Transaction: Referral letter
General information
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.0
DATE:
2002-10-15
DEFINITION:
The referral letter is primarily used to orientate the patient when referred from the first to the second line of the healthcare system. It contains key information on the current patient's issue and possibly a summary of his (her) medical history.
Guidelines
Generalities
This transaction only requires a level 1 of kmehr normalization. However, further levels may be applied (see structure overview).
Transaction elements
id |
id of the transaction according to the ID-KMEHR conventions. |
cd |
You must use the value "referral" from CD-TRANSACTION. You can always add your own local codes. |
date |
This is the date when the patient has been referred. |
time |
This is the time when the patient has been referred. |
author |
This is the person assuming the responsibility of medical content of the referral letter (i.e. the referrer) |
iscomplete |
If this is false, this means that you transfer only part of the information and that the recipient should expect a more complete version later. |
isvalidated |
If this is false, this means that the information has not been validated medically. |
Structure overview
You have the choice between
- text(s): to transfer your letter as free text,
- lnk(s): to encapsulate your letter as a multimedia object (Word document for example),
- heading(s) and/or item(s): to further structure your referral letter.
Headings
We recommend the use of the following headings from CD-HEADING.
history |
Patient's history (antecedents) |
clinical |
Clinical investigation (including patient's complaints) |
technical |
Technical investigation |
assessment |
Current diagnoses and hypotheses |
clinicalplan |
Clinical plan of action |
technicalplan |
Technical plan of action |
treatment |
Proposed treatment |
Each heading can contain:
- text(s): to transfer your paragraph as free text,
- lnk(s): to encapsulate your paragraph as a multimedia object (Word document for example),
- item(s): to further structure your paragraph.
Items
We recommend the use of the following items from CD-ITEM . Optional attributes are set within squared braces.
Any item from CD-ITEM can be used but we strongly recommend the following.
| Item type (cd) | Item purpose | Item structure |
healthissue |
to specify current problem(s), diagnoses, hypotheses but also antecedents. |
Any national standard dictionary could be used to code the content of the items but at this stage of the specification, we recommend to transfer the co ntent of the items as free text. |
allergy |
allergy |
|
adr |
adverse drug reaction |
|
vaccine |
vaccine administration |
|
medication |
pharmaceutical treatment |
|
treatment |
treatment other than pharmaceutical |
|
habits |
usage of alcohol, tobacco, drug, ... |
|
complaint |
patient's complaint |
|
clinical |
results of clinical investigations |
|
technical |
results of technical investigations |
|
transactionreason |
reason for referring the patient |
|
expirationdatetime |
this item will be used to indicate the expiration datetime of a transaction, typically to be deactivated from a healthcare server like the S3 |