TEMPLATE eReferral (eReferral)

TEMPLATE ID	eReferral
Concept	eReferral
Description	Not Specified
Purpose	Not Specified
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Language used	en
Citeable Identifier	1013.26.2
Root archetype id	openEHR-EHR-COMPOSITION.referral.v1
Referral document	Referral document: A document expressing all information required to make a request for provision of a specified service by another healthcare provider or organisation.
Other Context
Requestor Identifier	Requestor Identifier: Copy of INSTRUCTION.request-referral's Requestor Identifier.
Patient	Patient: Personal demographics including name(s) , addresse(s) and telecommunication contact details.
Personal name	Personal name: Details of personal name of an individual, provider or third party.
Personal name	Personal name: One or more names used by an individual.
Structured name	Structured name: Name in structured format.
Given name	Given name: Given / personal / first name.
Middle name	Middle name: Middle name or names.
Family name	Family name: Family name or Surname.
Identifier	Identifier: Identifier of individual.
Date of Birth	Date of Birth: Individual's date of birth.
Sex	Sex: Biological sex of the individual. Male Female Indeterminate
Address	Address: To record details of one or more personal addresses.
Address	Address: One or more adresses for an individual.
Address Type	Address Type: The type of address. Residential Correspondence Business Temporary
Structured address	Structured address: The structure of a postal address representing the residence of a patient or the physical location of an organisation. ENV 13606-4:2000 7.11.1.
Property number	Property number: The number of the property.
Address line	Address line: A series of address lines.
Post code	Post code: Post code.
Telecom details	Telecom details: Personal or organisational telephone, fax, and email details.
Mode	Mode: A qualifier for a telecom contact, describing its context e.g. 'Work', 'Home'. ENV 13606 - 4:2000 7.11.19. Home Work Contact
Telecoms	Telecoms: One or more telecoms contacts for an individual.
Telecoms type	Telecoms type: Telecom mechanism e.g. telephone, facsimile, pager etc. ENV 13606-4:2000 7.11.19 Telephone Fax Mobile phone Pager
Unstuctured telecoms	Unstuctured telecoms: An unstructured description of telecoms.
Structured telecoms	Structured telecoms: A structure for telephone numbers composed of separately identifiable elements. ENV13606-4:2000 7.11.18
Country code	Country code: Telephone country code. ENV13606-4:2000 7.11.18.
Area code	Area code: Telephone area code.
Number	Number: Telephone number.
Extension	Extension: Telephone extension number. ENV13606-4:2000 7.11.18.
Email address	Email address: Email address.
DateTime attested	DateTime attested: Date/Time that the referral has been authorised or approved.
Document Status	Document Status: *
Referral Details	Referral Details: To demonstrate a design pattern for representation Referral details within a Referral composition.
Referral request	Referral request: Request for provision of a specified service by another healthcare provider or organisation.
Request	Request: Current Activity.
Description
Service requested	Service requested: Identification of the service requested. This is often coded with an external terminology.
Description of service	Description of service: A detailed narrative description of the service requested.
Reason for request	Reason for request: A short description of the reason for the request. This is often coded with an external terminology.
Reason description	Reason description: A narrative description explaining the reason for request.
Intent	Intent: Stated intent of the request by the referrer.
Urgency	Urgency: Urgency of the request. Emergency Urgent Routine
Date &/or time service required	Date &/or time service required: The date and time that the service should be performed or completed.
Latest date service required	Latest date service required: The latest date that is acceptable for the service to be completed.
Supplementary information to follow	Supplementary information to follow: True indicates that additional information has been identified and will be forwarded when available eg incomplete pathology test results.
Supplementary information expected	Supplementary information expected: Details of the nature of supplementary information that is to follow e.g name of laboratory results.
Protocol
Requestor Identifier	Requestor Identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier.
Referred by	Referred by: Professional demographics details including name(s) , addresse(s) and telecommunication contact details.
Personal name	Personal name: Details of personal name of an individual, provider or third party.
Personal name	Personal name: One or more names used by an individual.
