1.3.6.1.4.1.19376.1.5.3.1.1.3

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Development Only

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

Draft.gif 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

Transition to new CDA Document template to support schematron-->>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 R Handled by the Medical Documents Content Profile by reference to constraints in HL7 CRS.
Pertinent Insurance Information R2 Refer to Appropriate Payers Section -- TBD
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='20240418012005'/>
  <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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