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draft Template  BC CDA Referral Notes (V2)

Id 2.16.840.1.113883.10.20.22.2.100 Effective Date 2019‑04‑06 03:03:15
Status draft Draft Version Label 2.1
Name BCCDAReferralNotesV2 Display Name BC CDA Referral Notes (V2)
Description
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.  This referral is in only one section, called external document, for an organizer to one document for classCode=ExternalAct to ED.text.
Context Pathname //
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 1 template
Used by as Name Version
bccdapilot-transaction-19 Transaction draft Create eReferral 2019‑04‑01 07:41:12
Uses as Name Version
2.16.840.1.113883.10.20.22.2.103 Containment draft External Documents Section (entries optional) (2.1) DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.20.22.2.100 (2019‑04‑06 02:03:17)
ref
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Specialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.2.100 BC CDA Referral Notes (V2) (DYNAMIC)
Item DT Card Conf Description Label
cda:ClinicalDocument
(BCCdotssV2)
treetree cda:templateId
II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1198-28947) such that it CONFdots8947
treeblank treetree @root
uid 1 … 1 F 2.16.840.1.113883.10.20.22.2.100 CONFdots8948
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.14" (CONF:1198-28948).
treeblank treetree @extension
st 1 … 1 F 2015-08-01 CONFdots2911
  SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32911).
treetree cda:code
1 … 1 SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet ReferralDocumentType urn:oid:2.16.840.1.113883.1.11.20.2.3 DYNAMIC (CONF:1198-28949).

The Referral Note recommends use of the document type code 57133-1 "Referral Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. For example, an Obstetrics and Gynecology Referral note would not be authored by a Pediatric Cardiologist. The type of referral and the target of the referral are specified via the participant (and not via the author).

CONFdots8949
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20.2.3 ReferralDocumentType (DYNAMIC)
treetree cda:component
1 … 1 M SHALL contain exactly one [1..1] component (CONF:1198-29062). CONFdots9062
treeblank treetree cda:structuredBody
1 … 1 M This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-29063). CONFdots9063
treeblank treeblank treetree cda:component
0 … 1 Contains 2.16.840.1.113883.10.20.22.2.103 External Documents Section (entries optional) (DYNAMIC) CONFdots9068
treeblank treeblank treeblank where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.103'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.103'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.103'] [@extension = '2015-08-01']]]