Consultation Note

The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter.

A Consultation Note includes the reason for the referral, history of present illness, physical examination, and decision-making components (Assessment and Plan).

resourceCompositionactiveView in C-CDA on FHIR IG

Profile Name

ConsultationNote

Canonical URL

http://hl7.org/fhir/us/ccda/StructureDefinition/Consultation-Note

Base Definition

US-Realm-Header

Derivation

constraint

Differential Elements (140)

Constraints and modifications from the base definition

Path	Cardinality	Type(s)	Must Support	Details
`Composition`	-	-	-	-
`Composition.type`	-	-	Yes	-
`Composition.encounter`	`1..*`	-	Yes	-
`Composition.section`	-	-	-	-
`Composition.section` Slice: allergies_and_intolerances_section	`1..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: allergy_intolerance_entry	-	Reference	Yes	Target: `us-core-allergyintolerance`
`Composition.section` Slice: history_of_present_illness_section	`1..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section` Slice: problem_section	`1..1`	-	-	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	Narrative	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: problem_section_entry	-	Reference	Yes	Target: `us-core-condition`
`Composition.section` Slice: medications_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `MedicationStatementus-core-medicationus-core-medicationrequest`
`Composition.section` Slice: physical_exam_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `Observation`
`Composition.section` Slice: results_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `us-core-observation-lab`
`Composition.section` Slice: advance_directives_section	`*..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: advance_directive_entry	-	Reference	Yes	Target: `Consent`
`Composition.section` Slice: assessment_and_plan_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `us-core-conditionObservationCommunication`
`Composition.section` Slice: assessment_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section` Slice: chief_complaint_and_reason_for_visit_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section` Slice: chief_complaint_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section` Slice: family_history_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `FamilyMemberHistory`
`Composition.section` Slice: functional_status_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `Observation`
`Composition.section` Slice: general_status_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section` Slice: past_medical_history_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `us-core-condition`
`Composition.section` Slice: immunizations_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `us-core-immunization`
`Composition.section` Slice: medical_equipment_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: medical_equipment_entry	-	Reference	Yes	Target: `Deviceus-core-procedure`
`Composition.section` Slice: mental_status_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `Observation`
`Composition.section` Slice: nutrition_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `NutritionOrderClinicalImpression`
`Composition.section` Slice: plan_of_treatment_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `us-core-goalus-core-medicationrequestus-core-encounterCommunicationAppointmentCommunicationRequestDeviceRequestNutritionOrderTaskServiceRequestVisionPrescriptionRequestGroup`
`Composition.section` Slice: procedures_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `us-core-procedure`
`Composition.section` Slice: reason_for_visit_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section` Slice: review_of_systems_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section` Slice: social_history_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `us-core-smokingstatus`
`Composition.section` Slice: vital_signs_section	`*..1`	-	-	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	-	-
`Composition.section.text`	`1..*`	-	-	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `vitalsigns`