ReferralNote

Referral Note

activeC-CDA on FHIR1.2.0resource121 key elements

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.
When patient is sent by a cardiologist to an emergency department for angina.
When a patient is referred by a nurse practitioner to an audiologist for hearing screening.
When a patient is referred by a hospitalist to social services.

Metadata

hl7.org/fhir

Canonical URL: http://hl7.org/fhir/us/ccda/StructureDefinition/Referral-Note
ID: Referral-Note
Type
Base Definition: US-Realm-Header
Derivation: constraint

Mandatory and Must-Support Elements

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

Path	Card.	Type	Flags	Description
type			S	type
:allergies_and_intolerances_section	1..1		S1+	Allergies and Intolerances Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	text
:allergies_and_intolerances_entry		Reference	S
:medications_section	1..1		S1+	Medications Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	text
:medications_entry		Reference	S
:problem_section	1..1		S1+	Problem Section
section.title			S1+	title
section.code			S1+	Problem list
section.text			S1+	text
:problem_entry		Reference	S
:reason_for_referral_section	1..1		S1+	Reason for Referral Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:reason_for_referral_entry		Reference	S
:functional_status_section			S	Functional Status Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	text
:functional_status_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.
:mental_status_section			S	Mental Status Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	text
:mental_status_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.
:nutrition_section			S	Nutrition Section
section.title			S1+	title
section.code			S1+	Diet and nutrition
section.text			S1+	text
:nutrition_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.
:plan_of_treatment_section			S	Plan of Treatment Section
section.title			S1+	title
section.code			S1+	Plan of treatment
section.text			S1+	text
:results_section	0..1		S	Results Section
section.title			S1+	title
section.code			S1+	Relevant diagnostic tests and laboratory data
section.text			S1+	text
:results_entry		Reference	S
:assessment_and_plan_section			S	Assessment and Plan Section. This section represents the clinicianâs conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
section.title			S1+	title
section.code			S1+	Assessment and plan
section.text			1+	text
:assessment_and_plan_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.
: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
:assessment_section			S	Assessment Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:family_history_section			S	Family History Section
section.title			S1+	title
section.code			S1+	History of family member diseases
section.text			S1+	text
:family_history_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.
:general_status_section			S	General Status Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:past_medical_history_section			S	Past Medical History Section
section.title			1+	title
section.code			S1+	code
section.text			S1+	text
:past_medical_history_entry		Reference	S
:history_of_present_illness_section			S	History of Present Illness Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:immunizations_section			S	Immunizations Section
section.title			S1+	title
section.code			S1+	History of immunization
section.text			S1+	text
:immunizations_entry		Reference	S
:medical_equipment_section			S	Medical Equipment Section
section.title			S1+	title
section.code			S1+	Medical equipment
section.text			S1+	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.
:physical_exam_section			S	Physical Exam Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	text
:physical_exam_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.
:procedures_section			S	Procedures Section
section.title			S1+	title
section.code			S1+	History of procedures
section.text			S1+	text
:procedures_entry		Reference	S
:review_of_systems_section			S	Review of Systems Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:social_history_section	0..1		S	Social History Section
section.title			S1+	title
section.code			S1+	Social history
section.text			S1+	text
:social_history_entry		Reference	S	Smoking status
:vital_signs_section	0..1		S	Vital Signs Section
section.title			S1+	title
section.code			S1+	Vital signs
section.text			S1+	text
:vital_signs_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.
:goals_section	0..1		S	Goals Section
section.title			S1+	title
section.code			S1+	Goals
section.text			S1+	text
:goals_entry		Reference	S	entry
:health_concerns_section	0..1		S	Health Concerns Section
section.title			S1+	title
section.code			S1+	Health concerns section code
section.text			S1+	text
:health_concerns_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.