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.\n\nA Consultation Note includes the reason for the referral, history of present illness, physical examination, and decision-making components (Assessment and Plan).
package_name: hl7.fhir.us.ccda
derivation: constraint
name: ConsultationNote
type: Composition
elements:
  type:
    label: Consultation Note
    short: Consultation Note
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.9.31'}
    mustSupport: true
    index: 0
  encounter: {label: encompassingEncounter, short: encompassingEncounter, mustSupport: true, index: 1}
  section:
    index: 2
    slicing:
      rules: open
      discriminator:
      - {path: code, type: value}
      min: null
      slices:
        functional_status_section:
          match:
            code:
              coding:
              - {code: 47420-5, system: 'http://loinc.org'}
          schema:
            label: Functional Status Section
            short: Functional Status Section
            index: 67
            elements:
              title: {short: title, index: 68}
              code:
                label: Functional status
                short: Functional status
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 47420-5, system: 'http://loinc.org'}
                index: 69
              text: {short: text, index: 70}
              entry:
                short: entry
                index: 71
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        refers: ['http://hl7.org/fhir/StructureDefinition/Observation']
                        index: 72
            required: [text, title, code]
        allergies_and_intolerances_section:
          match:
            code:
              coding:
              - {code: 48765-2, system: 'http://loinc.org'}
          schema:
            short: Allergies and Intolerances Section
            mustSupport: true
            _required: true
            label: Allergies and Intolerances Section
            index: 3
            elements:
              title: {short: title, mustSupport: true, index: 4}
              code:
                label: Allergies and adverse reactions
                short: Allergies and adverse reactions
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 48765-2, system: 'http://loinc.org'}
                index: 5
              text: {short: text, mustSupport: true, index: 6}
              entry:
                short: entry
                index: 7
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    allergy_intolerance_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance']
                        index: 8
            required: [text, title, code]
        mental_status_section:
          match:
            code:
              coding:
              - {code: 10190-7, system: 'http://loinc.org'}
          schema:
            label: Mental Status Section
            short: Mental Status Section
            index: 95
            elements:
              title: {short: title, index: 96}
              code:
                label: Mental status
                short: Mental status
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10190-7, system: 'http://loinc.org'}
                index: 97
              text: {short: text, index: 98}
              entry:
                short: entry
                index: 99
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        refers: ['http://hl7.org/fhir/StructureDefinition/Observation']
                        index: 100
            required: [text, title, code]
        chief_complaint_section:
          match:
            code:
              coding:
              - {code: 10154-3, system: 'http://loinc.org'}
          schema:
            label: Chief Complaint Section
            short: Chief Complaint Section
            index: 57
            elements:
              title: {short: title, index: 58}
              code:
                label: Chief complaint
                short: Chief complaint
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10154-3, system: 'http://loinc.org'}
                index: 59
              text: {short: This section contains only human readable content, index: 60}
            required: [text, title, code]
        general_status_section:
          match:
            code:
              coding:
              - {code: 10210-3, system: 'http://loinc.org'}
          schema:
            label: General Status Section
            short: General Status Section
            index: 73
            elements:
              title: {short: title, index: 74}
              code:
                label: Physical findings of General status
                short: Physical findings of General status
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10210-3, system: 'http://loinc.org'}
                index: 75
              text: {short: This section contains only human readable content, index: 76}
            required: [text, title, code]
        assessment_and_plan_section:
          match:
            code:
              coding:
              - {code: 51847-2, system: 'http://loinc.org'}
          schema:
            label: Assessment and Plan Section
            short: !!binary |-
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            index: 43
            elements:
              title: {short: title, index: 44}
              code:
                label: Assessment (evaluation) and plan
                short: Assessment (evaluation) and plan
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 51847-2, system: 'http://loinc.org'}
                index: 45
              text: {short: text, index: 46}
              entry:
                index: 47
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        refers: ['http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/Observation', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 48
            required: [text, title, code]
        nutrition_section:
          match:
            code:
              coding:
              - {code: 61144-2, system: 'http://loinc.org'}
          schema:
            label: Nutrition Section
            short: Nutrition Section
            index: 101
            elements:
              title: {short: title, index: 102}
              code:
                label: Diet and nutrition
                short: Diet and nutrition
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 61144-2, system: 'http://loinc.org'}
                index: 103
              text: {short: text, index: 104}
              entry:
                short: entry
                index: 105
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        refers: ['http://hl7.org/fhir/StructureDefinition/ClinicalImpression', 'http://hl7.org/fhir/StructureDefinition/NutritionOrder']
                        index: 106
            required: [text, title, code]
        reason_for_visit_section:
          match:
            code:
              coding:
              - {code: 29299-5, system: 'http://loinc.org'}
          schema:
            label: Reason for Visit Section
            short: Reason for Visit Section
            index: 119
            elements:
              title: {short: title, index: 120}
              code:
                label: Reason for visit
                short: Reason for visit
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 29299-5, system: 'http://loinc.org'}
                index: 121
              text: {short: This section contains only human readable content, index: 122}
            required: [text, title, code]
        immunizations_section:
