Close Referral with a Document

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 10/16/2018
  • SDWG: 12/6/2018

Templates

  • Consultation Note Document: 2.16.840.1.113883.10.20.22.1.4:2015-08-1

Validation location:

  • Lantana Validator

Comments

  • This example document shows how an ordered referral could have a completed Constulation Note Document fulfill the requirements of Closing the Loop quality measure https://ecqi.healthit.gov/ecqm/measures/cms50v7

  • Note that the examples task force has approved multiple samples in regards to this quality measure. The Planned Referral Act opens the loop (see example: Referral Request and Close Referral with a Note) and this Consultation Note Document would be eligible to close the loop.

Custodian

  • John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Keywords

  • Closing Loop, externalAct, Interventions, inFulfillmentOf

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Example: download example view on GitHub 

<?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<?xml-stylesheet type="text/xsl" href="CDA.xsl"?>
<!-- This sample shows illustrative information (excluding structuredBody) for a Consultation Note --> 
<!-- It was specifically developed to show how a consultation note can complete a referral loop --> 
<!-- The inFulfillmentOf element links back to the original requested referral --> 
<!-- Original sample adapted from Lantana samples provided with C-CDA 2.0 Guide -->
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
    xmlns:voc="urn:hl7-org:v3/voc" xmlns:sdtc="urn:hl7-org:sdtc"> > <!-- ** CDA Header ** -->
    <realmCode code="US"/>
    <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
    <!-- Identifies document as conformant to US Realm Header (V2) Template -->
    <templateId root="2.16.840.1.113883.10.20.22.1.1" extension="2015-08-01"/>
    <!-- Consultation Note V2  -->
    <templateId root="2.16.840.1.113883.10.20.22.1.4" extension="2015-08-01"/>
    <id extension="TT988" root="2.16.840.1.113883.19.5.99999.1"/>
    <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="11488-4"
        displayName="Consult note">
        <!-- Additional SNOMED code which is equivalent to the LOINC consultation note code -->
        <!-- The quality measure CMS50 v7 requires a concept from 2.16.840.1.113883.3.464.1003.121.12.1006 -->
        <!-- There is a potential for the LOINC codes to be added to the prior value set, although it is not currently available -->
        <translation code="371530004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"
            displayName="Clinical consultation report (record artifact)"/>
    </code>
    <title>Community Health Consult Note</title>
    <effectiveTime value="201806230900-0800"/>
    <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" displayName="normal" />
    <languageCode code="en-US"/>
    <setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19"/>
    <versionNumber value="1"/>
    <recordTarget>
        <patientRole>
            <!-- Example Social Security Number using the actual SSN OID. -->
            <id extension="000-00-0000" root="2.16.840.1.113883.4.1"/>
            <!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 -->
            <addr use="HP">
                <streetAddressLine>2222 Home Street</streetAddressLine>
                <city>Beaverton</city>
                <state>OR</state>
                <postalCode>97867</postalCode>
                <!-- US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1 -->
                <country>US</country>
            </addr>
            <!-- HP is "primary home" from HL7 AddressUse 2.16.840.1.113883.5.1119 -->
            <telecom value="tel:+1(555)555-2003" use="HP"/>
            <patient>
                <!-- The first name element represents what the patient is known as -->
                <name use="L">
                    <given>Eve</given>
                    <family qualifier="SP">Betterhalf</family>
                </name>
                <!-- The second name element represents another name associated with the patient -->
                <name use="SRCH">
                    <given>Eve</given>
                    <family qualifier="BR">Everywoman</family>
                </name>
                <administrativeGenderCode code="F" displayName="Female"
                    codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender"/>
                <!-- Date of birth need only be precise to the day -->
                <birthTime value="19750501"/>
                <maritalStatusCode code="M" displayName="Married" codeSystem="2.16.840.1.113883.5.2"
                    codeSystemName="MaritalStatusCode"/>
                <religiousAffiliationCode code="1013"
                    displayName="Christian (non-Catholic, non-specific)"
                    codeSystem="2.16.840.1.113883.5.1076" codeSystemName="HL7 Religious Affiliation"/>
                <!-- CDC Race and Ethnicity code set contains the five minimum race and ethnicity 
