ConsultationNote

Consultation Note

activeC-CDA on FHIR1.2.0resource85 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).

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/ccda/StructureDefinition/Consultation-Note
ID
Consultation-Note
Type
Base Definition
US-Realm-Header
Derivation
constraint
Mandatory and Must-Support Elements

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

PathCard.TypeFlagsDescription
type
S
Consultation Note
encounter
S1+
encompassingEncounter
:allergies_and_intolerances_section1..1
S1+
Allergies and Intolerances Section
section.title
S1+
title
section.code
S1+
Allergies and adverse reactions
section.text
S1+
text
:allergy_intolerance_entry
Reference
S
:history_of_present_illness_section1..1
S1+
History of Present Illness Section
section.title
S1+
title
section.code
S1+
History of present illness
section.text
S1+
This section contains only human readable content
:problem_section1..1
1+
Problem Section
section.title
S1+
title
section.code
S1+
Problem list
section.text
Narrative
1+
text
:problem_section_entry
Reference
S
section.title
1+
title
section.code
1+
History of medication use
section.text
1+
text
section.title
1+
title
section.code
1+
Physical findings
section.text
1+
text
section.title
1+
title
section.code
1+
Relevant diagnostic tests/laboratory data
section.text
1+
text
:advance_directives_section
S
Advance Directives Section
section.title
S1+
title
section.code
S1+
Advance directives
section.text
S1+
text
:advance_directive_entry
Reference
S
section.title
1+
title
section.code
1+
Assessment (evaluation) and plan
section.text
1+
text
section.title
1+
title
section.code
1+
Assessments (evaluation)
section.text
1+
This section contains only human readable content
section.title
1+
title
section.code
1+
Chief complaint and reason for visit
section.text
1+
This section contains only human readable content
section.title
1+
title
section.code
1+
Chief complaint
section.text
1+
This section contains only human readable content
section.title
1+
title
section.code
1+
Family history
section.text
1+
text
section.title
1+
title
section.code
1+
Functional status
section.text
1+
text
section.title
1+
title
section.code
1+
Physical findings of General status
section.text
1+
This section contains only human readable content
section.title
1+
title
section.code
1+
Past Medical History
section.text
1+
text
section.title
1+
title
section.code
1+
History of immunization
section.text
1+
text
section.title
1+
title
section.code
1+
History of medical device use
section.text
1+
text
:medical_equipment_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
section.title
1+
title
section.code
1+
Mental status
section.text
1+
text
section.title
1+
title
section.code
1+
Diet and nutrition
section.text
1+
text
section.title
1+
title
section.code
1+
Plan of treatment
section.text
1+
text
section.title
1+
title
section.code
1+
History of Procedures
section.text
1+
text
section.title
1+
title
section.code
1+
Reason for visit
section.text
1+
This section contains only human readable content
section.title
1+
title
section.code
1+
Review of systems
section.text
1+
This section contains only human readable content
section.title
1+
title
section.code
1+
Social history
section.text
1+
text
section.title
1+
title
section.code
1+
Vital signs
section.text
1+
text