Package | hl7.fhir.us.ccda |
Type | StructureDefinition |
Id | Id |
FHIR Version | R4 |
Source | http://hl7.org/fhir/us/ccda/https://build.fhir.org/ig/HL7/ccda-on-fhir/StructureDefinition-Consultation-Note.html |
Url | http://hl7.org/fhir/us/ccda/StructureDefinition/Consultation-Note |
Version | 2.0.0-ballot |
Status | active |
Date | 2025-02-12T20:53:41+00:00 |
Name | ConsultationNote |
Title | Consultation Note |
Experimental | False |
Realm | us |
Authority | hl7 |
Description | 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). |
Type | Composition |
Kind | resource |
CapabilityStatement | |
CcdaOnFhirClient ![]() | CCDA on FHIR Client |
CcdaOnFhirServer ![]() | CCDA on FHIR Server |
http://hl7.org/fhir/us/dental-data-exchange/StructureDefinition/dental-consult-note ![]() | Dental Consult Note |
Note: links and images are rebased to the (stated) source
Generated Narrative: StructureDefinition Consultation-Note
version: 18; Last updated: 2020-08-19 06:51:00+0000;
Information Source: #j21iyLdl5SyihDjY
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
![]() ![]() | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
![]() ![]() ![]() | S | 1..1 | CodeableConcept | Consultation Note Binding: ConsultDocumentType (required) |
![]() ![]() ![]() | S | 1..1 | Reference(US Core Encounter Profile) | encompassingEncounter |
![]() ![]() ![]() | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Allergies and Intolerances Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Allergies and adverse reactions Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | History of Present Illness Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | History of present illness Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | 1..1 | BackboneElement | Problem Section | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Problem list Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Narrative | text | |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | 0..1 | BackboneElement | Medications Section | |
![]() ![]() ![]() ![]() ![]() | 1..1 | string | title | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConcept | History of medication use Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Narrative | text | |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section | |
![]() ![]() ![]() ![]() | 0..1 | BackboneElement | Physical Exam Section | |
![]() ![]() ![]() ![]() ![]() | 1..1 | string | title | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConcept | Physical findings Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Narrative | text | |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
![]() ![]() ![]() ![]() | 0..1 | BackboneElement | Results Section | |
![]() ![]() ![]() ![]() ![]() | 1..1 | string | title | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConcept | Relevant diagnostic tests/laboratory data Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Narrative | text | |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section | |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Advance Directives Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Advance directives Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(Consent) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | 0..1 | BackboneElement | 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. | |
![]() ![]() ![]() ![]() ![]() | 1..1 | string | title | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConcept | Assessment (evaluation) and plan Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Narrative | text | |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. | |
![]() ![]() ![]() ![]() | 0..1 | BackboneElement | Assessment Section | |
![]() ![]() ![]() ![]() ![]() | 1..1 | string | title | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConcept | Assessments (evaluation) Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Narrative | This section contains only human readable content | |
![]() ![]() ![]() ![]() | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patientâs own description) and/or the reason for the patient's visit (the providerâs description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. | |
![]() ![]() ![]() ![]() ![]() | 1..1 | string | title | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConcept | Chief complaint and reason for visit Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46239-0 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Narrative | This section contains only human readable content | |
![]() ![]() ![]() ![]() | 0..1 | BackboneElement | Chief Complaint Section | |
![]() ![]() ![]() ![]() ![]() | 1..1 | string | title | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConcept | Chief complaint Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Narrative | This section contains only human readable content | |
![]() ![]() ![]() ![]() | 0..1 | BackboneElement | Family History Section | |
![]() ![]() ![]() ![]() ![]() | 1..1 | string | title | |
![]() ![]() ![]() ![]() ![]() | 1..1 | CodeableConcept | Family history Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Narrative | text | |
![]() ![]() ![]() ![]() ![]() |