abstractbaseDefinitioncopyrightdate- Values Differ
descriptionexperimentalfhirVersionjurisdiction
jurisdiction[0]kindnamepublisher- Values Differ
purposestatustitletypeurlversion- Values Differ
| Left: | Referral Note (http://hl7.org/fhir/us/ccda/StructureDefinition/Referral-Note) |
| Right: | Referral Note (http://hl7.org/fhir/us/ccda/StructureDefinition/Referral-Note) |
| Error | StructureDefinition.version | Values for version differ: '1.2.0-ballot' vs '1.2.0' |
| Information | StructureDefinition.date | Values for date differ: '2023-03-27T20:45:24+00:00' vs '2024-03-12T16:03:19+00:00' |
| Information | StructureDefinition.publisher | Values for publisher differ: 'HL7 Structured Documents Working Group' vs 'HL7 International / Cross-Group Projects' |
| Name | Value | Comments | |
|---|---|---|---|
| abstract | false | ||
| baseDefinition | http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header | ||
| copyright | |||
| date | 2023-03-27T20:45:24+00:00 | 2024-03-12T16:03:19+00:00 |
|
| description | 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. * When patient is sent by a cardiologist to an emergency department for angina. * When a patient is referred by a nurse practitioner to an audiologist for hearing screening. * When a patient is referred by a hospitalist to social services. | ||
| experimental | |||
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
| jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | ReferralNote | ||
| publisher | HL7 Structured Documents Working Group | HL7 International / Cross-Group Projects |
|
| purpose | |||
| status | active | ||
| title | Referral Note | ||
| type | Composition | ||
| url | http://hl7.org/fhir/us/ccda/StructureDefinition/Referral-Note | ||
| version | 1.2.0-ballot | 1.2.0 |
|
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | L Type | L Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||||||||
 id | Σ | 0..1 | id | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource | |||||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!Σ | 0..1 | uri | A set of rules under which this content was created | |||||||||
| language | S | 1..1 | code | language Binding: ?? (preferred): A human language.
| S | 1..1 | code | language Binding: ?? (preferred): A human language.
| |||||||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored | |||||||||
| identifier | SΣ | 1..1 | Identifier | identifier | SΣ | 1..1 | Identifier | identifier | |||||||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: ?? (required): The workflow/clinical status of the composition. | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: ?? (required): The workflow/clinical status of the composition. | |||||||||
| type | SΣ | 1..1 | CodeableConcept | type Binding: ?? (required) | SΣ | 1..1 | CodeableConcept | type Binding: ?? (required) | |||||||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: ?? (example): High-level kind of a clinical document at a macro level. | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: ?? (example): High-level kind of a clinical document at a macro level. | |||||||||
| subject | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | |||||||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | |||||||||
| date | SΣ | 1..1 | dateTime | date | SΣ | 1..1 | dateTime | date | |||||||||
| author | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | |||||||||
| title | SΣ | 1..1 | string | Document Title | SΣ | 1..1 | string | Document Title | |||||||||
| confidentiality | Σ | 0..0 | Σ | 0..0 | |||||||||||||
 Slices for attester | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| mode | 1..1 | code | personal | professional | legal | official Binding: ?? (required): The way in which a person authenticated a composition. | 1..1 | code | personal | professional | legal | official Binding: ?? (required): The way in which a person authenticated a composition. | |||||||||||
| time | 0..1 | dateTime | When the composition was attested | 0..1 | dateTime | When the composition was attested | |||||||||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||||||||
| custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | |||||||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | 0..* | BackboneElement | Relationships to other compositions/documents | |||||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: ?? (required): The type of relationship between documents. | 1..1 | code | replaces | transforms | signs | appends Binding: ?? (required): The type of relationship between documents. | |||||||||||
| target[x] | 1..1 | Identifier, Reference(Composition) | Target of the relationship | 1..1 | Identifier, Reference(Composition) | Target of the relationship | |||||||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | Σ | 0..* | BackboneElement | The clinical service(s) being documented | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: ?? (example): This list of codes represents the main clinical acts being documented. | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: ?? (example): This list of codes represents the main clinical acts being documented. | |||||||||
| period | Σ | 0..1 | Period | The period covered by the documentation | Σ | 0..1 | Period | The period covered by the documentation | |||||||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | Σ | 0..* | Reference(Resource) | The event(s) being documented | |||||||||
 Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | |||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| title | 0..1 | string | Label for section (e.g. for ToC) | 0..1 | string | Label for section (e.g. for ToC) | |||||||||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: ?? (example): Classification of a section of a composition/document. | 0..1 | CodeableConcept | Classification of section (recommended) Binding: ?? (example): Classification of a section of a composition/document. | |||||||||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | C | 0..1 | Narrative | Text summary of the section, for human interpretation | |||||||||
| mode | 0..1 | code | working | snapshot | changes Binding: ?? (required): The processing mode that applies to this section. | 0..1 | code | working | snapshot | changes Binding: ?? (required): The processing mode that applies to this section. | |||||||||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ?? (preferred): What order applies to the items in the entry. | 0..1 | CodeableConcept | Order of section entries Binding: ?? (preferred): What order applies to the items in the entry. | |||||||||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | C | 0..* | Reference(Resource) | A reference to data that supports this section | |||||||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ?? (preferred): If a section is empty, why it is empty. | C | 0..1 | CodeableConcept | Why the section is empty Binding: ?? (preferred): If a section is empty, why it is empty. | |||||||||
 section | C | 0..* | See section (Composition) | Nested Section | C | 0..* | See section (Composition) | Nested Section | |||||||||
| Documentation for this format | |||||||||||||||||