Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.140 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: PatientReferralAct | |||
Other Identifiers: : urn:oid:2.16.840.1.113883.10.20.22.4.140 |
This template represents the type of referral (e.g., for dental care, to a specialist, for aging problems) and represents whether the referral is for full care or shared care. It may contain a reference to another act in the document instance representing the clinical reason for the referral (e.g., problem, concern, procedure).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Act
Summary
Mandatory: 9 elements (14 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from CDAR2.Act
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Act | 1..1 | CDAR2.Act | ||
classCode | 1..1 | code | Required Pattern: PCPR | |
moodCode | 1..1 | code | Binding: Patient Referral Act moodCode (required) | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.140 | |
id | 1..* | II | In the case of a Consultation Note where this referral is being fulfilled by this consultation, this id would be referenced in the inFullfilmentOf/order/id of the Consultation Note. | |
code | 1..1 | CD | Binding: Referral Types (required) | |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: active | |
effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the time when the future referral is intended to take place. | |
priorityCode | 0..1 | CE | ||
author | 0..* | AuthorParticipation | ||
participant | 0..* | Participant2 | ||
typeCode | 1..1 | code | Required Pattern: REFT | |
participantRole | 1..1 | ParticipantRole | ||
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
Slices for entryRelationship | 0..* | Element | The following entryRelationship represents a reference to another act in the document instance representing the clinical reason for the referral (e.g., problem, concern, procedure). Slice: Unordered, Open by profile:observation | |
entryRelationship:entryRelationship1 | 0..* | Element | The following entryRelationship represents whether the referral is for full or shared care. | |
typeCode | 1..1 | code | Required Pattern: SUBJ | |
observation | 1..1 | Observation | ||
classCode | 1..1 | code | Required Pattern: OBS | |
moodCode | 1..1 | code | Required Pattern: RQO | |
code | 1..1 | CD | ||
code | 1..1 | string | Required Pattern: ASSERTION | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.4 | |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: completed | |
priorityCode | 0..1 | CE | Binding: ActPriority (preferred) | |
value | 1..1 | CD | Binding: Care Model (preferred) | |
entryRelationship:indication | 0..* | Element | ||
typeCode | 1..1 | code | Required Pattern: RSON | |
observation | 1..1 | Indication | ||
Documentation for this format |
This structure is derived from CDAR2.Act
Summary
Mandatory: 9 elements (14 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Act
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Act | 1..1 | CDAR2.Act | ||
classCode | 1..1 | code | Required Pattern: PCPR | |
moodCode | 1..1 | code | Binding: Patient Referral Act moodCode (required) | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.140 | |
id | 1..* | II | In the case of a Consultation Note where this referral is being fulfilled by this consultation, this id would be referenced in the inFullfilmentOf/order/id of the Consultation Note. | |
code | 1..1 | CD | Binding: Referral Types (required) | |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: active | |
effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the time when the future referral is intended to take place. | |
priorityCode | 0..1 | CE | ||
author | 0..* | AuthorParticipation | ||
participant | 0..* | Participant2 | ||
typeCode | 1..1 | code | Required Pattern: REFT | |
participantRole | 1..1 | ParticipantRole | ||
code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
Slices for entryRelationship | 0..* | Element | The following entryRelationship represents a reference to another act in the document instance representing the clinical reason for the referral (e.g., problem, concern, procedure). Slice: Unordered, Open by profile:observation | |
entryRelationship:entryRelationship1 | 0..* | Element | The following entryRelationship represents whether the referral is for full or shared care. | |
typeCode | 1..1 | code | Required Pattern: SUBJ | |
observation | 1..1 | Observation | ||
classCode | 1..1 | code | Required Pattern: OBS | |
moodCode | 1..1 | code | Required Pattern: RQO | |
code | 1..1 | CD | ||
code | 1..1 | string | Required Pattern: ASSERTION | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.5.4 | |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: completed | |
priorityCode | 0..1 | CE | Binding: ActPriority (preferred) | |
value | 1..1 | CD | Binding: Care Model (preferred) | |
entryRelationship:indication | 0..* | Element | ||
typeCode | 1..1 | code | Required Pattern: RSON | |
observation | 1..1 | Indication | ||
Documentation for this format |
Snapshot View
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
Act.moodCode | required | Patient Referral Act moodCode |
Act.templateId:primary.nullFlavor | required | NullFlavor |
Act.code | required | ReferralTypes |
Act.statusCode | required | ActStatus |
Act.statusCode.nullFlavor | required | NullFlavor |
Act.priorityCode | extensible | ActPriority |
Act.languageCode | required | HumanLanguage |
Act.subject.typeCode | required | Fixed Value: SBJ |
Act.subject.contextControlCode | required | Fixed Value: OP |
Act.subject.awarenessCode | extensible | TargetAwareness |
Act.informant.typeCode | required | Fixed Value: INF |
Act.informant.contextControlCode | required | Fixed Value: OP |
Act.participant.nullFlavor | required | NullFlavor |
Act.participant.typeCode | required | Pattern: REFT |
Act.participant.contextControlCode | required | Fixed Value: OP |
Act.participant.participantRole.classCode | required | RoleClassRoot |
Act.participant.participantRole.code | preferred | HealthcareProviderTaxonomy |
Act.entryRelationship:entryRelationship1.observation.classCode | required | Pattern: OBS |
Act.entryRelationship:entryRelationship1.observation.code | extensible | ObservationType |
Act.entryRelationship:entryRelationship1.observation.code.nullFlavor | required | NullFlavor |
Act.entryRelationship:entryRelationship1.observation.statusCode | required | ActStatus |
Act.entryRelationship:entryRelationship1.observation.statusCode.nullFlavor | required | NullFlavor |
Act.entryRelationship:entryRelationship1.observation.priorityCode | preferred | ActPriority |
Act.entryRelationship:entryRelationship1.observation.languageCode | required | HumanLanguage |
Act.entryRelationship:entryRelationship1.observation.value | preferred | Care Model |
Act.entryRelationship:entryRelationship1.observation.interpretationCode | required | ObservationInterpretation |
Act.entryRelationship:entryRelationship1.observation.methodCode | extensible | ObservationMethod |
Act.entryRelationship:entryRelationship1.observation.subject.typeCode | required | Fixed Value: SBJ |
Act.entryRelationship:entryRelationship1.observation.subject.contextControlCode | required | Fixed Value: OP |
Act.entryRelationship:entryRelationship1.observation.subject.awarenessCode | extensible | TargetAwareness |
Act.entryRelationship:entryRelationship1.observation.informant.typeCode | required | Fixed Value: INF |
Act.entryRelationship:entryRelationship1.observation.informant.contextControlCode | required | Fixed Value: OP |
Act.entryRelationship:entryRelationship1.observation.referenceRange.typeCode | required | Fixed Value: REFV |
Id | Grade | Path | Details | Requirements |
act-er-1 | error | Act.entryRelationship | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
act-er-1 | error | Act.entryRelationship:entryRelationship1 | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
obs-er-1 | error | Act.entryRelationship:entryRelationship1.observation.entryRelationship | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
act-er-1 | error | Act.entryRelationship:indication | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |