Proof of concept - not an authoritative source.

The information exchanged during a closed loop referral, from the referral request to the referral outcome. Based on the data items of the IHE 360X transactions (PCC TF-2 3.55 to 3.61), FHIR Workflow and HL7 v2 orders, with the UBRN from eRS. It is the same for a referral to an outpatient clinic, a community service or a virtual ward. National services such as BaRS are mapped onto this model (see the BaRS review), not the other way round. The PRSB Clinical Referral Information Standard v1.0 gives the clinical headings.

The referral stays small: the clinical content is in separate documents referenced as supporting information - a Discharge Report or clinic letter for the episode, a Patient Summary and referral forms. A referral may be one activity of a Care Plan.

The Mappings tab shows each element in HL7 v2 (360X) and FHIR.

• Differential Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Base

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Referral		0..*	Base	Clinical Referral Instances of this type can be the target of a Reference
Referral.referralId		1..1	Identifier	Referral ID
Referral.ubrn		0..1	Identifier	Unique Booking Reference Number
Referral.patient		1..1	BackboneElement	Patient
Referral.patient.nhsNumber		0..1	Identifier	NHS Number
Referral.patient.localIdentifier		0..*	Identifier	Local patient identifier
Referral.patient.demographics		1..1	BackboneElement	Demographics
Referral.referrer		1..1	BackboneElement	Referrer
Referral.referrer.clinician		1..1	Identifier	Referring clinician
Referral.referrer.organisation		1..1	Identifier	Referring organisation
Referral.recipient		0..1	BackboneElement	Referred to
Referral.recipient.service		0..1	Identifier	Service
Referral.recipient.clinician		0..1	Identifier	Clinician
Referral.recipient.organisation		0..1	Identifier	Organisation
Referral.serviceRequested		1..1	CodeableConcept	Service requested
Referral.priority		0..1	code	Priority
Referral.expectedBy		0..1	dateTime	Expected service provision time
Referral.validityPeriod		0..1	Period	Validity
Referral.reasonForReferral		1..*	CodeableConcept	Reason for referral
Referral.referralQuestion		0..1	string	Referral question
Referral.clinicalDocument		0..*	Reference(DocumentReference | Bundle)	Clinical document
Referral.patientSummary		0..1	Reference(DocumentReference | Bundle)	Patient summary
Referral.forms		0..*	Reference(QuestionnaireResponse)	Referral forms
Referral.observations		0..*	Reference(Observation)	Observations
Referral.carePlan		0..1	Reference(CarePlan)	Care plan
Referral.dateOfReferral		1..1	dateTime	Date of referral
Referral.status		1..1	code	Referral status
Referral.statusReason		0..1	CodeableConcept	Reason for decline or cancellation
Referral.appointment		0..*	BackboneElement	Appointment
Referral.appointment.appointmentId		1..1	Identifier	Appointment ID
Referral.appointment.dateTime		1..1	dateTime	Appointment date and time
Referral.appointment.provider		0..1	Identifier	Appointment provider
Referral.appointment.status		1..1	code	Appointment status
Referral.interimNote		0..*	Reference(DocumentReference | Bundle)	Interim consultation note
Referral.outcome		0..1	Reference(DocumentReference | Bundle)	Referral outcome
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Referral		0..*	Base	Clinical Referral Instances of this type can be the target of a Reference
Referral.referralId		1..1	Identifier	Referral ID
Referral.ubrn		0..1	Identifier	Unique Booking Reference Number
Referral.patient		1..1	BackboneElement	Patient
Referral.patient.@id		0..1	string	Unique id for inter-element referencing
Referral.patient.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Referral.patient.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Referral.patient.nhsNumber		0..1	Identifier	NHS Number
Referral.patient.localIdentifier		0..*	Identifier	Local patient identifier
Referral.patient.demographics		1..1	BackboneElement	Demographics
Referral.referrer		1..1	BackboneElement	Referrer
Referral.referrer.@id		0..1	string	Unique id for inter-element referencing
Referral.referrer.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Referral.referrer.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Referral.referrer.clinician		1..1	Identifier	Referring clinician
Referral.referrer.organisation		1..1	Identifier	Referring organisation
Referral.recipient		0..1	BackboneElement	Referred to
Referral.recipient.@id		0..1	string	Unique id for inter-element referencing
Referral.recipient.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Referral.recipient.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Referral.recipient.service		0..1	Identifier	Service
Referral.recipient.clinician		0..1	Identifier	Clinician
Referral.recipient.organisation		0..1	Identifier	Organisation
Referral.serviceRequested		1..1	CodeableConcept	Service requested
Referral.priority		0..1	code	Priority
Referral.expectedBy		0..1	dateTime	Expected service provision time
Referral.validityPeriod		0..1	Period	Validity
Referral.reasonForReferral		1..*	CodeableConcept	Reason for referral
Referral.referralQuestion		0..1	string	Referral question
Referral.clinicalDocument		0..*	Reference(DocumentReference | Bundle)	Clinical document
Referral.patientSummary		0..1	Reference(DocumentReference | Bundle)	Patient summary
Referral.forms		0..*	Reference(QuestionnaireResponse)	Referral forms
Referral.observations		0..*	Reference(Observation)	Observations
Referral.carePlan		0..1	Reference(CarePlan)	Care plan
Referral.dateOfReferral		1..1	dateTime	Date of referral
Referral.status		1..1	code	Referral status
Referral.statusReason		0..1	CodeableConcept	Reason for decline or cancellation
Referral.appointment		0..*	BackboneElement	Appointment
Referral.appointment.@id		0..1	string	Unique id for inter-element referencing
Referral.appointment.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Referral.appointment.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Referral.appointment.appointmentId		1..1	Identifier	Appointment ID
Referral.appointment.dateTime		1..1	dateTime	Appointment date and time
Referral.appointment.provider		0..1	Identifier	Appointment provider
Referral.appointment.status		1..1	code	Appointment status
Referral.interimNote		0..*	Reference(DocumentReference | Bundle)	Interim consultation note
Referral.outcome		0..1	Reference(DocumentReference | Bundle)	Referral outcome
Documentation for this format

