Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build United States of America flag

Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

Logical Model: Referral Note

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ReferralNote Version: 2.1
Active as of 2023-09-29 Computable Name: ReferralNote
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.1.14:2015-08-01

A Referral Note communicates pertinent information from a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery.

Examples of referral situations are when a patient is referred from a family physician to a cardiologist for cardiac evaluation or when patient is sent by a cardiologist to an emergency department for angina or when a patient is referred by a nurse practitioner to an audiologist for hearing screening or when a patient is referred by a hospitalist to social services.

Usage:

  • This Logical Model is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USRealmHeader

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
... templateId 2..*II
... templateId:primary 1..1II
.... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
.... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
.... intendedRecipient 1..1IntendedRecipient
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for participant 0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
Slice: Unordered, Open by value:typeCode
.... participant:participant1 0..*Participant1
..... typeCode 1..1csFixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name 1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
.... participant:participant2 0..*Participant1
..... typeCode 1..1csFixed Value: CALLBCK
..... associatedEntity 1..1AssociatedEntity
...... classCode 1..1csFixed Value: ASSIGNED
...... id 1..*II
...... addr 0..*AD
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... name 1..*PN
...... scopingOrganization 0..1Organization
... component
.... structuredBody C1..1StructuredBody1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
1198-29103: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
..... Slices for component 5..*InfrastructureRootSlice: Unordered, Open by value:section.code
...... component:planOfTreatment 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:advanceDirectives 0..1InfrastructureRoot
....... section 1..1AdvanceDirectivesSectionBase for all types and resources
...... component:historyOfPresentIllness 0..1InfrastructureRoot
....... section 1..1HistoryofPresentIllnessSectionBase for all types and resources
...... component:familyHistory 0..1InfrastructureRoot
....... section 1..1FamilyHistorySectionBase for all types and resources
...... component:immunizations 0..1InfrastructureRoot
....... section 1..1ImmunizationsSectionBase for all types and resources
...... component:problem 1..1InfrastructureRoot
....... section 1..1ProblemSectionBase for all types and resources
...... component:procedures 0..1InfrastructureRoot
....... section 1..1ProceduresSectionBase for all types and resources
...... component:results 0..1InfrastructureRoot
....... section 1..1ResultsSectionBase for all types and resources
...... component:reviewOfSystems 0..1InfrastructureRoot
....... section 1..1ReviewofSystemsSectionBase for all types and resources
...... component:socialHistory 0..1InfrastructureRoot
....... section 1..1SocialHistorySectionBase for all types and resources
...... component:vitalSigns 0..1InfrastructureRoot
....... section 1..1VitalSignsSectionBase for all types and resources
...... component:functionalStatus 0..1InfrastructureRoot
....... section 1..1FunctionalStatusSectionBase for all types and resources
...... component:physicalExam 0..1InfrastructureRoot
....... section 1..1PhysicalExamSectionBase for all types and resources
...... component:nutrition 0..1InfrastructureRoot
....... section 1..1NutritionSectionBase for all types and resources
...... component:mentalStatus 0..1InfrastructureRoot
....... section 1..1MentalStatusSectionBase for all types and resources
...... component:medicalEquip 0..1InfrastructureRoot
....... section 1..1MedicalEquipmentSectionBase for all types and resources
...... component:allergiesAndIntolerances 1..1InfrastructureRoot
....... section 1..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:assessment 0..1InfrastructureRoot
....... section 1..1AssessmentSectionBase for all types and resources
...... component:assessmentAndPlan 0..1InfrastructureRoot
....... section 1..1AssessmentandPlanSectionBase for all types and resources
...... component:medicalHistory 0..1InfrastructureRoot
....... section 1..1PastMedicalHistoryBase for all types and resources
...... component:generalStatus 0..1InfrastructureRoot
....... section 1..1GeneralStatusSectionBase for all types and resources
...... component:medications 1..1InfrastructureRoot
....... section 1..1MedicationsSectionBase for all types and resources
...... component:reasonForReferral 1..1InfrastructureRoot
....... section 1..1ReasonforReferralSectionBase for all types and resources
...... component:payers 1..1InfrastructureRoot
....... section 1..1PayersSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredINDRoleclassCodes

