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.
Differential Elements (145)
Constraints and modifications from the base definition
| Path | Cardinality | Type(s) | Must Support | Details |
|---|---|---|---|---|
Composition | - | - | - | - |
Composition.type | - | - | Yes | - |
Composition.section | - | - | - | - |
Composition.sectionSlice: allergies_and_intolerances_section | 1..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: allergy_entry | - | Reference | Yes | Target: us-core-allergyintolerance |
Composition.sectionSlice: hospital_course_section | 1..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: discharge_diagnosis_section | 1..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: discharge_diagnosis_entry | - | Reference | Yes | Target: us-core-condition |
Composition.sectionSlice: plan_of_treatment_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: sliceEntry | - | Reference | - | Target: us-core-goalus-core-medicationrequestus-core-encounterCommunicationAppointmentCommunicationRequestDeviceRequestNutritionOrderTaskServiceRequestVisionPrescriptionRequestGroup |
Composition.sectionSlice: discharge_medications_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: discharge_medications_entry | - | Reference | Yes | Target: MedicationStatementus-core-medicationus-core-medicationrequest |
Composition.sectionSlice: admission_diagnosis_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: admission_diagnosis_entry | - | Reference | Yes | Target: us-core-condition |
Composition.sectionSlice: admission_medications_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: admission_medications_entry | - | Reference | Yes | Target: MedicationStatementus-core-medicationus-core-medicationrequest |
Composition.sectionSlice: chief_complaint_and_reason_for_visit_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: chief_complaint_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: family_history_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: family_history_entry | - | Reference | Yes | Target: FamilyMemberHistory |
Composition.sectionSlice: functional_status_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: functional_status_entry | - | Reference | Yes | Target: us-core-conditionObservationClinicalImpression |
Composition.sectionSlice: history_of_present_illness_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: hospital_consultations_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: hospital_discharge_instructions_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: hospital_discharge_physical_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: hospital_discharge_studies_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: immunizations_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: immunizations_entry | - | Reference | Yes | Target: us-core-immunization |
Composition.sectionSlice: nutrition_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: nutrition_entry | - | Reference | Yes | Target: Observation |
Composition.sectionSlice: past_medical_history_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: past_medical_history_entry | - | Reference | Yes | Target: us-core-condition |
Composition.sectionSlice: problem_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: problem_entry | - | Reference | Yes | Target: us-core-condition |
Composition.sectionSlice: procedures_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: procedure_entry | - | Reference | Yes | Target: us-core-procedure |
Composition.sectionSlice: reason_for_visit_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: review_of_systems_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: social_history_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: smoking_status_entry | - | Reference | Yes | Target: us-core-smokingstatus |
Composition.sectionSlice: vital_signs_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: vital_signs_entry | - | Reference | Yes | Target: vitalsigns |
Composition.sectionSlice: goals_section | 0..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: goals_entry | - | Reference | Yes | Target: us-core-goal |
Composition.sectionSlice: health_concerns_section | 0..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: health_concerns_entry | - | Reference | Yes | Target: us-core-allergyintoleranceus-core-conditionus-core-observation-labus-core-smokingstatusvitalsignsClinicalImpressionObservationRiskAssessmentListDocumentReference |