DischargeSummary

Discharge Summary

activeC-CDA on FHIR1.2.0resource125 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.

Metadata

hl7.org/fhir

Canonical URL: http://hl7.org/fhir/us/ccda/StructureDefinition/Discharge-Summary
ID: Discharge-Summary
Type
Base Definition: US-Realm-Header
Derivation: constraint

Mandatory and Must-Support Elements

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

Path	Card.	Type	Flags	Description
type			S	Discharge Summary
:allergies_and_intolerances_section	1..1		S1+	Allergies and Intolerances Section
section.title			S1+	title
section.code			S1+	Allergies and adverse reactions
section.text			S1+	text
:allergy_entry		Reference	S
:hospital_course_section	1..1		S1+	Hospital Course Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:discharge_diagnosis_section	1..1		S1+	Discharge Diagnosis Section
section.title			S1+	title
section.code			S1+	Hospital discharge diagnosis
section.text			S1+	text
:discharge_diagnosis_entry		Reference	S
:plan_of_treatment_section			S	Plan of Treatment Section
section.title			S1+	title
section.code			S1+	Plan of treatment
section.text			S1+	text
:discharge_medications_section			S	Discharge Medications Section
section.title			S1+	title
section.code			S1+	Hospital discharge medications
section.text			S1+	text
:discharge_medications_entry		Reference	S
:admission_diagnosis_section			S	Admission Diagnosis Section
section.title			S1+	title
section.code			S1+	Hospital admission diagnosis
section.text			S1+	text
:admission_diagnosis_entry		Reference	S
:admission_medications_section			S	Admission Medications Section
section.title			S1+	title
section.code			S1+	Medications on admission
section.text			S1+	text
:admission_medications_entry		Reference	S
:chief_complaint_and_reason_for_visit_section			S	Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patientâs own description) and/or the reason for the patient's visit (the providerâs description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:chief_complaint_section			S	Chief Complaint Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:family_history_section			S	Family History Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	text
:family_history_entry		Reference	S	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:functional_status_section			S	Functional Status Section
section.title			S1+	title
section.code			S1+	Functional status
section.text			S1+	text
:functional_status_entry		Reference	S	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:history_of_present_illness_section			S	History of Present Illness Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:hospital_consultations_section			S	Hospital Consultations Section
section.title			S1+	title
section.code			S1+	Hospital consultations
section.text			S1+	This section contains only human readable content
:hospital_discharge_instructions_section			S	Hospital Discharge Instructions Section
section.title			S1+	title
section.code			S1+	Hospital discharge instructions
section.text			S1+	This section contains only human readable content
:hospital_discharge_physical_section			S	Hospital Discharge Physical Section
section.title			S1+	title
section.code			S1+	Hospital discharge physical
section.text			S1+	This section contains only human readable content
:hospital_discharge_studies_section			S	Hospital Discharge Studies Section
section.title			S1+	title
section.code			S1+	Hospital discharge studies summary
section.text			S1+	This section contains only human readable content
:immunizations_section			S	Immunizations Section
section.title			S1+	title
section.code			S1+	Immunizations
section.text			S1+	text
:immunizations_entry		Reference	S
:nutrition_section			S	Nutrition Section
section.title			S1+	title
section.code			S1+	Diet and nutrition
section.text			S1+	text
:nutrition_entry		Reference	S	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:past_medical_history_section			S	Past Medical History Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	text
:past_medical_history_entry		Reference	S
:problem_section			S	Problem Section
section.title			S1+	title
section.code			S1+	Problem list
section.text			S1+	text
:problem_entry		Reference	S
:procedures_section			S	Procedures Section
section.title			S1+	title
section.code			S1+	History of procedures
section.text			S1+	text
:procedure_entry		Reference	S
:reason_for_visit_section			S	Reason for Visit Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:review_of_systems_section			S	Review of Systems Section
section.title			S1+	title
section.code			S1+	Review of systems
section.text			S1+	This section contains only human readable content
:social_history_section			S	Social History Section
section.title			S1+	title
section.code			S1+	Social history
section.text			S1+	text
:smoking_status_entry		Reference	S	Smoking status
:vital_signs_section			S	Vital Signs Section
section.title			S1+	title
section.code			S1+	Vital signs
section.text			S1+	text
:vital_signs_entry		Reference	S
:goals_section	0..1		S	Goals Section
section.title			S1+	title
section.code			S1+	Goals
section.text			S1+	text
:goals_entry		Reference	S	entry
:health_concerns_section	0..1		S	Health Concerns Section
section.title			S1+	title
section.code			S1+	Health concerns section code
section.text			S1+	text
:health_concerns_entry		Reference	S	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.