Referral Note
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.
#### Document Sections Although document templates may contain any section, the following sections are specifically called out by this template:
Required Sections
- AssessmentandPlanSection or both AssessmentSection and PlanofTreatmentSection
- ProblemSection
- AllergiesAndIntolerancesSection
- MedicationsSection
- ReasonforReferralSection
Recommended Sections
- PlanofTreatmentSection
- ResultsSection
- FunctionalStatusSection
- MentalStatusSection
- NutritionSection
Additional Sections
- AdvanceDirectivesSection
- HistoryofPresentIllnessSection
- FamilyHistorySection
- ImmunizationsSection
- ProceduresSection
- ReviewofSystemsSection
- SocialHistorySection
- VitalSignsSection
- PhysicalExamSection
- MedicalEquipmentSection
- PastMedicalHistory
- GeneralStatusSection
- PayersSection
Metadata
hl7.org/fhir- Canonical URL
- http://hl7.org/cda/us/ccda/StructureDefinition/ReferralNote
- ID
- ReferralNote
- Type
- Base Definition
- USRealmHeader
- Derivation
- constraint
Elements with cardinality > 0 or marked as Must Support (S)