					categories defined by OMB Standards -->
                <raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238"
                    codeSystemName="Race &amp; Ethnicity - CDC"/>
                <!-- The raceCode extension is only used if raceCode is valued -->
                <sdtc:raceCode code="2076-8" displayName="Native Hawaiian or Other Pacific Islander"
                    codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC"/>
                <ethnicGroupCode code="2186-5" displayName="Not Hispanic or Latino"
                    codeSystem="2.16.840.1.113883.6.238" codeSystemName="Race &amp; Ethnicity - CDC"/>
                <guardian>
                    <code code="POWATT" displayName="Power of Attorney"
                        codeSystem="2.16.840.1.113883.1.11.19830" codeSystemName="ResponsibleParty"/>
                    <addr use="HP">
                        <streetAddressLine>2222 Home Street</streetAddressLine>
                        <city>Beaverton</city>
                        <state>OR</state>
                        <postalCode>97867</postalCode>
                        <country>US</country>
                    </addr>
                    <telecom value="tel:+1(555)555-2008" use="MC"/>
                    <guardianPerson>
                        <name>
                            <given>Boris</given>
                            <given qualifier="CL">Bo</given>
                            <family>Betterhalf</family>
                        </name>
                    </guardianPerson>
                </guardian>
                <birthplace>
                    <place>
                        <addr>
                            <streetAddressLine>4444 Home Street</streetAddressLine>
                            <city>Beaverton</city>
                            <state>OR</state>
                            <postalCode>97867</postalCode>
                            <country>US</country>
                        </addr>
                    </place>
                </birthplace>
                <languageCommunication>
                    <!-- "eng" is ISO 639-2 alpha-3 code for "English" -->
                    <languageCode code="eng"/>
                    <modeCode code="ESP" displayName="Expressed spoken"
                        codeSystem="2.16.840.1.113883.5.60" codeSystemName="LanguageAbilityMode"/>
                    <proficiencyLevelCode code="G" displayName="Good"
                        codeSystem="2.16.840.1.113883.5.61"
                        codeSystemName="LanguageAbilityProficiency"/>
                    <!-- Patient's preferred language -->
                    <preferenceInd value="true"/>
                </languageCommunication>
            </patient>
            <providerOrganization>
                <!-- Organizations SHOULD have an NPI; this is a real root; fake extension -->
                <id extension="219BX" root="2.16.840.1.113883.4.6"/>
                <name>The DoctorsTogether Physician Group</name>
                <telecom use="WP" value="tel: +1(555)555-5000"/>
                <addr>
                    <streetAddressLine>1007 Health Drive</streetAddressLine>
                    <city>Portland</city>
                    <state>OR</state>
                    <postalCode>99123</postalCode>
                    <country>US</country>
                </addr>
            </providerOrganization>
        </patientRole>
    </recordTarget>
    <author>
        <time value="20130731"/>
        <assignedAuthor>
            <id extension="555555555" root="2.16.840.1.113883.4.6"/>
            <code code="207QA0505X" displayName="Allopathic &amp; Osteopathic Physicians; Family Medicine, Adult Medicine"
                codeSystem="2.16.840.1.113883.6.101"
                codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
            <addr>
                <streetAddressLine>1004 Healthcare Drive </streetAddressLine>
                <city>Portland</city>
                <state>OR</state>
                <postalCode>99123</postalCode>
                <country>US</country>
            </addr>
            <telecom use="WP" value="tel:+1(555)-1004"/>
            <assignedPerson>
                <name>
                    <given>Patricia</given>
                    <given qualifier="CL">Patty</given>
                    <family>Primary</family>
                    <suffix qualifier="AC">M.D.</suffix>
                </name>
            </assignedPerson>
        </assignedAuthor>
    </author>
    <dataEnterer>
        <assignedEntity>
            <id extension="333777777" root="2.16.840.1.113883.4.6"/>
            <addr>
                <streetAddressLine>1007 Healthcare Drive</streetAddressLine>
                <city>Portland</city>
                <state>OR</state>
                <postalCode>99123</postalCode>
                <country>US</country>
            </addr>
            <telecom use="WP" value="tel:+1(555)-1050"/>
