| Australian Digital Health Agency Medicare Records FHIR Implementation Guide 2.1.0

Australian Digital Health Agency Medicare Records FHIR Implementation Guide. The current version which supersedes this version is 2.2.0. It is based on FHIR® version 3.0.2. See the Directory of published versions for a list of available versions.

#### StructureDefinition: ADHA MBS DVA ReferralRequest - Detailed Descriptions

Definitions for the profile.

1. 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 organization.
Control | 0..*
Alternate Names | ReferralRequest TransferOfCare Request
2. ReferralRequest.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Control | 0..1
Type | id
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
3. ReferralRequest.meta
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.
Control | 1..1
Type | Meta
4. ReferralRequest.meta.id
Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
5. ReferralRequest.meta.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Slicing | This element introduces a set of slices on ReferralRequest.meta.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: value @ url
6. ReferralRequest.meta.versionId
Definition | The version specific identifier, as it appears in the version portion of the URL. This values changes when the resource is created, updated, or deleted.
Control | 0..1
Type | id
Comments | The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
7. ReferralRequest.meta.lastUpdated
Definition | When the resource last changed - e.g. when the version changed.
Control | 0..1
Type | instant
Comments | This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant.
8. ReferralRequest.meta.profile
Definition | A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.
Control | 1..*
Type | uri
Comments | It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
9. ReferralRequest.meta.security
Definition | Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
Control | 0..*
Binding | The codes SHALL be taken from All Security Labels; other codes may be used where these codes are not suitable Security Labels from the Healthcare Privacy and Security Classification System
Type | Coding
Comments | The security labels can be updated without changing the stated version of the resource The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
10. ReferralRequest.meta.tag
Definition | Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
Control | 0..*
Binding | For example codes, see Common Tags Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones
Type | Coding
Comments | The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
11. ReferralRequest.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.
Control | 0..1
Type | uri
Is Modifier | true
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.
12. ReferralRequest.language
Definition | The base language in which the resource is written.
Control | 0..1
Binding | The codes SHALL be taken from Common Languages; other codes may be used where these codes are not suitable A human language
Additional Bindings | Purpose
All Languages | Max Binding
Type | code
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
13. ReferralRequest.text
Definition | A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: dom-1
Type | Narrative
Alternate Names | narrativehtmlxhtmldisplay
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.
14. ReferralRequest.contained
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Control | 0..*
Type | Resource
Alternate Names | inline resourcesanonymous resourcescontained resources
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.
15. ReferralRequest.extension
Definition | May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
16. ReferralRequest.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Control | 0..*
Type | Extension
Is Modifier | true
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
17. ReferralRequest.identifier
Definition | Business identifier that uniquely identifies the referral/care transfer request instance.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..*
Type | Identifier
Must Support | true
18. ReferralRequest.definition
Definition | A protocol, guideline, orderset or other definition that is adhered to in whole or in part by this request.
Control | 0..*
Type | Reference(ActivityDefinition PlanDefinition))
19. ReferralRequest.basedOn
Definition | Indicates any plans, proposals or orders that this request is intended to satisfy - in whole or in part.
Control | 0..*
Type | Reference(ReferralRequest CarePlan ProcedureRequest))
Alternate Names | fulfills
20. ReferralRequest.replaces
Definition | Completed or terminated request(s) whose function is taken by this new request.
Control | 0..*
Type | Reference(ReferralRequest))
Requirements | Allows tracing the continuation of a therapy or administrative process instantiated through multiple requests.
Alternate Names | supersedespriorrenewed order
Comments | The replacement could be because the initial request was immediately rejected (due to an issue) or because the previous request was completed, but the need for the action described by the request remains ongoing.
21. ReferralRequest.groupIdentifier
Definition | The business identifier of the logical "grouping" request/order that this referral is a part of.
Control | 0..1
Type | Identifier
Requirements | Allows multiple orders to be collected as part of a single requisition.
Alternate Names | grouperIdrequisition
22. ReferralRequest.status
Definition | The status of the authorization/intention reflected by the referral request record.
Control | 1..1
Binding | The codes SHALL be taken from RequestStatus The status of the referral
Type | code
Is Modifier | true
Must Support | true
Requirements | Workflow status is handled by the Task resource.
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Fixed Value | completed
23. ReferralRequest.intent
Definition | Distinguishes the "level" of authorization/demand implicit in this request.
Control | 1..1
Binding | The codes SHALL be taken from RequestIntent Codes identifying the stage lifecycle stage of a reques
Type | code
Is Modifier | true
Must Support | true
Requirements | The same resource structure is used when capturing proposals/recommendations, plans and actual requests.
Alternate Names | category
Fixed Value | order
24. ReferralRequest.type
Definition | An indication of the type of referral (or where applicable the type of transfer of care) request.