Structured name	Structured name: Name in structured format.
Given name	Given name: Given / personal / first name.
Middle name	Middle name: Middle name or names.
Family name	Family name: Family name or Surname.
Professional details	Professional details: Details of a professional carer.
Professional role	Professional role: Role of a professional in care of an individual.
Unstructured role	Unstructured role: Unstructured description of the role. Usual GP Locum GP
Professional Identifier	Professional Identifier: Professional identifier of the individual.
Telecom details	Telecom details: Personal or organisational telephone, fax, and email details.
Mode	Mode: A qualifier for a telecom contact, describing its context e.g. 'Work', 'Home'. ENV 13606 - 4:2000 7.11.19. Home Work Contact
Telecoms	Telecoms: One or more telecoms contacts for an individual.
Telecoms type	Telecoms type: Telecom mechanism e.g. telephone, facsimile, pager etc. ENV 13606-4:2000 7.11.19 Telephone Fax Mobile phone Pager
Unstuctured telecoms	Unstuctured telecoms: An unstructured description of telecoms.
Structured telecoms	Structured telecoms: A structure for telephone numbers composed of separately identifiable elements. ENV13606-4:2000 7.11.18
Country code	Country code: Telephone country code. ENV13606-4:2000 7.11.18.
Area code	Area code: Telephone area code.
Number	Number: Telephone number.
Extension	Extension: Telephone extension number. ENV13606-4:2000 7.11.18.
Email address	Email address: Email address.
Address	Address: To record details of one or more personal addresses.
Address	Address: One or more adresses for an individual.
Address Type	Address Type: The type of address. Residential Correspondence Business Temporary
Structured address	Structured address: The structure of a postal address representing the residence of a patient or the physical location of an organisation. ENV 13606-4:2000 7.11.1.
Property number	Property number: The number of the property.
Address line	Address line: A series of address lines.
Post code	Post code: Post code.
Organisation	Organisation: Details of an organisation
Name of Organisation	Name of Organisation: Name of the organisation
Identifier	Identifier: Identifier of organisation
Receiver identifier	Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.
Referred to	Referred to: Professional demographics details including name(s) , addresse(s) and telecommunication contact details.
Personal name	Personal name: Details of personal name of an individual, provider or third party.
Personal name	Personal name: One or more names used by an individual.
Name Type	Name Type: Type of name described. Preferred name Previous name Birth name AKA Alias Maiden name
Structured name	Structured name: Name in structured format.
Given name	Given name: Given / personal / first name.
Middle name	Middle name: Middle name or names.
Family name	Family name: Family name or Surname.
Professional details	Professional details: Details of a professional carer.
Specialty	Specialty: The speciality of the carer.
Professional Identifier	Professional Identifier: Professional identifier of the individual.
Telecom details	Telecom details: Personal or organisational telephone, fax, and email details.
Mode	Mode: A qualifier for a telecom contact, describing its context e.g. 'Work', 'Home'. ENV 13606 - 4:2000 7.11.19. Home Work Contact
Telecoms	Telecoms: One or more telecoms contacts for an individual.
Telecoms type	Telecoms type: Telecom mechanism e.g. telephone, facsimile, pager etc. ENV 13606-4:2000 7.11.19 Telephone Fax Mobile phone Pager
Unstuctured telecoms	Unstuctured telecoms: An unstructured description of telecoms.
Structured telecoms	Structured telecoms: A structure for telephone numbers composed of separately identifiable elements. ENV13606-4:2000 7.11.18
Country code	Country code: Telephone country code. ENV13606-4:2000 7.11.18.
Area code	Area code: Telephone area code.
Number	Number: Telephone number.
Extension	Extension: Telephone extension number. ENV13606-4:2000 7.11.18.
Email address	Email address: Email address.
Address	Address: To record details of one or more personal addresses.
Address	Address: One or more adresses for an individual.
Address Type	Address Type: The type of address. Residential Correspondence Business Temporary
Structured address	Structured address: The structure of a postal address representing the residence of a patient or the physical location of an organisation. ENV 13606-4:2000 7.11.1.
