Template 2.16.840.1.113883.10.20.22.1.4 Consultation Note

2012‑01‑12

Template 2.16.840.1.113883.10.20.22.1.4 - ConsultationNote
Id 2.16.840.1.113883.10.20.22.1.4
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑734
Version valid from 2012‑01‑12 status draft
Description For the purpose of this Implementation Guide, a consultation visit is defined by the evaluation and management guidelines for a consultation established by the Centers for Medicare and Medicaid Services (CMS). According to those guidelines, a Consultation Note must be generated as a result of a physician or nonphysician practitioner's (NPP) request for an opinion or advice from another physician or NPP. Consultations must involve face-to-face time with the patient or fall under guidelines for telemedicine visits.

A Consultation Note must be provided to the referring physician or NPP and must include the reason for the referral, history of present illness, physical examination, and decision-making component (Assessment and Plan).

An NPP is defined as any licensed medical professional as recognized by the state in which the professional practices, including, but not limited to, physician assistants, nurse practitioners, clinical nurse specialists, social workers, registered dietitians, physical therapists, and speech therapists.

Reports on visits requested by a patient, family member, or other third party are not covered by this specification. Second opinions, sometimes called "confirmatory consultations," also are not covered here. Any question on use of the Consultation Note defined here should be resolved by reference to CMS or American Medical Association (AMA) guidelines.
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-734
treetree cda:templateId
II 1..1 M conf‑9477
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8375
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.4
treetree cda:code
1..1 M conf‑8376
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.31 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.9.31"
treetree cda:inFulfillmentOf
1..1 M conf‑8382
treeblank treetree cda:order
1..1 R conf‑8385
treeblank treeblank treetree cda:id
II 1..* M conf‑9102
treetree cda:componentOf
1..1 M conf‑8386
treeblank treetree cda:encompassingEncounter
1..1 M conf‑8387
treeblank treeblank treetree cda:id
II 1..1 M conf‑8388
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8389
Schematron assert Role red error
Test string-length(@value)>=8 or (string-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))))
Message
The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)
treeblank treeblank treetree cda:responsibleParty
0..1 O The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. conf‑8391
Schematron assert Role red error
Test cda:assignedEntity[cda:assignedPerson or cda:representedOrganization]
Message
The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both.
treeblank treeblank treetree cda:encounterParticipant
0..* O The encounterParticipant element, if present, records only participants in the encounter, not necessarily in the entire episode of care. conf‑8392
Schematron assert Role red error
Test cda:assignedEntity[cda:assignedPerson or cda:representedOrganization]
Message
An encounterParticipant element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both.
treetree cda:component
1..1 M A Consultation Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.4), coded entries are optional. conf‑8397
Schematron assert Role red error
Test count(cda:structuredBody | cda:nonXMLBody)=1
Message
A Consultation Note can have either a structuredBody or a nonXMLBody.
treeblank treetree cda:structuredBody
If structuredBody, the component/structuredBody SHALL conform to the section constraints below conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.8 with overridden cardinality 0 .. *
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan of Care Section.
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present
Schematron assert Role red error
Test //cda:section/cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.1' or //cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12'
Message
SHALL include a Reason for Referral or Reason for Visit section
Schematron assert Role red error
Test count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])<=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])=0)
Message
SHALL NOT include a combined Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.8 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.10 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.9 with overridden cardinality 0 .. 1
1..1 M conf‑9503
Contains inherited template rules 1.3.6.1.4.1.19376.1.5.3.1.3.4 with overridden cardinality 1 .. 1 mandatory
1..1 R conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.2.10 with overridden cardinality 1 .. 1 required
0..1 O conf‑9503
Contains inherited template rules 1.3.6.1.4.1.19376.1.5.3.1.3.1 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.12 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.6 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.13 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.15 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.2.5 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.20 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.2 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.1 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.5 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.7 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.3 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 1.3.6.1.4.1.19376.1.5.3.1.3.18 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.17 with overridden cardinality 0 .. 1
0..1 O conf‑9503
Contains inherited template rules 2.16.840.1.113883.10.20.22.2.4 with overridden cardinality 0 .. 1