Referral - tabular view

A non-urgent referral from a HCP to an outpatient clinic.

Indicates that the act is for information and understanding.

• Fixed value "INFRM"

Indicates that this is an event.

• Fixed value "EVN"

This identifier is unique within the Choose and Book  Service. It identifies the Unique Booking Reference Number(UBRN) allocated to the service request associated with the referral. 

The Identifier External datatype flavour is used to carry this information as follows:

• The root attribute shall contain an OID with the value 2.16.840.1.113883.2.1.3.2.4.1
• The extension attribute shall contain the UBRN

Refers to the patient who is the subject of the referral.

Refers to the referring HCP.

Refers to the clinical information items contained in the referral.

Refers to a set of headings which categorise the clinical information items in the referral.

Each clinical information item may be categorised by one or more headings.

Each clinical information item shall be categorised by at least one heading.

Information about a kind of action requested by the referral. 

Details about the patient.

Indicates that the role is that of a patient.

• Fixed value "PAT"

.

Information about the person who is the identified patient.

A choice of items that are components of a category within a referral.

Refers to a performer of an act that is a component of the referral.

A compound statement may be nested within another compound statement .This enables components to be linked within a category heading.

A record containing medication information relevant to one or more category heading.

A record containing uncategorised text relevant to one or more category headings. This should be text that cannot be carried elsewhere.

A record containing observation details relevant to one or more category heading.

A record containing details about a procedure relevant  to one or more category heading.

Details about a category header.

Each category header may only appear once.

Indicates that this is an observation.

• Fixed value: "OBS"

Indicates that this is an event.

• Fixed value: "EVN"

A unique identifier for this instance of a category header. 

The Identifier Global datatype flavour is used to carry this information as follows:

• A UUID is held in the root attribute

A code describing the category heading.

The Coded with Code System datatype flavour is used to carry this information as follows:

• The code attribute will contain a value from the list of codes in the ReferralCategoryHeading vocabulary;

• The codeSystem attribute will contain the OID referenced in the ReferralCategoryHeading  vocabulary

.

References to the set of clinical information items that exist within a specific category header.

Description of the action requested by the referral.

Indicates that this is an act.

• Fixed value: "ACT"

Indicates that this is a request.

• Fixed value: "RQO"

A code describing the action requested within the referral.

The Coded with Code System datatype flavour is used to carry this information as follows:

• The code attribute will contain a value from the list of codes in the ServiceTypeRequested vocabulary;

• The codeSystem attribute will contain the OID referenced in the ServiceTypeRequested  vocabulary

Additional text that is not carried within the code attribute. It SHALL NOT contradict any coded information.

Details about the person who is the patient.

Indicates that the entity is a person.

• Fixed value "PSN"

Indicates that the entity is a single identifiable person.

• Fixed value "INSTANCE"

The primary religious preference of the patient (e.g. Hinduism, Islam, Roman Catholic Church) in coded form.

The Coded with Code System datatype flavour is used to carry this information as follows

• The code attribute will contain a value from the list of codes in the ReligiousAffiliation vocabulary;

• The codeSystem attribute will contain the OID referenced in the ReligiousAffiliation  vocabulary

The ethnic category of the patient represented in coded form.

The Coded with Code System datatype flavour is used to carry this information as follows:

• The code attribute shall contain a value from the list of codes in the EthnicCategory vocabulary.
• The codeSystem attribute will contain the OID referenced in the EthnicCategory  vocabulary

A compound statement contains a collection of other referral components.

All referral components within a compound statement shall belong under the same category header. 

Indicates that this is an observation.

• Fixed value: "OBS"

Indicates that this is an event.

• Fixed value: "EVN"

A unique identifier for this instance of a compound statement component. 

The Identifier Global datatype flavour is used to carry this information as follows:

• A UUID is held in the root attribute

A code naming the collection of components in this Compound.

The vocabulary that this code value is taken from depends upon the value of the CompoundStatement.levelCode attribute as defined below.

1.  CompoundStatement.levelCode is "9b40." (Topic)

• The CompoundStatement.EhrCompoundCode is a clinical code that describes a topic within a single encounter or composition. 

2.  CompoundStatement.levelCode is "9b41." (Category)

• The CompoundStatement.EhrCompoundCode is a consultation category code that names sections of an encounter record or composition.

3.  CompoundStatement.levelCode is "9b42." (Cluster)

• The CompoundStatement.EhrCompoundCode is a clinical code representing the contents of the cluster  (e.g. "Haematology investigations").

