PLAN
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
Data needed for state and local referral forms, if different than above	Optional Sections	section

|Data= |style='border:1px solid black;'|Reason for Referral |align=center style='border:1px solid black;'|R |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.1 |-

|style='border:1px solid black;'|History Present Illness |align=center style='border:1px solid black;'|R |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.4 |-

|style='border:1px solid black;'|Active Problems |align=center style='border:1px solid black;'|R |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.6 |-

|style='border:1px solid black;'|Current Meds |align=center style='border:1px solid black;'|R |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.19 |-

|style='border:1px solid black;'|Allergies |align=center style='border:1px solid black;'|R |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.13 |-

|style='border:1px solid black;'|Resolved Problems |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.8 |-

|style='border:1px solid black;'|List of Surgeries |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.11 |-

|style='border:1px solid black;'|Immunizations |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.23 |-

|style='border:1px solid black;'|Family History |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.14 |-

|style='border:1px solid black;'|Social History |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.16 |-

|style='border:1px solid black;'|Pertinent Review of Systems |align=center style='border:1px solid black;'|O |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.18 |-

|style='border:1px solid black;'|Vital Signs |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.25 |-

|style='border:1px solid black;'|Physical Exam |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.24 |-

|style='border:1px solid black;'|Relevant Diagnostic Surgical Procedures / Clinical Reports and Relevant Diagnostic Test and Reports (Lab, Imaging, EKG’s, etc.) including links. |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.27 |-

|style='border:1px solid black;'|Plan of Care (new meds, labs, or x-rays ordered) |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.1.10.3.1 |-

|style='border:1px solid black;'|Mode of Transport to the Emergency Department |align=center style='border:1px solid black;'|R |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2 |-

|style='border:1px solid black;'|Estimated Time of Arrival |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1 |-

|style='border:1px solid black;'|Proposed disposition |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2 |-

|style='border:1px solid black;'|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. |align=center style='border:1px solid black;'|R |style='border:1px solid black;' |1.3.6.1.4.1.19376.1.5.3.1.3.34 |-

|style='border:1px solid black;'|Patient Administrative Identifiers |align=center style='border:1px solid black;'|R |style='border:1px solid black;' |These are handed by the Medical Documents Content Profile by reference to constraints in HL7 CRS. |-

|style='border:1px solid black;'|Pertinent Insurance Information |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' | |-

|style='border:1px solid black;'|Data needed for state and local referral forms, if different than above |align=center style='border:1px solid black;'|R2 |style='border:1px solid black;' |These are handed by including additional sections within the summary. |-

}}

1. These data elements are different from what appears in the XDS-MS profile. All other data elements have identical definitions.