Property number	Property number: The number of the property.
Address line	Address line: A series of address lines.
Post code	Post code: Post code.
Organisation	Organisation: Details of an organisation
Name of Organisation	Name of Organisation: Name of the organisation
Identifier	Identifier: Identifier of organisation
Request status	Request status: The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information.
Patient's contact	Patient's contact: Personal demographics including name(s) , addresse(s) and telecommunication contact details.
Personal name	Personal name: Details of personal name of an individual, provider or third party.
Personal name	Personal name: One or more names used by an individual.
Name Type	Name Type: Type of name described. Preferred name Previous name Birth name AKA Alias Maiden name
Structured name	Structured name: Name in structured format.
Given name	Given name: Given / personal / first name.
Middle name	Middle name: Middle name or names.
Family name	Family name: Family name or Surname.
Unstructured name	Unstructured name: Name in free text unstructured format.
Relationship to subject	Relationship to subject: The relationship of this individual to the subject e.g. family member, informal carer.
Address	Address: To record details of one or more personal addresses.
Address	Address: One or more adresses for an individual.
Address Type	Address Type: The type of address. Residential Correspondence Business Temporary
Structured address	Structured address: The structure of a postal address representing the residence of a patient or the physical location of an organisation. ENV 13606-4:2000 7.11.1.
Property number	Property number: The number of the property.
Address line	Address line: A series of address lines.
Post code	Post code: Post code.
Telecom details	Telecom details: Personal or organisational telephone, fax, and email details.
Mode	Mode: A qualifier for a telecom contact, describing its context e.g. 'Work', 'Home'. ENV 13606 - 4:2000 7.11.19. Home Work Contact
Telecoms	Telecoms: One or more telecoms contacts for an individual.
Telecoms type	Telecoms type: Telecom mechanism e.g. telephone, facsimile, pager etc. ENV 13606-4:2000 7.11.19 Telephone Fax Mobile phone Pager
Unstuctured telecoms	Unstuctured telecoms: An unstructured description of telecoms.
Structured telecoms	Structured telecoms: A structure for telephone numbers composed of separately identifiable elements. ENV13606-4:2000 7.11.18
Country code	Country code: Telephone country code. ENV13606-4:2000 7.11.18.
Area code	Area code: Telephone area code.
Number	Number: Telephone number.
Extension	Extension: Telephone extension number. ENV13606-4:2000 7.11.18.
Email address	Email address: Email address.
Duration	Duration: Length of time the referral is valid.
Duration	Duration: Duration for which the referral is valid.
Indefinite	Indefinite: If true, referral is for an indefinite period of time.
Current & Past Medical History	Current & Past Medical History: Suggested design pattern for including a Problem List in a template.
Exclusion statement - Problems and Diagnoses	Exclusion statement - Problems and Diagnoses: Statements about problems and diagnoses that need to be positively recorded as absent or excluded.
Data
Global Statement	Global Statement: Global statements about the exclusion. This can be used to capture any information that is needed to be explicitly recorded as being absent or excluded within the record. No significant past history
Problem	Problem: An issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree.
Data
Problem	Problem: Identification of the index problem.
Date clinically recognised	Date clinically recognised: Date the problem was recognised by a healthcare provider.
Date of resolution	Date of resolution: The date that the problem resolved or went into remission.
Diagnosis	Diagnosis: A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria
Data
Diagnosis	Diagnosis: The index diagnosis Value set: ac0.1
Date clinically recognised	Date clinically recognised: Date the problem was recognised by clinicians
Date of resolution	Date of resolution: The date that the problem resolved or went into remission
Medical History overview	Medical History overview: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations. Annotations Notes.Comment: For use ONLY if structured data is not available
Data
Synopsis	Synopsis: The summary, assessment, conclusions or evaluation of the clinical findings.
Current Medications	Current Medications: Suggested design pattern for including an Medication Order List in a template.
Exclusion statement - Medications	Exclusion statement - Medications: Statements about medications that need to be positively recorded as absent or excluded.