4.  CompoundStatement.levelCode is "9b43." (Battery)

• The CompoundStatement.EhrCompoundCode is a clinical code representing the name of the overall investigation (e.g. "Blood Pressure", "Full blood count").

Any of the Concept Descriptor datatype flavours can be used and will include the following attributes:

• The code attribute shall contain a value 
• The codeSystem attribute shall contain an OID as defined below.

The data fields in the message are constructed to support future strategic use of SNOMED CT codes. If these codes are not currently available to populate the message, a suitable alternative from an identified coding scheme should be found. Valid coding schemes are as follows:

Indicates the status of the component. The fixed value shall be "completed".

The clinically relevant date and time.

Eg. For an investigation result it is the time of sampling or undertaking an examination not the time of analysis or reporting.

This is the time when the observations or actions recorded in the Compound actually took place.

System date and time of recording this observation on the original system.

An optional indicator in coded form of the priority assigned to actions described within this compound. For example where the compound represents a battery of requests or observations.

The Coded with Code System datatype flavour is used to carry this information as follows:

• The code attribute shall contain a value from the list of codes in the PriorityType vocabulary.
• The codeSystem attribute will contain the OID referenced in the PriorityType  vocabulary

Indicates using a code whether this compound contains items that are part of a:

• Topic ("9b40.") - A subdivision of a Composition related to a particular clinical issue.
• Category ("9b41.") - A subdivision of a Composition or Topic containing similar elements (e.g. Subjective, Objective, Assessment, Plan)
• Cluster ("9b42.") - A subdivision of a Composition, Topic or Category containing closely related Statements and or Batteries.(e.g. a series of Blood Pressure readings, a combination of a Full Blood Count and ESR).
• Battery ("9b43.") - A subdivision of a Composition, Topic, Category  or Cluster containing Statements that comprise the observations from an identifiable investigation (e.g. Blood Pressure, Full Blood Count, Electrolytes and Urea).

The Coded with Code System datatype flavour is used to carry this information as follows:

• The code attribute shall contain a value from the list of codes in the EhrCompoundLevel vocabulary.
• The codeSystem attribute will contain the OID referenced in the EhrCompoundLevel  vocabulary

Allows the author to indicate using a code that the components within a statement are in some way uncertain.

The Coded with Code System datatype flavour is used to carry this information as follows:

• The code attribute shall contain a value from the list of codes in the ActUncertainty vocabulary.

A code indicating whether a set of observations were interpreted as abnormal by the party responsible for undertaking the original observations.

Note

• The primary intended use of this is for representation of laboratory investigations in line with current UK clinical EDI requirements.

The Coded Plain datatype flavour is used to carry this information as follows:

• The code attribute shall contain a value from the list of codes in the Interpretation vocabulary.
• The codeSystem attribute shall contain an OID with the value 2.16.840.1.113883.2.1.3.2.4.16.8
• The displayName attribute shall contain the text description of the code. 

The compound statement shall contain one or more other components chosen from the referral component. All the components shall be categorised by the same category heading.

Details about relevant medication that is being taken by the patient or has been taken.

Indicates that this component relates to substance administration.

• Fixed value: "SBADM"

Indicates that this is an event.

• Fixed value: "EVN"

A unique identifier for this instance of a medication component. 

The Identifier Global datatype flavour is used to carry this information as follows:

• A UUID is held in the root attribute

A code representing the medication.

Date/time or period of intended or actual treatment.

The date of prescription of the medication.

The route of administration of the drug.

The quantity supplied.

The maximum daily dose. This is given in terms of value and units.

Refers to the substance of the medication. 

Refers to the quantity of medication supplied.

Refers to the dosage carried as unstructured data.

Refers to the medication reveiw required indicator.

Refers to the timing of the medication.

Refers to the trigger for administering the medication.

Refers to free text associated with the medication details.

The Narrative statements exists to accommodate referral information which is not semantically processable by a computer system. 

The reason that the information is presented in this form may be:

• That it is not semantically processable in the sending system.
• That the semantics in the sending system cannot be reliably represented in the message
• That the information has been degraded from a semantically processable form to allow receipt by an application that does not support the semantics of the sending system.

Indicates that this is an observation.

• Fixed value: "OBS"

Indicates that this is an event.

• Fixed value: "EVN"

A unique identifier for this instance of a narrative statement component. 

