DischargeSummary

Discharge Summary

activeC-CDA Templates4.0.0logical20 key elements

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.

#### Document Sections Although document templates may contain any section, the following sections are specifically called out by this template:

Required Sections

  • AllergiesAndIntolerancesSection
  • HospitalCourseSection
  • DischargeDiagnosisSection
  • PlanofTreatmentSection
  • HospitalConsultationsSection
  • ProceduresSection
  • ResultsSection

Recommended Sections

  • DischargeMedicationsSection

Additional Sections

  • ChiefComplaintSection
  • ChiefComplaintandReasonforVisitSection
  • NutritionSection
  • FamilyHistorySection
  • FunctionalStatusSection
  • PastMedicalHistory
  • HistoryofPresentIllnessSection
  • AdmissionDiagnosisSection
  • AdmissionMedicationsSectionEntriesOptional
  • HospitalDischargeInstructionsSection
  • HospitalDischargePhysicalSection
  • HospitalDischargeStudiesSummarySection
  • ImmunizationsSection
  • ProblemSection
  • ReasonforVisitSection
  • ReviewofSystemsSection
  • SocialHistorySection
  • VitalSignsSection
  • AdvanceDirectivesSection

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/cda/us/ccda/StructureDefinition/DischargeSummary
ID
DischargeSummary
Type
Base Definition
USRealmHeader
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
templateId
1+
:discharge-summary1..1
1+
templateId.root
1+
templateId.extension
1+
sdtcCategory.code
1+
sdtcCategory.codeSystem
1+
componentOf
1+
The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header.
componentOf.encompassingEncounter.effectiveTime.low
1+
The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low.
componentOf.encompassingEncounter.effectiveTime.high
1+
The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high.
componentOf.encompassingEncounter.dischargeDispositionCode
1+
The dischargeDispositionCode records the disposition of the patient at time of discharge. Access to the National Uniform Billing Committee (NUBC) code system requires a membership. The following conformance statement aligns with HITSP C80 requirements. The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, must be displayed when the document is rendered.
componentOf.encompassingEncounter.encounterParticipant.assignedEntity
1+
component.structuredBody
1+
In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional.
component.structuredBody.component
1+
:allergies1..1
1+
:hospitalCourse1..1
1+
:dischargeDx1..1
1+
:planOfTreatment1..1
1+
:hospitalConsults1..1
1+
:procedures1..1
1+
:results1..1
1+