Data
Global Statements	Global Statements: The statement about the absence or exclusion. Use to capture any information that is needed to be explicitly recorded as being absent or excluded within the record. Not currently taking any medication
Medication order	Medication order: An order or instruction created by a clinician which specifies which medication to take, when, for how long etc.
Medication activity	Medication activity: Information about the medication action(s) to be carried out.
null	The description of a medication for recording as part of an ACTION or INSTRUCTION
Item Description	Item Description: The name of the intervention - which may be coded
Dose Instruction	Dose Instruction: Dose, frequency, route & instruction as narrative.
Medications overview	Medications overview: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations. Annotations Notes.Comment: For use ONLY if structured data is not available
Data
Synopsis	Synopsis: The summary, assessment, conclusions or evaluation of the clinical findings.
Allergies/Adverse Reactions	Allergies/Adverse Reactions: Suggested design pattern for including an Adverse Reaction List in a template.
Exclusion statement - Adverse Reaction	Exclusion statement - Adverse Reaction: Statements about Adverse Reactions that need to be positively recorded as absent or excluded.
Data
Global Statement	Global Statement: Global statements about the exclusion. This can be used to capture any information that is needed to be explicitly recorded as being absent or excluded within the record. No known adverse reactions
Adverse reaction	Adverse reaction: Recording the presence of a harmful or undesirable response to an agent or substance including food, as determined by the clinician - excluding poisoning and abnormal use
Data
Agent description	Agent description: The agent or substance or class that caused the adverse reaction.
Exposure and reaction detail	Exposure and reaction detail: Details of the reaction experienced by the person.
Reaction description	Reaction description: A description of the reaction to this agent as experienced by the person.
Allergies/Adverse Reactions overview	Allergies/Adverse Reactions overview: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations. Annotations Notes.Comment: For use ONLY if structured data is not available
Data
Synopsis	Synopsis: The summary, assessment, conclusions or evaluation of the clinical findings.
Diagnostic Investigations	Diagnostic Investigations: Suggested design pattern for including Diagnostic Reports in a template.
Laboratory test	Laboratory test: To record the result of a laboratory test which may be used to record a single valued test but will often be specialised or templated to represent multiple value or 'panel' tests. This archetype also acts as the parent for specialisations appropriate for more specific laboratory tests microbiology, histopathology.
Data
Any event	Any event: Any event
Data
Test name	Test name: Specific identifier for this lab test. e.g. Full blood count , blood glucose, urine microbiology. May equate to the result name for a single value result. Commonly a coded term e.g from LOINC or SNOMED-CT.
Laboratory test type	Laboratory test type: The type of high-level diagnostic service e.g. biochemistry, haematology.
Test status	Test status: The status of the lab test as a whole. Interim Final Supplementary Corrected (amended) Aborted Never performed
Overall interpretation	Overall interpretation: An overall interpretative comment on this test.
Multimedia representation	Multimedia representation: Representations of the whole test in mutlimedia e.g image, audio, video.
Protocol
Date/Time result issued	Date/Time result issued: The date and/or time that the result was issued for the recorded ‘test status’. The date and time related to the results status is useful for version control and cumulative results for the report.
Imaging test	Imaging test: To record the result of an imaging test.
Data
Any event	Any event: *
Data
Imaging details	Imaging details: Details of imaging, used in requests for imaging, records of imaging procedures and imaging reports.
Imaging category	Imaging category: The type of imaging. Text Coded Text X-ray CT scan Perfusion scan Ultrasound Echocardiography
Imaging test name	Imaging test name: Imaging test requested / performed
Overall findings	Overall findings: Summary of imaging findings.
Imaging quality	Imaging quality: Information on the quality of the imaging that may influence reporting.
Diagnostic Test overview	Diagnostic Test overview: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations. Annotations Notes.Comment: For use ONLY if structured data is not available
Data
Synopsis	Synopsis: The summary, assessment, conclusions or evaluation of the clinical findings.

TEMPLATE eReferral (eReferral)

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