Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.3"
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| − | {{CDA Document|Referral Summary|1.3.6.1.4.1.19376.1.5.3.1.1.3 | + | {{CDA Document|Referral Summary|1.3.6.1.4.1.19376.1.5.3.1.1.3|Draft| |
| − | + | 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.| | |
| − | 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. | + | Index={{T3|Data Elements|HL7 Care Record Summary|CDA Release 2.0| |
| − | + | {{R3|Reason for Referral|Reason for Referral|REASON FOR REFERRAL}} | |
| − | + | {{R3|History Present Illness|History of Present Illness|HISTORY OF PRESENT ILLNESS}} | |
| − | | | + | {{R3|Active Problems|Conditions|PROBLEM LIST}} |
| − | + | {{R3|Medications|HISTORY OF MEDICATION USE}} | |
| − | + | {{R3|Allergies|Allergies and Adverse Reactions|HISTORY OF ALLERGIES}} | |
| − | | | + | {{R3|Resolved Problems|Conditions|HISTORY OF PAST ILLNESS}} |
| − | | | + | {{R3|List of Surgeries|Past Surgical History|HISTORY OF PRIOR SURGERIES}} |
| − | |Reason for Referral | + | {{R3|Immunizations|Immunizations|HISTORY OF IMMUNIZATIONS}} |
| − | |Reason for Referral | + | {{R3|Family History|Family History|HISTORY OF FAMILY ILLNESS}} |
| − | |REASON FOR REFERRAL | + | {{R3|Social History|Social History|SOCIAL HISTORY}} |
| − | + | {{R3|Pertinent Review of Systems|Review of Systems|REVIEW OF SYSTEMS}} | |
| − | |History Present Illness | + | {{R3|Vital Signs|Physical Exam|VITAL SIGNS}} |
| − | |History of Present Illness | + | {{R3|Physical Exam|Physical Exam|GENERAL STATUS, PHYSICAL FINDINGS}} |
| − | |HISTORY OF PRESENT ILLNESS | + | {{R3|Relevant Diagnostic Surgical Procedures / Clinical Reports (including links)|Studies and Reports|RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA}} |
| − | + | {{R3|Relevant Diagnostic Test and Reports (Lab, Imaging, EKG<nowiki>'</nowiki>s, etc.) including links. | |
| − | |Active Problems | + | |Studies and Reports|RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA}} |
| − | |Conditions | + | {{R3|Plan of Care (new meds labs, or x-rays ordered)|Care Plan|TREATMENT PLAN}} |
| − | |PROBLEM LIST | + | {{R3|Advance Directives|Advance Directives|ADVANCE DIRECTIVES}} |
| − | + | {{R3|Patient Administrative Identifiers|Header|patientRole/id}} | |
| − | + | {{R3|Pertinent Insurance Information|Participant|participant<nowiki>[</nowiki>@roleCode=<nowiki>'</nowiki>HLD<nowiki>']</nowiki>}} | |
| − | |Medications | + | {{R3|Data needed for state and local referral forms, if different than above|Optional Sections|section}} |
| − | |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<nowiki>'</nowiki>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<nowiki>[</nowiki>@roleCode=<nowiki>'</nowiki>HLD<nowiki>']</nowiki> | ||
| − | |||
| − | |Data needed for state and local referral forms, if different than above | ||
| − | |Optional Sections | ||
| − | |section | ||
| − | |||
| − | |||
Revision as of 16:18, 11 May 2007
{{CDA Document|Referral Summary|1.3.6.1.4.1.19376.1.5.3.1.1.3|Draft| 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.| 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 | ||||
| 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 | |||||
| Data needed for state and local referral forms, if different than above | Optional Sections | section | ||||
| 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 | ||||
| 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 | |||||
| Data needed for state and local referral forms, if different than above | Optional Sections | section |