Constraints

Id	Grade	Path(s)	Description	Expression
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Differential View

This structure is derived from Base

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Referral		0..*	Base	Clinical Referral Instances of this type can be the target of a Reference
Referral.referralId		1..1	Identifier	Referral ID
Referral.ubrn		0..1	Identifier	Unique Booking Reference Number
Referral.patient		1..1	BackboneElement	Patient
Referral.patient.nhsNumber		0..1	Identifier	NHS Number
Referral.patient.localIdentifier		0..*	Identifier	Local patient identifier
Referral.patient.demographics		1..1	BackboneElement	Demographics
Referral.referrer		1..1	BackboneElement	Referrer
Referral.referrer.clinician		1..1	Identifier	Referring clinician
Referral.referrer.organisation		1..1	Identifier	Referring organisation
Referral.recipient		0..1	BackboneElement	Referred to
Referral.recipient.service		0..1	Identifier	Service
Referral.recipient.clinician		0..1	Identifier	Clinician
Referral.recipient.organisation		0..1	Identifier	Organisation
Referral.serviceRequested		1..1	CodeableConcept	Service requested
Referral.priority		0..1	code	Priority
Referral.expectedBy		0..1	dateTime	Expected service provision time
Referral.validityPeriod		0..1	Period	Validity
Referral.reasonForReferral		1..*	CodeableConcept	Reason for referral
Referral.referralQuestion		0..1	string	Referral question
Referral.clinicalDocument		0..*	Reference(DocumentReference | Bundle)	Clinical document
Referral.patientSummary		0..1	Reference(DocumentReference | Bundle)	Patient summary
Referral.forms		0..*	Reference(QuestionnaireResponse)	Referral forms
Referral.observations		0..*	Reference(Observation)	Observations
Referral.carePlan		0..1	Reference(CarePlan)	Care plan
Referral.dateOfReferral		1..1	dateTime	Date of referral
Referral.status		1..1	code	Referral status
Referral.statusReason		0..1	CodeableConcept	Reason for decline or cancellation
Referral.appointment		0..*	BackboneElement	Appointment
Referral.appointment.appointmentId		1..1	Identifier	Appointment ID
Referral.appointment.dateTime		1..1	dateTime	Appointment date and time
Referral.appointment.provider		0..1	Identifier	Appointment provider
Referral.appointment.status		1..1	code	Appointment status
Referral.interimNote		0..*	Reference(DocumentReference | Bundle)	Interim consultation note
Referral.outcome		0..1	Reference(DocumentReference | Bundle)	Referral outcome
Documentation for this format

