Specification - Extended

HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm

Document Description

extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38

Existing Wording

Currently the Referral Note (V2) document type doesn't include a Payers section. We should add that as an optional section because sometimes the "Referred From" provider needs to tell the "Referred To" provider which insurance coverage the patient has. And in some cases the provider needs to route a copy of the document to the patient's insurance company so they also need a way to indicate which plan the patient is on (or at least which plan they believe the patient to be on).

Proposed Wording

1.1.20 Referral Note (V2) Table 51: Referral Note (V2) Contexts Contained By: Contains: US Realm Patient Name (PTN.US.FIELDED) (optional) Assessment Section (optional) Review of Systems Section (optional) History of Present Illness Section (optional) General Status Section (optional) US Realm Person Name (PN.US.FIELDED) (required) Medications Section (entries required) (V2) (required) Plan of Treatment Section (V2) (optional) Medical Equipment Section (V2) (optional) Nutrition Section (optional) Procedures Section (entries optional) (V2) (optional) Functional Status Section (V2) (optional) Reason for Referral Section (V2) (required) Assessment and Plan Section (V2) (optional) Mental Status Section (V2) (optional) Immunizations Section (entries required) (V3) (optional) Results Section (entries required) (V3) (optional) Past Medical History (V3) (optional) Vital Signs Section (entries required) (V3) (optional) Problem Section (entries required) (V3) (required) Physical Exam Section (V3) (optional) Social History Section (V3) (optional) Advance Directives Section (entries optional) (V3) (optional) Family History Section (V3) (optional) Allergies and Intolerances Section (entries required) (V3) (required) Payers Section (V3) (optional)