Constraints

IdGradePath(s)DetailsRequirements
1198-29102errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
:
1198-29103errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
... realmCode 1..1CS
.... @code 1..1csRequired Pattern: US
... typeId 1..1II
.... @root 1..1stFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stExtension
Fixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2023-05-01
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... @extension 1..1stRequired Pattern: 2015-08-01
... code C1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... recordTarget 1..*RecordTarget
.... patientRole 1..1PatientRole
..... id 1..*II
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
... author 1..*Author
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:id1 0..1IIid
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
... Slices for informant 0..*InformantSlice: Unordered, Open by value:relatedEntity
.... informant:informant1 0..*Informantinformant
..... assignedEntity 1..1AssignedEntity
...... id C1..*II
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... assignedPerson 1..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
.... informant:informant2 0..*Informantinformant
..... relatedEntity 1..1RelatedEntity
... custodian 1..1Custodian
.... assignedCustodian 1..1AssignedCustodian
..... representedCustodianOrganization 1..1CustodianOrganization
...... id 1..*II
...... name 1..1ON
...... telecom 1..1TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..1USRealmAddressADUSFIELDEDBase for all types and resources
... informationRecipient 1..1InformationRecipient
.... intendedRecipient 1..1IntendedRecipient
..... @classCode 1..1cs
..... addr 0..*AD
..... telecom 0..*TEL
..... informationRecipient 1..1Person
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for authenticator 0..*AuthenticatorSlice: Unordered, Open by value:ClinicalDocument.signatureCode, value:ClinicalDocument.assignedEntity, value:ClinicalDocument.time
.... authenticator:authenticator1 0..*Authenticatorauthenticator
..... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
..... signatureCode 1..1CS
...... @code 1..1csRequired Pattern: S
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... telecom 1..*TEL
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... assignedPerson 1..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for participant C0..*Participant1This participant represents the clinician to contact for questions about the referral note. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
Slice: Unordered, Open by value:typeCode
.... participant:All Slices Content/Rules for all slices
..... associatedEntity 1..1AssociatedEntity
.... participant:participant1 C0..*Participant1
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: IND
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: INDRoleclassCodes (required)
...... associatedPerson 1..1Person
....... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
.... participant:participant2 C0..*Participant1
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: CALLBCK
..... associatedEntity 1..1AssociatedEntity
...... @classCode 1..1csBinding: RoleClassAssociative (required)
Fixed Value: ASSIGNED
...... id 1..*II
...... addr 0..*AD
...... telecom 1..*TEL
...... associatedPerson 1..1Person
....... name 1..*PN
...... scopingOrganization 0..1Organization
... component 1..1Component
.... structuredBody C1..1StructuredBody1198-29102: This structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
1198-29103: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
..... Slices for component 5..*InfrastructureRootSlice: Unordered, Open by value:section.code
...... component:All Slices Content/Rules for all slices
....... section 1..1Section
...... component:planOfTreatment 0..1InfrastructureRoot
....... section 1..1PlanofTreatmentSectionBase for all types and resources
...... component:advanceDirectives 0..1InfrastructureRoot