Snapshot ViewView

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Referral		0..*	Base	Clinical Referral Instances of this type can be the target of a Reference
Referral.referralId		1..1	Identifier	Referral ID
Referral.ubrn		0..1	Identifier	Unique Booking Reference Number
Referral.patient		1..1	BackboneElement	Patient
Referral.patient.@id		0..1	string	Unique id for inter-element referencing
Referral.patient.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Referral.patient.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Referral.patient.nhsNumber		0..1	Identifier	NHS Number
Referral.patient.localIdentifier		0..*	Identifier	Local patient identifier
Referral.patient.demographics		1..1	BackboneElement	Demographics
Referral.referrer		1..1	BackboneElement	Referrer
Referral.referrer.@id		0..1	string	Unique id for inter-element referencing
Referral.referrer.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Referral.referrer.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Referral.referrer.clinician		1..1	Identifier	Referring clinician
Referral.referrer.organisation		1..1	Identifier	Referring organisation
Referral.recipient		0..1	BackboneElement	Referred to
Referral.recipient.@id		0..1	string	Unique id for inter-element referencing
Referral.recipient.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Referral.recipient.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Referral.recipient.service		0..1	Identifier	Service
Referral.recipient.clinician		0..1	Identifier	Clinician
Referral.recipient.organisation		0..1	Identifier	Organisation
Referral.serviceRequested		1..1	CodeableConcept	Service requested
Referral.priority		0..1	code	Priority
Referral.expectedBy		0..1	dateTime	Expected service provision time
Referral.validityPeriod		0..1	Period	Validity
Referral.reasonForReferral		1..*	CodeableConcept	Reason for referral
Referral.referralQuestion		0..1	string	Referral question
Referral.clinicalDocument		0..*	Reference(DocumentReference | Bundle)	Clinical document
Referral.patientSummary		0..1	Reference(DocumentReference | Bundle)	Patient summary
Referral.forms		0..*	Reference(QuestionnaireResponse)	Referral forms
Referral.observations		0..*	Reference(Observation)	Observations
Referral.carePlan		0..1	Reference(CarePlan)	Care plan
Referral.dateOfReferral		1..1	dateTime	Date of referral
Referral.status		1..1	code	Referral status
Referral.statusReason		0..1	CodeableConcept	Reason for decline or cancellation
Referral.appointment		0..*	BackboneElement	Appointment
Referral.appointment.@id		0..1	string	Unique id for inter-element referencing
Referral.appointment.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Referral.appointment.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Referral.appointment.appointmentId		1..1	Identifier	Appointment ID
Referral.appointment.dateTime		1..1	dateTime	Appointment date and time
Referral.appointment.provider		0..1	Identifier	Appointment provider
Referral.appointment.status		1..1	code	Appointment status
Referral.interimNote		0..*	Reference(DocumentReference | Bundle)	Interim consultation note
Referral.outcome		0..1	Reference(DocumentReference | Bundle)	Referral outcome
Documentation for this format

Constraints

Id	Grade	Path(s)	Description	Expression
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

This structure is derived from Base

Summary

Mandatory: 0 element(13 nested mandatory elements)

Structures

This structure refers to these other structures:

• Observation (https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/Observation)

From Logical Model to Implementation Model

This logical model says what information a closed loop referral carries. An implementation splits it into FHIR resources, each owned by one side of the exchange, and sends them by one of the Exchange Options. The Mappings tab gives the element-level mapping; this section shows the breakdown.

Next: the Clinical Referral Domain Model goes into more detail on how the bulk of this model - the request: ServiceRequest and what it references - is implemented, field by field, in FHIR and HL7 v2.

flowchart LR
    subgraph LM [Clinical Referral - logical model]
        L1[Identification]
        L2[Patient]
        L3[Referrer / Recipient]
        L4[Request and reason]
        L5[Supporting information]
        L6[Status]
        L7[Appointment]
        L8[Interim note / Outcome]
    end
    subgraph RI [Owned by the Referral Initiator]
        SR[ServiceRequest<br/>Referral Request]
        PR[PractitionerRole<br/>Practitioner, Organization]
        DOC1[Documents and forms<br/>HDR, EPS, QuestionnaireResponse,<br/>Observation]
    end
    subgraph RR [Owned by the Referral Recipient]
        T[Task<br/>Referral Task]
        AP[Appointment, Slot<br/>Referral Appointment]
        EN[Encounter<br/>Visit / Hospital Spell]
        DOC2[Documents<br/>HDR, clinic letter]
        HS[HealthcareService<br/>Organization]
    end
    PT[Patient]
    L1 --> SR
    L2 --> PT
    L3 --> PR
    L3 --> HS
    L4 --> SR
    L5 --> DOC1
    L6 --> T
    L7 --> AP
    L7 --> EN
    L8 --> DOC2
    SR -. "supportingInfo" .-> DOC1
    T -. "basedOn / focus" .-> SR
    T -. "output" .-> DOC2
    AP -. "basedOn" .-> SR

Breakdown

How the Pieces Travel

The same resources are exchanged differently depending on the exchange option:

Rules that hold whatever the exchange option:

• The Referral ID is in every message and every resource that refers to the referral.
• The Referral Initiator owns the request (ServiceRequest); the Referral Recipient owns the work (Task, Appointment, Encounter) and the documents it writes.
• Clinical content travels as documents (HDR, EPS, forms), referenced from the referral, so they can also be shared through an API instead of being sent (EU Health Data API).

Example: the GP to cardiology referral - Referral Request, Referral Task - Accepted, Appointment, Referral Task - Completed, and as messages Referral Order (O19) and Referral Order Status (O51), accepted.