2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R3 R2

4.8.6 Resource ReferralRequest - Detailed Descriptions

Detailed Descriptions for the elements in the ReferralRequest resource.

ReferralRequest
Definition

Used to record and send details about a request for referral service or transfer of a patient to the care of another provider or provider organisation.

Control1..1
Alternate NamesReferralRequest TransferOfCare Request
ReferralRequest.status
Definition

The workflow status of the referral or transfer of care request.

Control1..1
BindingReferralStatus: Required: http://hl7.org/fhir/referralstatus (The status of the referral)
Typecode
Is Modifiertrue
Summarytrue
ReferralRequest.identifier
Definition

Business Id that uniquely identifies the referral/care transfer request instance.

Control0..*
TypeIdentifier
ReferralRequest.type
Definition

An indication of the type of referral (or where applicable the type of transfer of care) request.

Control0..1
TypeCodeableConcept
Summarytrue
Comments

Examples of referral type: - consultation; second opinion; third opinion - Assume management - Request for procedure(s)

HL7 v2.8 Example - Table 0336: S = second opinion p = patient preference o = provider ordered w = work load.

ReferralRequest.specialty
Definition

Indication of the clinical domain or discipline to which the referral or transfer of care request is sent.

Control0..1
TypeCodeableConcept
Comments

Examples: Cardiology Gastroenterology Diabetology.

ReferralRequest.priority
Definition

An indication of the urgency of referral (or where applicable the type of transfer of care) request.

Control0..1
TypeCodeableConcept
Summarytrue
ReferralRequest.patient
Definition

The patient who is the subject of a referral or transfer of care request.

Control0..1
TypeReference(Patient)
Summarytrue
Comments

Referral of family, group or community is to be catered for by profiles.

ReferralRequest.requester
Definition

The healthcare provider or provider organization who/which initaited the referral/transfer of care request. Can also be Patient (a self referral).

Control0..1
TypeReference(Practitioner | Organization | Patient)
Summarytrue
ReferralRequest.recipient
Definition

The healthcare provider(s) or provider organization(s) who/which is to receive the referral/transfer of care request.

Control0..*
TypeReference(Practitioner | Organization)
Summarytrue
Comments

There will be a primary receiver. But the request can be received by any number of "copied to" providers or organisations.

ReferralRequest.encounter
Definition

The encounter at which the request for referral or transfer of care is initiated.

Control0..1
TypeReference(Encounter)
ReferralRequest.dateSent
Definition

Date/DateTime the request for referral or transfer of care is sent by the author.

Control0..1
TypedateTime
Summarytrue
ReferralRequest.reason
Definition

Description of clinical condition indicating why referral/transfer of care is requested.

Control0..1
TypeCodeableConcept
Summarytrue
Comments

Examples: "2nd degree AV block"

Oral Health example ReferralReasonCode: 01 = Pathological Anomalies 02 = Disabled (physical or mental) 03 = Complexity of Treatment 04 = Seizure Disorders 05 = Extensive Surgery 06 = Surgical Complexity 07 = Rampant decay 08 = Medical History (to provide details upon request) 09 = Temporal Mandibular Joint Anomalies 10 = Accidental Injury 11 = Anaesthesia complications (local or general) 12 = Developmental Anomalies 13 = Behavioral Management.

ReferralRequest.description
Definition

The reason gives a short description of why the referral is being made, the description expands on this to support a more complete clinical summary.

Control0..1
Typestring
Comments

This would be a good candidate for a 'markdown' data type.

ReferralRequest.serviceRequested
Definition

The service(s) that is/are requested to be provided to the patient.

Control0..*
TypeCodeableConcept
Summarytrue
Comments

Examples: "cardiac pacemaker insertion"

HL7 v3 Concept domain - ReferralReasonCode examples: - Specialized medical assistance - Other care requirement.

ReferralRequest.supportingInformation
Definition

Any additional (administrative, financial or clinical) information required to support request for referral or transfer of care.

Control0..*
TypeReference(Any)
Summarytrue
Comments

Examples include: Presenting problems/chief complaints Medical History Family History Alerts Allergy/Intolerance and Adverse Reactions Medications Observations/Assessments (may include cognitive and fundtional assessments) Diagnostic Reports Care Plan.

ReferralRequest.fulfillmentTime
Definition

The period of time within which the services identified in the referral/transfer of care is specified or required to occur.

Control0..1
TypePeriod
Requirements

Use cases: (1) to indicate that the requested service is not to happen before a specified date (2) to indicate that the requested service must happen before a specified date (3) to indicate that the requested service must happen during the specified dates ("low" and "high" values).

Alternate NamesEffectiveTime
Summarytrue