....... section 1..1AdvanceDirectivesSectionBase for all types and resources
...... component:historyOfPresentIllness 0..1InfrastructureRoot
....... section 1..1HistoryofPresentIllnessSectionBase for all types and resources
...... component:familyHistory 0..1InfrastructureRoot
....... section 1..1FamilyHistorySectionBase for all types and resources
...... component:immunizations 0..1InfrastructureRoot
....... section 1..1ImmunizationsSectionBase for all types and resources
...... component:problem 1..1InfrastructureRoot
....... section 1..1ProblemSectionBase for all types and resources
...... component:procedures 0..1InfrastructureRoot
....... section 1..1ProceduresSectionBase for all types and resources
...... component:results 0..1InfrastructureRoot
....... section 1..1ResultsSectionBase for all types and resources
...... component:reviewOfSystems 0..1InfrastructureRoot
....... section 1..1ReviewofSystemsSectionBase for all types and resources
...... component:socialHistory 0..1InfrastructureRoot
....... section 1..1SocialHistorySectionBase for all types and resources
...... component:vitalSigns 0..1InfrastructureRoot
....... section 1..1VitalSignsSectionBase for all types and resources
...... component:functionalStatus 0..1InfrastructureRoot
....... section 1..1FunctionalStatusSectionBase for all types and resources
...... component:physicalExam 0..1InfrastructureRoot
....... section 1..1PhysicalExamSectionBase for all types and resources
...... component:nutrition 0..1InfrastructureRoot
....... section 1..1NutritionSectionBase for all types and resources
...... component:mentalStatus 0..1InfrastructureRoot
....... section 1..1MentalStatusSectionBase for all types and resources
...... component:medicalEquip 0..1InfrastructureRoot
....... section 1..1MedicalEquipmentSectionBase for all types and resources
...... component:allergiesAndIntolerances 1..1InfrastructureRoot
....... section 1..1AllergiesAndIntolerancesSectionBase for all types and resources
...... component:assessment 0..1InfrastructureRoot
....... section 1..1AssessmentSectionBase for all types and resources
...... component:assessmentAndPlan 0..1InfrastructureRoot
....... section 1..1AssessmentandPlanSectionBase for all types and resources
...... component:medicalHistory 0..1InfrastructureRoot
....... section 1..1PastMedicalHistoryBase for all types and resources
...... component:generalStatus 0..1InfrastructureRoot
....... section 1..1GeneralStatusSectionBase for all types and resources
...... component:medications 1..1InfrastructureRoot
....... section 1..1MedicationsSectionBase for all types and resources
...... component:reasonForReferral 1..1InfrastructureRoot
....... section 1..1ReasonforReferralSectionBase for all types and resources
...... component:payers 1..1InfrastructureRoot
....... section 1..1PayersSectionBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalDocument.coderequiredReferralDocumentType
ClinicalDocument.confidentialityCodepreferredHL7 BasicConfidentialityKind
ClinicalDocument.languageCoderequiredhttp://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.11526
ClinicalDocument.recordTarget.patientRole.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCoderequiredAdministrative Gender (HL7 V3)
ClinicalDocument.recordTarget.patientRole.patient.raceCoderequiredRace Category Excluding Nulls
ClinicalDocument.recordTarget.patientRole.patient.ethnicGroupCoderequiredEthnicity
ClinicalDocument.author.assignedAuthor.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.authenticator:authenticator1.assignedEntity.telecom.userequiredTelecom Use (US Realm Header)
ClinicalDocument.participant:participant1.typeCoderequiredFixed Value: IND
ClinicalDocument.participant:participant1.associatedEntity.classCoderequiredINDRoleclassCodes
ClinicalDocument.participant:participant2.typeCoderequiredFixed Value: CALLBCK
ClinicalDocument.participant:participant2.associatedEntity.classCoderequiredFixed Value: ASSIGNED