          match:
            code:
              coding:
              - {code: 11369-6, system: 'http://loinc.org'}
          schema:
            label: Immunizations Section
            short: Immunizations Section
            index: 83
            elements:
              title: {short: title, index: 84}
              code:
                label: History of immunization
                short: History of immunization
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 11369-6, system: 'http://loinc.org'}
                index: 85
              text: {short: text, index: 86}
              entry:
                short: entry
                index: 87
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization']
                        index: 88
            required: [text, title, code]
        past_medical_history_section:
          match:
            code:
              coding:
              - {code: 11348-0, system: 'http://loinc.org'}
          schema:
            label: Past Medical History Section
            short: Past Medical History Section
            index: 77
            elements:
              title: {short: title, index: 78}
              code:
                label: Past Medical History
                short: Past Medical History
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 11348-0, system: 'http://loinc.org'}
                index: 79
              text: {short: text, index: 80}
              entry:
                short: entry
                index: 81
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 82
            required: [text, title, code]
        results_section:
          match:
            code:
              coding:
              - {code: 30954-2, system: 'http://loinc.org'}
          schema:
            label: Results Section
            short: Results Section
            index: 31
            elements:
              title: {short: title, index: 32}
              code:
                label: Relevant diagnostic tests/laboratory data
                short: Relevant diagnostic tests/laboratory data
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 30954-2, system: 'http://loinc.org'}
                index: 33
              text: {short: text, index: 34}
              entry:
                short: entry
                index: 35
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab']
                        index: 36
            required: [text, title, code]
        history_of_present_illness_section:
          match:
            code:
              coding:
              - {code: 10164-2, system: 'http://loinc.org'}
          schema:
            short: History of Present Illness Section
            mustSupport: true
            _required: true
            label: History of Present Illness Section
            index: 9
            elements:
              title: {short: title, mustSupport: true, index: 10}
              code:
                label: History of present illness
                short: History of present illness
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10164-2, system: 'http://loinc.org'}
                index: 11
              text: {short: This section contains only human readable content, mustSupport: true, index: 12}
            required: [text, title, code]
        medications_section:
          match:
            code:
              coding:
              - {code: 10160-0, system: 'http://loinc.org'}
          schema:
            label: Medications Section
            short: Medications Section
            index: 19
            elements:
              title: {short: title, index: 20}
              code:
                label: History of medication use
                short: History of medication use
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10160-0, system: 'http://loinc.org'}
                index: 21
              text: {short: text, index: 22}
              entry:
                short: entry
                index: 23
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        refers: ['http://hl7.org/fhir/StructureDefinition/MedicationStatement', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest']
                        index: 24
            required: [text, title, code]
        social_history_section:
          match:
            code:
              coding:
              - {code: 29762-2, system: 'http://loinc.org'}
          schema:
            label: Social History Section
            short: Social History Section
            index: 127
            elements:
              title: {short: title, index: 128}
              code:
                label: Social history
                short: Social history
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 29762-2, system: 'http://loinc.org'}
                index: 129
              text: {short: text, index: 130}
              entry:
                short: entry
                index: 131
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: Smoking status
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus']
                        index: 132
            required: [text, title, code]
        procedures_section:
          match:
            code:
              coding:
              - {code: 47519-4, system: 'http://loinc.org'}
          schema:
            label: Procedures Section
            short: Procedures Section
            index: 113
            elements:
              title: {short: title, index: 114}
              code:
                label: History of Procedures
                short: History of Procedures
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 47519-4, system: 'http://loinc.org'}
                index: 115
              text: {short: text, index: 116}
              entry:
                short: entry
                index: 117
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure']
                        index: 118
            required: [text, title, code]
        chief_complaint_and_reason_for_visit_section:
          match:
            code:
              coding:
              - {code: 46239-0, system: 'http://loinc.org'}
          schema:
            label: Chief Complaint and Reason for Visit Section
            short: !!binary |-
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            index: 53
            elements:
              title: {short: title, index: 54}
              code:
                label: Chief complaint and reason for visit
                short: Chief complaint and reason for visit
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 46239-0, system: 'http://loinc.org'}
                index: 55
              text: {short: This section contains only human readable content, index: 56}
            required: [text, title, code]
        plan_of_treatment_section:
          match:
            code:
              coding:
              - {code: 18776-5, system: 'http://loinc.org'}
          schema:
            label: Plan of Treatment Section
            short: Plan of Treatment Section
            index: 107
            elements:
              title: {short: title, index: 108}
              code:
                label: Plan of treatment
                short: Plan of treatment
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 18776-5, system: 'http://loinc.org'}
                index: 109
              text: {short: text, index: 110}
              entry:
                short: entry
                index: 111
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        refers: ['http://hl7.org/fhir/StructureDefinition/Appointment', 'http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/CommunicationRequest', 'http://hl7.org/fhir/StructureDefinition/DeviceRequest', 'http://hl7.org/fhir/StructureDefinition/NutritionOrder', 'http://hl7.org/fhir/StructureDefinition/RequestGroup', 'http://hl7.org/fhir/StructureDefinition/ServiceRequest', 'http://hl7.org/fhir/StructureDefinition/Task', 'http://hl7.org/fhir/StructureDefinition/VisionPrescription', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest']
                        index: 112
            required: [text, title, code]
        problem_section:
          match:
            code:
              coding:
              - {code: 11450-4, system: 'http://loinc.org'}
          schema:
            label: Problem Section
            short: Problem Section
            _required: true
            index: 13
            elements:
              title: {short: title, mustSupport: true, index: 14}
              code:
                label: Problem list
                short: Problem list
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 11450-4, system: 'http://loinc.org'}
                index: 15
              text: {type: Narrative, short: text, index: 16}
              entry:
                short: entry
                index: 17
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    problem_section_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 18
            required: [text, title, code]
        review_of_systems_section:
          match:
            code:
              coding:
              - {code: 10187-3, system: 'http://loinc.org'}
          schema:
            label: Review of Systems Section
            short: Review of Systems Section
            index: 123
            elements:
              title: {short: title, index: 124}
              code:
                label: Review of systems
                short: Review of systems
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10187-3, system: 'http://loinc.org'}
                index: 125
              text: {short: This section contains only human readable content, index: 126}
            required: [text, title, code]
        vital_signs_section:
          match:
            code:
              coding:
              - {code: 8716-3, system: 'http://loinc.org'}
          schema:
            label: Vital Signs Section
            short: Vital Signs Section
            index: 133
            elements:
              title: {short: title, index: 134}
              code:
                label: Vital signs
                short: Vital signs
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 8716-3, system: 'http://loinc.org'}
                index: 135
              text: {short: text, index: 136}
              entry:
                short: entry
                index: 137
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        refers: ['http://hl7.org/fhir/StructureDefinition/vitalsigns']
                        index: 138
            required: [text, title, code]
        physical_exam_section:
          match:
            code:
              coding:
              - {code: 29545-1, system: 'http://loinc.org'}
          schema:
            label: Physical Exam Section
            short: Physical Exam Section
            index: 25
            elements:
              title: {short: title, index: 26}
              code:
                label: Physical findings
                short: Physical findings
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 29545-1, system: 'http://loinc.org'}
                index: 27
              text: {short: text, index: 28}
              entry:
                short: entry
                index: 29
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        refers: ['http://hl7.org/fhir/StructureDefinition/Observation']
                        index: 30
            required: [text, title, code]
        medical_equipment_section:
          match:
            code:
              coding:
              - {code: 46264-8, system: 'http://loinc.org'}
          schema:
            label: Medical Equipment Section
            short: Medical Equipment Section
            index: 89
            elements:
              title: {short: title, index: 90}
              code:
                label: History of medical device use
                short: History of medical device use
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 46264-8, system: 'http://loinc.org'}
                index: 91
              text: {short: text, index: 92}
              entry:
                short: entry
                index: 93
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    medical_equipment_entry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure']
                        index: 94
            required: [text, title, code]
        family_history_section:
          match:
            code:
              coding:
              - {code: 10157-6, system: 'http://loinc.org'}
          schema:
            label: Family History Section
            short: Family History Section
            index: 61
            elements:
              title: {short: title, index: 62}
              code:
                label: Family history
                short: Family history
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10157-6, system: 'http://loinc.org'}
                index: 63
              text: {short: text, index: 64}
              entry:
                short: entry
                index: 65
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        refers: ['http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory']
                        index: 66
            required: [text, title, code]
        advance_directives_section:
          match:
            code:
              coding:
              - {code: 42348-3, system: 'http://loinc.org'}
          schema:
            label: Advance Directives Section
            short: Advance Directives Section
            mustSupport: true
            index: 37
            elements:
              title: {short: title, mustSupport: true, index: 38}
              code:
                label: Advance directives
                short: Advance directives
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 42348-3, system: 'http://loinc.org'}
                index: 39
              text: {short: text, mustSupport: true, index: 40}
              entry:
                index: 41
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    advance_directive_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/Consent']
                        index: 42
            required: [text, title, code]
        assessment_section:
          match:
            code:
              coding:
              - {code: 51848-0, system: 'http://loinc.org'}
          schema:
            label: Assessment Section
            short: Assessment Section
            index: 49
            elements:
              title: {short: title, index: 50}
              code:
                label: Assessments (evaluation)
                short: Assessments (evaluation)
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 51848-0, system: 'http://loinc.org'}
                index: 51
              text: {short: This section contains only human readable content, index: 52}
            required: [text, title, code]
package_version: 2.0.0-ballot
class: profile
kind: resource
url: http://hl7.org/fhir/us/ccda/StructureDefinition/Consultation-Note
base: http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header
version: 2.0.0-ballot
required: [encounter]