Control | 0..1
Binding | For example codes, see SNOMED CT Patient Referral Codes for types of referral; e.g. consult, transfer, temporary transfer
Type | CodeableConcept
25. ReferralRequest.priority
Definition | An indication of the urgency of referral (or where applicable the type of transfer of care) request.
Control | 0..1
Binding | The codes SHALL be taken from RequestPriority Codes indicating the relative priority of the referral
Type | code
26. ReferralRequest.serviceRequested
Definition | The service(s) that is/are requested to be provided to the patient. For example: cardiac pacemaker insertion.
Control | 0..*
Binding | For example codes, see Practice Setting Code Value Set Codes indicating the types of services that might be requested as part of a referral
Type | CodeableConcept
27. ReferralRequest.subject
Definition | The patient who is the subject of a referral or transfer of care request.
Control | 1..1
Type | Reference(AUBasePatient))
Must Support | true
Comments | Referral of family, group or community is to be catered for by profiles.
28. ReferralRequest.context
Definition | The encounter at which the request for referral or transfer of care is initiated.
Control | 0..1
Type | Reference(Encounter EpisodeOfCare))
Alternate Names | encounter
29. ReferralRequest.occurrence[x]
Definition | The period of time within which the services identified in the referral/transfer of care is specified or required to occur.
Control | 0..1
Type | Choice of: dateTime, Period
[x] Note | See Choice of Data Types for further information about how to use [x]
Requirements | Use cases: (1) to indicate that the requested service is not to happen before a specified date, and saving the start date in Period.start; (2) to indicate that the requested service must happen before a specified date, and saving the end date in Period.end; (3) to indicate that the requested service must happen during the specified dates ("start" and "end" values).
Alternate Names | timing
Comments | When the occurrenceDateTime is used, then it is indicating that the requested service must happen before the specified date.
30. ReferralRequest.authoredOn
Definition | Date/DateTime of creation for draft requests and date of activation for active requests.
Control | 0..1
Type | dateTime
Alternate Names | createdOn
31. ReferralRequest.requester
Definition | The individual who initiated the request and has responsibility for its activation.
Control | 1..1
Type | BackboneElement
Must Support | true
Alternate Names | author
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count())) rfr-1: onBehalfOf can only be specified if agent is practitioner or device (: (agent.resolve() is Device) or (agent.resolve() is Practitioner) or onBehalfOf.exists().not())
32. ReferralRequest.requester.id
Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
33. ReferralRequest.requester.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensionsuser content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
34. ReferralRequest.requester.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Control | 0..*
Type | Extension
Is Modifier | true
Alternate Names | extensionsuser contentmodifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
35. ReferralRequest.requester.agent
Definition | The device, practitioner, etc. who initiated the request.
Control | 1..1
Type | Reference(AUBasePractitioner))
Must Support | true
36. ReferralRequest.requester.onBehalfOf
Definition | The organization the device or practitioner was acting on behalf of.
Control | 0..1 This element is affected by the following invariants: rfr-1
Type | Reference(AUBaseOrganisation))
Must Support | true
Requirements | Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when authoring the request.
37. ReferralRequest.specialty
Definition | Indication of the clinical domain or discipline to which the referral or transfer of care request is sent. For example: Cardiology Gastroenterology Diabetology.
Control | 0..1
Binding | The codes SHALL be taken from https://healthterminologies.gov.au/fhir/ValueSet/anzsco-1; other codes may be used where these codes are not suitable
Type | CodeableConcept
Must Support | true
38. ReferralRequest.recipient
Definition | The healthcare provider(s) or provider organization(s) who/which is to receive the referral/transfer of care request.
Control | 0..*
Type | Reference(Practitioner Organization HealthcareService))
Comments | There will be a primary receiver. But the request can be received by any number of "copied to" providers or organizations.
39. ReferralRequest.reasonCode
Definition | Description of clinical condition indicating why referral/transfer of care is requested. For example: Pathological Anomalies, Disabled (physical or mental), Behavioral Management.
Control | 0..*
Binding | For example codes, see SNOMED CT Clinical Findings Codes indicating why the referral is being requested
Type | CodeableConcept
40. ReferralRequest.reasonReference
Definition | Indicates another resource whose existence justifies this request.
Control | 0..*
Type | Reference(Condition Observation))
41. ReferralRequest.description
Definition | The reason element gives a short description of why the referral is being made, the description expands on this to support a more complete clinical summary.
Control | 0..1
Type | string
42. ReferralRequest.supportingInfo
Definition | Any additional (administrative, financial or clinical) information required to support request for referral or transfer of care. For example: 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.
Control | 0..*
Type | Reference(Resource))
43. ReferralRequest.note
Definition | Comments made about the referral request by any of the participants.
Control | 0..*
Type | Annotation
44. ReferralRequest.relevantHistory
Definition | Links to Provenance records for past versions of this resource or fulfilling request or event resources that identify key state transitions or updates that are likely to be relevant to a user looking at the current version of the resource.
Control | 0..*
Type | Reference(Provenance))
Alternate Names | eventHistory
Comments | This element does not point to the Provenance associated with the current version of the resource - as it would be created after this version existed. The Provenance for the current version can be retrieved with a _revinclude.