Constraints

IdGradePath(s)DetailsRequirements
1198-29102errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-29102).
:
1198-29103errorClinicalDocument.component.structuredBodyThis structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-29103).
:
4537-5299errorClinicalDocument.recordTarget.patientRole.patient.birthTime**SHALL** be precise to year (CONF:4537-5299).
:
4537-5300warningClinicalDocument.recordTarget.patientRole.patient.birthTime**SHOULD** be precise to day (CONF:4537-5300).
:
4537-9946warningClinicalDocument.informant:informant1.assignedEntity.idIf assignedEntity/id is a provider then this id, **SHOULD** include zero or one [0..1] id where id/@root ="2.16.840.1.113883.4.6" National Provider Identifier (CONF:4537-9946).
:
4537-9991warningClinicalDocument.idThis id **SHALL** be a globally unique identifier for the document (CONF:4537-9991).
:
4537-9992errorClinicalDocument.codeThis code **SHALL** specify the particular kind of document (e.g., History and Physical, Discharge Summary, Progress Note) (CONF:4537-9992).
:
4537-10006errorClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2**SHALL** contain associatedEntity/associatedPerson *AND/OR* associatedEntity/scopingOrganization (CONF:4537-10006).
:
4537-10007warningClinicalDocument.participant, ClinicalDocument.participant:participant1, ClinicalDocument.participant:participant2When participant/@typeCode is *IND*, associatedEntity/@classCode **SHOULD** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes *DYNAMIC* (CONF:4537-10007).
:
4537-16790errorClinicalDocument.author.assignedAuthorThere **SHALL** be exactly one assignedAuthor/assignedPerson or exactly one assignedAuthor/assignedAuthoringDevice (CONF:4537-16790).
:
4537-32418warningClinicalDocument.recordTarget.patientRole.patient.birthTime**MAY** be precise to the minute (CONF:4537-32418).
:
4537-32948errorClinicalDocument.codeThis code **SHALL** be drawn from the LOINC document type ontology (LOINC codes where SCALE = DOC) (CONF:4537-32948).
:
81-7278errorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.name**SHALL NOT** have mixed content except for white space (CONF:81-7278).
:
81-7296errorClinicalDocument.recordTarget.patientRole.addr, ClinicalDocument.author.assignedAuthor.addr, ClinicalDocument.informant:informant1.assignedEntity.addr, ClinicalDocument.custodian.assignedCustodian.representedCustodianOrganization.addr, ClinicalDocument.authenticator:authenticator1.assignedEntity.addr**SHALL NOT** have mixed content except for white space (CONF:81-7296).
:
81-9371errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10127errorClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**SHALL** be precise to the day (CONF:81-10127).
:
81-10128warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**SHOULD** be precise to the minute (CONF:81-10128).
:
81-10129warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.time**MAY** be precise to the second (CONF:81-10129).
:
81-10130warningClinicalDocument.effectiveTime, ClinicalDocument.author.time, ClinicalDocument.authenticator:authenticator1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10130).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
pn-no-lserrorClinicalDocument.recordTarget.patientRole.patient.name, ClinicalDocument.informant:informant1.assignedEntity.assignedPerson.name, ClinicalDocument.informationRecipient.intendedRecipient.informationRecipient.name, ClinicalDocument.authenticator:authenticator1.assignedEntity.assignedPerson.name, ClinicalDocument.participant:participant1.associatedEntity.associatedPerson.nameNo PN name part may have a qualifier of LS.
: (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalDocument 1..1USRealmHeaderXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
... @classCode 0..1csBinding: ActClass (extensible)
Fixed Value: DOCCLIN
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... realmCode 1..1CS
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: US
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... typeId 1..1II
.... @root 1..1stFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1stExtension
Fixed Value: POCD_HD000040
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:us-realm 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.1
..... @extension 1..1stRequired Pattern: 2023-05-01
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.1.14
..... @extension 1..1stRequired Pattern: 2015-08-01
... id C1..1II
... code C1..1CEThe Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).
Binding: ReferralDocumentType (required)