The Identifier Global datatype flavour is used to carry this information as follows:

• A UUID is held in the root attribute

Example

<id root="41CB01EC-8794-4B9B-ADC4-AB5BD0954EBE"/>

The marked up text content of the Narrative.

Indicates the status of the component. In this context the status shall be "completed".

The Coded Only datatype flavour is used to carry this information as follows:

• The code attribute shall default to "completed"

System date and time of recording this narrative on the original system.

An observation statement is used to carry most elements of a referral. This includes problem being referred, investigations, examinations, diagnoses, social history and family history. 

There shall be an observation statement that carries the problem being referred.

Indicates that this is an observation.

• Fixed value: "OBS"

Indicates that this is an event.

• Fixed value: "EVN"

A unique identifier for this instance of an observation component. 

The Identifier Global datatype flavour is used to carry this information as follows:

• A UUID is held in the root attribute

A code specifying the nature of the observation.

Observation shall be coded with additional information held in Observation Commentary.

Any of the Concept Descriptor datatype flavours can be used and will include the following attributes:

• The code attribute shall contain a value 
• The codeSystem attribute shall contain an OID as defined below.

The data fields in the message are constructed to support future strategic use of SNOMED CT codes. If these codes are not currently available to populate the message, a suitable alternative from an identified coding scheme should be found. Valid coding schemes are as follows:

Text specifying the nature of the observation.

Text shall only be used if no code value is available and SHALL NOT be used in conjunction with Observation Commentary.

The clinically relevant date and time.

Eg. For an investigation result it is the time of sampling  not the time of analysis or reporting.

Date/time of the observation.

Allows the author to indicate using a code that the components within a statement are in some way uncertain.

The Coded Only datatype flavour is used to carry this information as follows:

• The code attribute shall contain a value from the list of codes in the ActUncertainty vocabulary.

The result value of an observation action.The result value of an observation action. The following are the approved uses for clinical observations within the NPfIT:

Quantitative measurement - PQ::Physical quantity (real number with unit.  This includes time periods, e.g. 30 minutes, 2 days)

Titre (eg.,1:64) and other ratios - RTO :: A ratio of two integer numbers

Index (number without unit) - PQ with a dimensionless unit (e.g., an integer or real number

 Ranges (eg.,<3;12-20) - IVL<PQ> :: Interval of physical quantity)

Ordinals (eg.,stage lIa. ++) - CO - coded ordinals

Non-ordinal Values represented using a controlled terminology  (e.g. organism type shigella.. Note such values are of the concept given by the observation.code, and do not replace it.

CV, with mandatory code & coding system id, version id required (i.e. must be used where relevant), display name optional, original text not applicable, and code system name optional .  This would include binary codes, which should be given more specific meaning such as present / absent, true / false by this means.

Uncoded nominal results (eg.,organism type)

ST a string (This representation is deprecated, and CV should be used in it's stead wherever possible)

Blobs(images, scanned documents, biosignals, audio recordings)

ED - the reference and thumbnail properties are not applicable

A code indicating whether a set of observations were interpreted as abnormal by the party responsible for undertaking the original observations.

Note

• The primary intended use of this is for representation of laboratory investigations in line with current UK clinical EDI requirements.

The Coded Plain datatype flavour is used to carry this information as follows:

• The code attribute shall contain a value from the list of codes in the Interpretation vocabulary.
• The codeSystem attribute shall contain an OID with the value 2.16.840.1.113883.2.1.3.2.4.16.8
• The displayName attribute shall contain the text description of the code. 

Refers to notes/comments about an observation

Refers to normal reference ranges for a laboratory result.

Details about a procedure.

Indicates that this is a procedure.

• Fixed value: "PROC"

Indicates that this is an event.

• Fixed value: "EVN"

A unique identifier for this instance of an procedure event component. 

The Identifier Global datatype flavour is used to carry this information as follows:

• A UUID is held in the root attribute

Procedure shall be coded with additional information held in Procedure Commentary

Any of the Concept Descriptor datatype flavours can be used and will include the following attributes:

• The code attribute shall contain a value 
• The codeSystem attribute shall contain an OID as defined below.

The data fields in the message are constructed to support future strategic use of SNOMED CT codes. If these codes are not currently available to populate the message, a suitable alternative from an identified coding scheme should be found. Valid coding schemes are as follows:

Text specifying the nature of the procedure.