            <assignedPerson>
                <name>
                    <given>Ellen</given>
                    <family>Enter</family>
                </name>
            </assignedPerson>
        </assignedEntity>
    </dataEnterer>
    <informant>
        <assignedEntity>
            <id extension="888888888" root="2.16.840.1.113883.19.5"/>
            <addr>
                <streetAddressLine>1007 Healthcare Drive</streetAddressLine>
                <city>Portland</city>
                <state>OR</state>
                <postalCode>99123</postalCode>
                <country>US</country>
            </addr>
            <telecom use="WP" value="tel:+1(555)-1003"/>
            <assignedPerson>
                <name>
                    <given>Harold</given>
                    <family>Hippocrates</family>
                    <suffix qualifier="AC">D.O.</suffix>
                </name>
            </assignedPerson>
        </assignedEntity>
    </informant>
    <custodian>
        <assignedCustodian>
            <representedCustodianOrganization>
                <id extension="321CX" root="2.16.840.1.113883.4.6"/>
                <name>Good Health HIE</name>
                <telecom use="WP" value="tel:+1(555)-1009"/>
                <addr use="WP">
                    <streetAddressLine>1009 Healthcare Drive </streetAddressLine>
                    <city>Portland</city>
                    <state>OR</state>
                    <postalCode>99123</postalCode>
                    <country>US</country>
                </addr>
            </representedCustodianOrganization>
        </assignedCustodian>
    </custodian>
    <informationRecipient>
        <intendedRecipient>
            <informationRecipient>
                <name>
                    <given>Sara</given>
                    <family>Specialize</family>
                    <suffix qualifier="AC">M.D.</suffix>
                </name>
            </informationRecipient>
            <receivedOrganization>
                <name>The DoctorsApart Physician Group</name>
            </receivedOrganization>
        </intendedRecipient>
    </informationRecipient>
    <authenticator>
        <time value="201308011030-0800"/>
        <signatureCode code="S"/>
        <assignedEntity>
            <id extension="555555555" root="2.16.840.1.113883.4.6"/>
            <code code="207QA0505X" displayName="Allopathic &amp; Osteopathic Physicians; Family Medicine, Adult Medicine"
                codeSystem="2.16.840.1.113883.6.101"
                codeSystemName="Healthcare Provider Taxonomy (HIPAA)"/>
            <addr>
                <streetAddressLine>1004 Healthcare Drive </streetAddressLine>
                <city>Portland</city>
                <state>OR</state>
                <postalCode>99123</postalCode>
                <country>US</country>
            </addr>
            <telecom use="WP" value="tel:+1(555)-1004"/>
            <assignedPerson>
                <name>
                    <given>Patricia</given>
                    <given qualifier="CL">Patty</given>
                    <family>Primary</family>
                    <suffix qualifier="AC">M.D.</suffix>
                </name>
            </assignedPerson>
        </assignedEntity>
    </authenticator>
    <!-- Describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note -->
    <inFulfillmentOf typeCode="FLFS">
        <order classCode="ACT" moodCode="RQO">
            <!-- Note that the following id corresponds to referral request -->
            <!-- The semantics indicate that the referral was closed/completed -->
            <id root="9a6d1bac-17d3-4195-89a4-1121bc809b4e"/>
            <code code="103697008" displayName="Patient referral for dental care"
                codeSystemName="SNOMED CT" codeSystem="2.16.840.1.113883.6.96"/>
        </order>
    </inFulfillmentOf>
    <componentOf>
        <encompassingEncounter>
            <id extension="9937012" root="2.16.840.1.113883.19"/>
            <code codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" code="99213"
                displayName="Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter."/>
            <effectiveTime value="20180623"/>
            <location>
                <healthCareFacility>
                    <id root="2.16.540.1.113883.19.2"/>
                </healthCareFacility>
            </location>
        </encompassingEncounter>
    </componentOf>
    <!-- Note that structured body is omitted in this example, so this sample will not validate without errors -->
    <!-- The structuredBody SHALL contain History of Present Illness Section,  Allergies and Intolerances Section, Problems Section, -->
    <!-- Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section -->
    <!-- Reason for Referral or Reason for Visit Section -->
    <component>
        <structuredBody>
            <component> </component>
        </structuredBody>
    </component>
</ClinicalDocument>

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