... title 1..1STThe title can either be a locally defined name or the displayName corresponding to clinicalDocument/code
... effectiveTime C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
... confidentialityCode 1..1CEBinding: HL7 BasicConfidentialityKind (preferred)
... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
... setId C0..1II
... versionNumber C0..1INT
... copyTime 0..1TS
... recordTarget 1..*RecordTarget
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: RCT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... patientRole 1..1PatientRole
..... @classCode 0..1csBinding: RoleClassRelationshipFormal (required)
Fixed Value: PAT
..... templateId 0..*II
..... id 1..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... patient 1..1Patient
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... id 0..1II
...... name C1..*USRealmPatientNamePTNUSFIELDEDBase for all types and resources
...... sdtcDesc 0..1EDXML Namespace: urn:hl7-org:sdtc
XML: desc (urn:hl7-org:sdtc)
...... administrativeGenderCode 1..1CEBinding: Administrative Gender (HL7 V3) (required)
...... birthTime C1..1TS
...... sdtcDeceasedInd C0..1BLXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedInd
XML: deceasedInd (urn:hl7-org:sdtc)
...... sdtcDeceasedTime 0..1TSXML Namespace: urn:hl7-org:sdtc
sdtc:deceasedTime
XML: deceasedTime (urn:hl7-org:sdtc)
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... @value C0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
...... sdtcMultipleBirthInd 0..1BLXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthInd (urn:hl7-org:sdtc)
...... sdtcMultipleBirthOrderNumber 0..1INT_POSXML Namespace: urn:hl7-org:sdtc
XML: multipleBirthOrderNumber (urn:hl7-org:sdtc)
...... maritalStatusCode 0..1CEBinding: Marital Status (required)
...... religiousAffiliationCode 0..1CEBinding: Religious Affiliation (required)
...... raceCode 1..1CEBinding: Race Category Excluding Nulls (required)
...... sdtcRaceCode C0..*CEXML Namespace: urn:hl7-org:sdtc
The sdtc:raceCode is only used to record additional values when the patient has indicated multiple races or additional race detail beyond the five categories required for Meaningful Use Stage 2. The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the additional raceCode elements.
XML: raceCode (urn:hl7-org:sdtc)
Binding: Race Value Set (required)
...... ethnicGroupCode 1..1CEBinding: Ethnicity (required)
...... sdtcEthnicGroupCode 0..*CEXML Namespace: urn:hl7-org:sdtc
ethnicGroupCode
XML: ethnicGroupCode (urn:hl7-org:sdtc)
Binding: Detailed Ethnicity (required)
...... guardian 0..*Guardian
....... @classCode 0..1csBinding: RoleClassAgent (required)
Fixed Value: GUARD
....... templateId 0..*II
....... id 0..*II
....... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
....... code 0..1CEBinding: Personal And Legal Relationship Role Type (required)
....... addr C0..*USRealmAddressADUSFIELDEDBase for all types and resources
....... telecom 0..*TEL
........ @nullFlavor 0..1csBinding: NullFlavor (required)
........ @value 0..1url
........ useablePeriod 0..*
......... useablePeriodIVL_TS
......... useablePeriodEIVL_TS
......... useablePeriodPIVL_TS
......... useablePeriodSXPR_TS
........ @use 0..1csBinding: Telecom Use (US Realm Header) (required)
....... guardianPerson 1..1Person
........ @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
........ sdtcAsPatientRelationship 0..*CEXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
....... guardianOrganization 0..1Organization
...... birthplace 0..1Birthplace
....... @classCode 0..1csBinding: RoleClassPassive (required)
Fixed Value: BIRTHPL
....... templateId 0..*II
....... place 1..1Place
........ @classCode 0..1csBinding: EntityClassPlace (required)
Fixed Value: PLC
........ @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
........ templateId 0..*II
........ name 0..1EN
........ addr C1..1AD
......... nullFlavor C0..1csPrimitive Type code
Binding: NullFlavor (required)
......... @isNotOrdered 0..1bl
......... @use 0..*cs
......... delimiter 0..*ADXP
.......... @partType 0..1csFixed Value: DEL
......... country 0..1ADXP
.......... @partType 0..1csFixed Value: CNT
......... state 0..*ADXP
.......... @partType 0..1csFixed Value: STA
......... county 0..*ADXP
.......... @partType 0..1csFixed Value: CPA
......... city 0..*ADXP
.......... @partType 0..1csFixed Value: CTY
......... postalCode 0..*ADXP
.......... @partType 0..1csFixed Value: ZIP
......... streetAddressLine 0..*ADXP
.......... @partType 0..1csFixed Value: SAL
......... houseNumber 0..*ADXP
.......... @partType 0..1csFixed Value: BNR
......... houseNumberNumeric 0..*ADXP
.......... @partType 0..1csFixed Value: BNN
......... direction 0..*ADXP
.......... @partType 0..1csFixed Value: DIR
......... streetName 0..*ADXP
.......... @partType 0..1csFixed Value: STR
......... streetNameBase 0..*ADXP
.......... @partType 0..1csFixed Value: STB
......... streetNameType 0..*ADXP
.......... @partType 0..1csFixed Value: STTYP
......... additionalLocator 0..*ADXP
.......... @partType 0..1csFixed Value: ADL
......... unitID 0..*ADXP
.......... @partType 0..1csFixed Value: UNID
......... unitType 0..*ADXP
.......... @partType 0..1csFixed Value: UNIT
......... careOf 0..*ADXP
.......... @partType 0..1csFixed Value: CAR
......... censusTract 0..*ADXP
.......... @partType 0..1csFixed Value: CEN
......... deliveryAddressLine 0..*ADXP
.......... @partType 0..1csFixed Value: DAL
......... deliveryInstallationType 0..*ADXP
.......... @partType 0..1csFixed Value: DINST
......... deliveryInstallationArea 0..*ADXP
.......... @partType 0..1csFixed Value: DINSTA
......... deliveryInstallationQualifier 0..*ADXP
.......... @partType 0..1csFixed Value: DINSTQ
......... deliveryMode 0..*ADXP
.......... @partType 0..1csFixed Value: DMOD
......... deliveryModeIdentifier 0..*ADXP
.......... @partType 0..1csFixed Value: DMODID
......... buildingNumberSuffix 0..*ADXP
.......... @partType 0..1csFixed Value: BNS
......... postBox 0..*ADXP
.......... @partType 0..1csFixed Value: POB
......... precinct 0..*ADXP
.......... @partType 0..1csFixed Value: PRE
......... other 0..1st
......... useablePeriod 0..*
.......... useablePeriodIVL_TS
.......... useablePeriodEIVL_TS
.......... useablePeriodPIVL_TS
.......... useablePeriodSXPR_TS
...... languageCommunication 0..*LanguageCommunication
....... templateId 0..*II
....... languageCode 1..1CSBinding: VSAC 2.16.840.1.113883.1.11.11526 (required)
....... modeCode 0..1CEBinding: LanguageAbilityMode (required)
....... proficiencyLevelCode 0..1CEBinding: LanguageAbilityProficiency (required)
....... preferenceInd 0..1BL
..... providerOrganization 0..1Organization
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... realmCode 0..*CS
...... typeId 0..1II
...... templateId 0..*II
...... id 1..*II
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 0..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1st
...... name 1..*ON
...... telecom 1..*TEL
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... @value 0..1url
....... useablePeriod 0..*
........ useablePeriodIVL_TS
........ useablePeriodEIVL_TS
........ useablePeriodPIVL_TS
........ useablePeriodSXPR_TS
....... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
...... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
...... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
...... asOrganizationPartOf 0..1OrganizationPartOf
... author 1..*Author
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: AUT
.... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... functionCode 0..1CE
.... time C1..1USRealmDateandTimeDTMUSFIELDEDBase for all types and resources
.... assignedAuthor C1..1AssignedAuthor
..... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
..... templateId 0..*II
..... Slices for id 1..*IISlice: Unordered, Open by value:root
...... id:id1 0..1IIid
....... @nullFlavor 0..1csBinding: NullFlavor (required)
Fixed Value: UNK
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.4.6
....... @extension 0..1st
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @code 1..1csBinding: Healthcare Provider Taxonomy (preferred)
...... @codeSystem 0..1oid, uuid, ruid
...... @codeSystemName 0..1st
...... @codeSystemVersion 0..1st
...... @displayName 0..1st
...... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
...... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... originalText 0..1ED
...... translation 0..*CD
..... addr C1..*USRealmAddressADUSFIELDEDBase for all types and resources
..... telecom 1..*TEL
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @value 0..1url
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..1csBinding: Telecom Use (US Realm Header) (required)
..... assignedPerson 0..1Person
...... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II
...... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... sdtcAsPatientRelationship 0..*CEXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
..... assignedAuthoringDevice 0..1AuthoringDevice
...... @classCode 0..1csBinding: EntityClassDevice (required)
Fixed Value: DEV
...... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
...... templateId 0..*II