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pending Template  Consultation Note

Template 2.16.840.1.113883.10.20.22.1.4 - ConsultationNote
Id 2.16.840.1.113883.10.20.22.1.4
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Document Level Template
Context Pathname //
Open/Closed Open (other than defined elements are allowed)
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 non-physician 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.
Used by / Uses
Used by / Uses 21 templates
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.2.8 Containment AssessmentSection DYNAMIC
2.16.840.1.113883.10.20.22.2.10 Containment PlanofCareSection DYNAMIC
2.16.840.1.113883.10.20.22.2.9 Containment AssessmentandPlanSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.4 Containment HistoryofPresentIllnessSection DYNAMIC
2.16.840.1.113883.10.20.2.10 Containment PhysicalExamSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.1 Containment ReasonforReferralSection DYNAMIC
2.16.840.1.113883.10.20.22.2.12 Containment ReasonforVisitSection DYNAMIC
2.16.840.1.113883.10.20.22.2.6 Containment AllergiesSectionentriesoptional DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Containment ChiefComplaintSection DYNAMIC
2.16.840.1.113883.10.20.22.2.13 Containment ChiefComplaintandReasonforVisitSection DYNAMIC
2.16.840.1.113883.10.20.22.2.15 Containment FamilyHistorySection DYNAMIC
2.16.840.1.113883.10.20.2.5 Containment GeneralStatusSection DYNAMIC
2.16.840.1.113883.10.20.22.2.20 Containment HistoryofPastIllnessSection DYNAMIC
2.16.840.1.113883.10.20.22.2.2 Containment ImmunizationsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.1 Containment MedicationsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.5 Containment ProblemSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.7 Containment ProceduresSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.3 Containment ResultsSectionentriesoptional DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.18 Containment ReviewofSystemsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.17 Containment SocialHistorySection DYNAMIC
2.16.840.1.113883.10.20.22.2.4 Containment VitalSignsSectionentriesoptional DYNAMIC
Item DT Card Conf Description Label
cda:ClinicalDocument
(ConsultationNote)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8375). conf‑8375
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.1.4
  Schematron assert role red error
  test count(cda:templateId[@root='2.16.840.1.113883.10.20.22.1.4'])=1
  Message SHALL contain exactly one [1..1] templateId (CONF:8375).
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:17176). conf‑17176
treetree cda:inFulfillmentOf
1 .. * M SHALL contain at least one [1..*] inFulfillmentOf (CONF:8382). conf‑8382
treeblank treetree cda:order
1 .. 1 M Such inFulfillmentOfs SHALL contain exactly one [1..1] order (CONF:8385). conf‑8385
treeblank treeblank treetree cda:id
1 .. * M This order SHALL contain at least one [1..*] id (CONF:9102). conf‑9102
treetree cda:componentOf
1 .. 1 M SHALL contain exactly one [1..1] componentOf (CONF:8386). conf‑8386
treeblank treetree cda:encompassingEncounter
1 .. 1 M This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8387). conf‑8387
treeblank treeblank treetree cda:id
1 .. 1 M This encompassingEncounter SHALL contain exactly one [1..1] id (CONF:8388). conf‑8388
treeblank treeblank treetree cda:effectiveTime
1 .. 1 M This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:8389).

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
conf‑8389
  Schematron assert role red error
  test string-length(cda:componentOf/cda:encompassingEncounter/cda:effectiveTime//@value)>=8
  Message The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
treeblank treeblank treetree cda:responsibleParty
0 .. 1 This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:8391).

The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care.

The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both.
conf‑8391
  Schematron assert role red error
  test not(cda:componentOf/cda:encompassingEncounter/cda:responsibleParty) or cda:componentOf/cda:encompassingEncounter/cda:responsibleParty/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 .. * This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:8392).

The encounterParticipant element, if present, records only participants in the encounter, not necessarily in the entire episode of care.

An encounterParticipant element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both.
conf‑8392
  Schematron assert role red error
  test not(cda:componentOf/cda:encompassingEncounter/cda:encounterParticipant) or cda:componentOf/cda:encompassingEncounter/cda:encounterParticipant/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 SHALL contain exactly one [1..1] component (CONF:8397).

A Consultation Note can have either a structuredBody or a nonXMLBody.

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.

If structuredBody, the component/structuredBody SHALL conform to the section constraints below

SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan of Care Section.

SHALL include a Reason for Referral or Reason for Visit section

SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present

SHALL NOT include a combined Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section
conf‑8397
  Schematron assert role red error
  test count(cda:component/cda:structuredBody | cda:component/cda:nonXMLBody)=1
  Message A Consultation Note can have either a structuredBody or a nonXMLBody.
Choice min 1 element(s) and max 1 element(s). Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
treeblank treeblank treetree cda:nonXMLBody
conf‑8397
treeblank treeblank treetree cda:structuredBody
conf‑8397
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.8']]
0 .. 1 conf‑9487
  Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.10']]
0 .. 1 conf‑9489
  Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.9']]
0 .. 1 conf‑9491
  Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.4']]
1 .. 1 M conf‑9493
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.2.10']]
0 .. 1 R conf‑9495
  Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.1']]
0 .. 1 conf‑9498
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 Reason for Referral Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12']]
0 .. 1 conf‑9500
  Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (DYNAMIC)
  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:templateId[@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 //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
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.6']]
0 .. 1 conf‑9507
  Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1']]
0 .. 1 conf‑9509
  Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.13']]
0 .. 1 conf‑9511
  Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.15']]
0 .. 1 conf‑9513
  Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.2.5']]
0 .. 1 conf‑9515
  Contains 2.16.840.1.113883.10.20.2.5 General Status Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.20']]
0 .. 1 conf‑9517
  Contains 2.16.840.1.113883.10.20.22.2.20 History of Past Illness Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.2']]
0 .. 1 conf‑9519
  Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.1']]
0 .. 1 conf‑9521
  Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.5']]
0 .. 1 conf‑9523
  Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.7']]
0 .. 1 conf‑9525
  Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.3']]
0 .. 1 conf‑9527
  Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.18']]
0 .. 1 conf‑9529
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.17']]
0 .. 1 conf‑9531
  Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.4']]
0 .. 1 conf‑9533
  Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (DYNAMIC)
  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:templateId[@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 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