ConsultationNote

Consultation Note

activeC-CDA Templates4.0.0logical18 key elements

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).

#### Document Sections Although document templates may contain any section, the following sections are specifically called out by this template:

Required Sections

  • ReasonforReferralSection or ReasonforVisitSection
  • AssessmentandPlanSection or both AssessmentSection and PlanofTreatmentSection
  • HistoryofPresentIllnessSection
  • AllergiesAndIntolerancesSection
  • ProblemSection

Recommended Sections

  • MedicationsSection
  • PhysicalExamSection
  • ResultsSection

Additional Sections

  • ChiefComplaintSection
  • ChiefComplaintandReasonforVisitSection
  • FamilyHistorySection
  • GeneralStatusSection
  • PastMedicalHistory
  • ImmunizationsSection
  • ProceduresSection
  • SocialHistorySection
  • VitalSignsSection
  • AdvanceDirectivesSection
  • FunctionalStatusSection
  • ReviewofSystemsSection
  • MedicalEquipmentSection
  • MentalStatusSection
  • NutritionSection

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote
ID
ConsultationNote
Type
Base Definition
USRealmHeader
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
templateId
1+
:consult-note1..1
1+
templateId.root
1+
templateId.extension
1+
sdtcCategory.code
1+
sdtcCategory.codeSystem
1+
participant.associatedEntity.id
1+
participant.associatedEntity.telecom
1+
participant.associatedEntity.associatedPerson
1+
participant.associatedEntity.associatedPerson.name
1+
inFulfillmentOf
1+
The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note.
componentOf
1+
A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter.
componentOf.encompassingEncounter.encounterParticipant.assignedEntity
1+
component.structuredBody
1+
component.structuredBody.component
1+
:hpi1..1
1+
:allergies1..1
1+
:problems1..1
1+