Text shall only be used if no code value is available and SHALL NOT be used in conjunction with Procedure Commentary.

The clinically relevant date and time.

Eg. This is the time of undertaking an examination not the time of reporting.

Refers to notes/comments about a procedure.

Refers to a component using a unique identifier.

Indicates that this is an act.

• Fixed value: "ACT"

Indicates that this is an event.

• Fixed value: "EVN"

A unique identifier for this instance of a referral component. 

The Identifier Global datatype flavour is used to carry this information as follows:

• A UUID is held in the root attribute

Details about the drug

 Indicates that this is a manufactured material.

• Fixed value: "THER"

Information about the substance that forms the medication.

Details about the amount of medication supplied. 

Indicates that the drug is supplied.

• Fixed value: "SPLY"

Indicates that this is an event.

• Fixed value: "EVN"

The total amount of drug quantity supplied.

The dosage carried as unstructured text.

Indicates that this act relates to substance administration.

• Fixed value: "SBADM"

Indicates that this is an event.

• Fixed value: "EVN"

Carries all dosage information.

A text string should be composed if any items cannot be coded and SHALL NOT be used in conjunction with structured information.

The medication review required indicator. 

Indicates that this is an observation within a medication component.

• Fixed value: "OBS"

Indicates that this is an event.

• Fixed value: "EVN"

A code describing the act. In this context the value shall be "ReviewRequired"

The Coded Only datatype flavour is used to carry this information as follows:

• The code attribute shall default to "ReviewRequired"

A value indicating whether a medication review is required. 

 The value attribute may be "false" indicating that no review is required,  or "true" indicating that a review is required.

Details of the times of administration of the medication.

Indicates that this relates to substance administration.

• Fixed value: "SBADM"

Indicates that this is an event.

• Fixed value: "EVN"

Text string allowing full description of administration times.

eg. Three times a day after meals.

Describes the trigger for administrating medication.

Indicates that this relates to substance administration.

• Fixed value: "SBADM"

Indicates that this is an event.

• Fixed value: "EVN"

Text string describing the trigger for administering medication.

Comments/notes about the medication component.

Indicates that this is an observation within a medication component.

• Fixed value: "OBS"

Indicates that this is an event.

• Fixed value: "EVN"

Additional comments about a medication component. 

This SHALL NOT contradict any coded information.

Comments/notes about an observation.

Indicates that this is an observation.

• Fixed value: "OBS"

Indicates that this is an event.

• Fixed value: "EVN"

Additional comments about an observation. 

This SHALL NOT contradict any coded information.

Details of normal reference ranges.

Indicates that this is an observation.

• Fixed value: "OBS"

Indicates that this is an event.

• Fixed value: "EVN.CRT"

A textual comment on the reference range.

The reference range values.

A code indicating whether a set of observations were interpreted as abnormal by the party responsible for undertaking the original observations.

Note

• The primary intended use of this is for representation of laboratory investigations in line with current UK clinical EDI requirements.

The Coded Plain datatype flavour is used to carry this information as follows:

• The code attribute shall contain a value from the list of codes in the Interpretation vocabulary.
• The codeSystem attribute shall contain an OID with the value 2.16.840.1.113883.2.1.3.2.4.16.8
• The displayName attribute shall contain the text description of the code. 

Comments/notes about a procedure.

Indicates that this is an observation.

• Fixed value: "OBS"

Indicates that this is an event.

• Fixed value: "EVN"

Details about the drug.

Indicates that this is a manufactured material.

• Fixed value: "MMAT"

Indicates that the entity is a general description of a kind of thing.

• Fixed value: "KIND"

A code specifying the nature of the substance.

Any of the Concept Descriptor datatype flavours can be used and will include the following attributes:

• The code attribute shall contain a value 
• The codeSystem attribute shall contain an OID as defined below.

The data fields in the message are constructed to support future strategic use of SNOMED CT codes. If these codes are not currently available to populate the message, a suitable alternative from an identified coding scheme should be found. Valid coding schemes are as follows:

The strength of the drug.

The name of the drug.

A code specifying the drug formulation.

Any of the Concept Descriptor datatype flavours can be used and will include the following attributes:

• The code attribute shall contain a value 
• The codeSystem attribute shall contain an OID as defined below.

The data fields in the message are constructed to support future strategic use of SNOMED CT codes. If these codes are not currently available to populate the message, a suitable alternative from an identified coding scheme should be found. Valid coding schemes are as follows: