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.cda.us.ccda
derivation: constraint
name: ConsultationNote
type: http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument
elements:
  templateId:
    array: true
    min: 2
    index: 0
    slicing:
      slices:
        consult-note:
          match: {}
          schema:
            _required: true
            index: 1
            elements:
              root:
                pattern: {type: String, value: 2.16.840.1.113883.10.20.22.1.4}
                index: 2
              extension:
                pattern: {type: String, value: '2024-05-01'}
                index: 3
            required: [root, extension]
            extensions: {}
  code:
    short: The Consultation Note recommends use of  the document type code 11488-4 "Consult Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
    binding: {strength: required, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.31'}
    index: 4
  participant:
    short: This participant represents the person to contact for questions about the consult summary. This call back contact individual may be a different person than the individual(s) identified in the author or legalAuthenticator participant.
    index: 5
    slicing:
      rules: open
      discriminator:
      - {path: typeCode, type: value}
      min: null
      slices:
        participant1:
          match: {typeCode: CALLBCK}
          schema:
            array: true
            index: 6
            elements:
              typeCode:
                pattern: {type: Code, value: CALLBCK}
                index: 7
              associatedEntity:
                constraint:
                  should-addr: {human: SHOULD contain addr, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote', severity: warning, expression: addr.exists()}
                index: 8
                elements:
                  classCode:
                    pattern: {type: Code, value: ASSIGNED}
                    index: 9
                  id: {index: 10}
                  addr: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/AD', index: 11}
                  telecom: {index: 12}
                  associatedPerson:
                    index: 13
                    elements:
                      name: {index: 14}
                    required: [name]
                  scopingOrganization: {index: 15}
                required: [id, associatedPerson, telecom]
  inFulfillmentOf:
    short: The inFulfillmentOf element describes prior orders that are fulfilled (in whole or part) by the service events described in the Consultation Note. For example, a prior order might be the consultation that is being reported in the note.
    index: 16
    elements:
      order:
        index: 17
        elements:
          id: {short: 'Where a referral is being fulfilled by this consultation, this id would be the same as the id in the Patient Referral Act template.', index: 18}
  componentOf:
    short: A Consultation Note is always associated with an encounter; the id element of the encompassingEncounter is required to be present and represents the identifier for the encounter.
    index: 19
    elements:
      encompassingEncounter:
        index: 20
        elements:
          id: {index: 21}
          effectiveTime: {index: 22}
          encounterParticipant:
            short: The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.
            index: 23
            elements:
              assignedEntity:
                constraint:
                  1198-32906: {human: 'This assignedEntity SHALL contain an assignedPerson or a representedOrganization or both (CONF:1198-32906).', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote', severity: error, expression: assignedPerson.exists() or representedOrganization.exists()}
                index: 24
            required: [assignedEntity]
  component:
    index: 25
    elements:
      structuredBody:
        constraint:
          ap-combo: {human: 'This structuredBody **SHALL NOT** contain an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present.', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote', severity: error, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection'')).exists() implies component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection'') or section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection'')).empty()'}
          cc-rfv-combo: {human: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present., source: 'http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote', severity: error, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintandReasonforVisitSection'')).exists() implies component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ChiefComplaintSection'') or section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection'')).empty()'}
          1198-9504: {human: '**SHALL** include a Reason for Referral or Reason for Visit section (CONF:1198-9504).', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote', severity: error, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforReferralSection'') or section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ReasonforVisitSection'')).exists()'}
          ap-or-a-and-p: {human: '**SHALL** include an Assessment and Plan Section, or both an Assessment Section and a Plan of Treatment Section.', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote', severity: error, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentandPlanSection'')).exists() or (component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentSection'') or section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection'')).count() = 2)'}
          should-section-medications: {human: SHOULD contain a Medications Section, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote', severity: warning, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/MedicationsSection''))'}
          should-section-physical-exam: {human: SHOULD contain a Physical Exam Section, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote', severity: warning, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/PhysicalExamSection''))'}
          should-section-results: {human: SHOULD contain a Results Section, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote', severity: warning, expression: 'component.where(section.hasTemplateIdOf(''http://hl7.org/cda/us/ccda/StructureDefinition/ResultsSection''))'}
        index: 26
        elements:
          component:
            array: true
            min: 5
            index: 27
            slicing:
              rules: open
              discriminator:
              - {path: section, type: profile}
              min: 5
              slices:
                component19:
                  match: {}
                  schema:
                    index: 64
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 65}
                component21:
                  match: {}
                  schema:
                    index: 70
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 71}
                component3:
                  match: {}
                  schema:
                    index: 32
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 33}
                component5:
                  match: {}
                  schema:
                    _required: true
                    index: 36
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 37}
                component25:
                  match: {}
                  schema:
                    index: 66
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 67}
                component17:
                  match: {}
                  schema:
                    index: 60
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 61}
                component4:
                  match: {}
                  schema:
                    index: 34
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 35}
                component6:
                  match: {}
                  schema:
                    index: 38
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 39}
                component7:
                  match: {}
                  schema:
                    _required: true
                    index: 40
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 41}
                component8:
                  match: {}
                  schema:
                    index: 42
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 43}
                component24:
                  match: {}
                  schema:
                    index: 76
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 77}
                component10:
                  match: {}
                  schema:
                    index: 46
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 47}
                component1:
                  match: {}
                  schema:
                    index: 28
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 29}
                component13:
                  match: {}
                  schema:
                    index: 52
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 53}
                component12:
                  match: {}
                  schema:
                    index: 50
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 51}
                component23:
                  match: {}
                  schema:
                    index: 74
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 75}
                component22:
                  match: {}
                  schema:
                    index: 72
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 73}
                component2:
                  match: {}
                  schema:
                    index: 30
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 31}
                component11:
                  match: {}
                  schema:
                    index: 48
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 49}
                component16:
                  match: {}
                  schema:
                    index: 58
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 59}
                component15:
                  match: {}
                  schema:
                    _required: true
                    index: 56
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 57}
                component9:
                  match: {}
                  schema:
                    index: 44
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 45}
                component18:
                  match: {}
                  schema:
                    index: 62
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 63}
                component14:
                  match: {}
                  schema:
                    index: 54
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 55}
                component20:
                  match: {}
                  schema:
                    index: 68
                    elements:
                      section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 69}
    required: [structuredBody]
package_version: 3.0.0-ballot
class: logical
kind: logical
url: http://hl7.org/cda/us/ccda/StructureDefinition/ConsultationNote
base: http://hl7.org/cda/us/ccda/StructureDefinition/USRealmHeader
version: 3.0.0-ballot
required: [inFulfillmentOf, componentOf]