Discharge Summary

The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge. The Joint Commission requires the following information to be included in the Discharge Summary (http://www.jointcommission.org/):

The reason for hospitalization (the admission)

The procedures performed, as applicable

The care, treatment, and services provided

The patients condition and disposition at discharge

Information provided to the patient and family

Provisions for follow-up care

The best practice for a Discharge Summary is to include the discharge disposition in the display of the header.

resourceCompositionactiveView in C-CDA on FHIR IG
Profile Name
DischargeSummary
Base Definition
Derivation
constraint

Differential Elements (145)

Constraints and modifications from the base definition

PathCardinalityType(s)Must SupportDetails
Composition----
Composition.type--Yes-
Composition.section----
Composition.section
Slice: allergies_and_intolerances_section
1..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: allergy_entry
-
Reference
Yes
Target: us-core-allergyintolerance
Composition.section
Slice: hospital_course_section
1..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: discharge_diagnosis_section
1..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: discharge_diagnosis_entry
-
Reference
Yes
Target: us-core-condition
Composition.section
Slice: plan_of_treatment_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: sliceEntry
-
Reference
-
Target: us-core-goalus-core-medicationrequestus-core-encounterCommunicationAppointmentCommunicationRequestDeviceRequestNutritionOrderTaskServiceRequestVisionPrescriptionRequestGroup
Composition.section
Slice: discharge_medications_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: discharge_medications_entry
-
Reference
Yes
Target: MedicationStatementus-core-medicationus-core-medicationrequest
Composition.section
Slice: admission_diagnosis_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: admission_diagnosis_entry
-
Reference
Yes
Target: us-core-condition
Composition.section
Slice: admission_medications_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: admission_medications_entry
-
Reference
Yes
Target: MedicationStatementus-core-medicationus-core-medicationrequest
Composition.section
Slice: chief_complaint_and_reason_for_visit_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: chief_complaint_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: family_history_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: family_history_entry
-
Reference
Yes
Target: FamilyMemberHistory
Composition.section
Slice: functional_status_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: functional_status_entry
-
Reference
Yes
Target: us-core-conditionObservationClinicalImpression
Composition.section
Slice: history_of_present_illness_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: hospital_consultations_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: hospital_discharge_instructions_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: hospital_discharge_physical_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: hospital_discharge_studies_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: immunizations_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: immunizations_entry
-
Reference
Yes
Target: us-core-immunization
Composition.section
Slice: nutrition_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: nutrition_entry
-
Reference
Yes
Target: Observation
Composition.section
Slice: past_medical_history_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: past_medical_history_entry
-
Reference
Yes
Target: us-core-condition
Composition.section
Slice: problem_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: problem_entry
-
Reference
Yes
Target: us-core-condition
Composition.section
Slice: procedures_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: procedure_entry
-
Reference
Yes
Target: us-core-procedure
Composition.section
Slice: reason_for_visit_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: review_of_systems_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: social_history_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: smoking_status_entry
-
Reference
Yes
Target: us-core-smokingstatus
Composition.section
Slice: vital_signs_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: vital_signs_entry
-
Reference
Yes
Target: vitalsigns
Composition.section
Slice: goals_section
0..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: goals_entry
-
Reference
Yes
Target: us-core-goal
Composition.section
Slice: health_concerns_section
0..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: health_concerns_entry
-
Reference
Yes
Target: us-core-allergyintoleranceus-core-conditionus-core-observation-labus-core-smokingstatusvitalsignsClinicalImpressionObservationRiskAssessmentListDocumentReference