1.3.6.1.4.1.19376.1.5.3.1.1.4

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The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif Discharge Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.4

This use case is described fully in the XDS-MS profile found in PCC TF-1. Briefly, it involves an episodic transfer of care in the form of a patient discharge from a hospital to home. The important data elements identified by physicians and nurses for this use case are listed in the table below under the column "Data Elements". These are mapped to the categories given HL7 Care Record Summary Implementation Guide, and HL7 CDA Release 2.0 in the next two columns.

A discharge summary is a type of medical summary, and incorporates the constraints defined for Medical Summaries.

This section defines additional constraints for Medical Summary Content used in a Discharge Summary. These tables present the data elements described above, along with their optionality, and references to the section and template where these sections or header data elements are further defined.

In no case are these IHE requirements less strict than those defined by the HL7 Care Record Summary.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:xds-ms:2007

Parent Template

This document is an instance of the Medical Summary template.

Standards
CDAR2 HL7 CDA Release 2.0
CRS HL7 Care Record Summary
CCD ASTM/HL7 Continuity of Care Document
Data Element Index
Data Elements HL7 Care Record Summary CDA Release 2.0
Date of Admission Header encompassingEncounter/effectiveTime
Date of Discharge Header encompassingEncounter/effectiveTime
Participating Providers and Roles Header documentationOf/serviceEvent/performer
Discharge Disposition (who, how, where) Care Plan DISCHARGE DISPOSITION
Admitting Diagnosis Conditions HOSPITAL ADMISSION DX
History of Present Illness History of Present Illness HISTORY OF PRESENT ILLNESS
Hospital Course Hospital Course HOSPITAL COURSE
Discharge Diagnosis (including active and resolved problems) Conditions HOSPITAL DISCHARGE DX
Selected Medicine Administered during Hospitalization Medications HISTORY OF MEDICATION USE
Discharge Medications Medications HOSPITAL DISCHARGE MEDICATIONS
Allergies and adverse reactions Allergies and Adverse Reactions HISTORY OF ALLERGIES
Discharge Diet Optionally found in Care Plan DISCHARGE DIET
Review of Systems Review of Systems REVIEW OF SYSTEMS
Vital Signs (most recent, high/low/average) Physical Exam VITAL SIGNS
Functional Status Functional Status HISTORY OF FUNCTIONAL STATUS
Relevant Procedures and Reports (including links) Studies and Reports HOSPITAL DISCHARGE STUDIES
Relevant Diagnostic Tests and Reports (including links) Studies and Reports HOSPITAL DISCHARGE STUDIES
Plan of Care Care Plan TREATMENT PLAN
Administrative Identifiers Header patient/id
Pertinent Insurance Information Header participant[@classCode='HLD']
Specification
Data Element Name Opt Template ID
Active Problems R 1.3.6.1.4.1.19376.1.5.3.1.3.6
Resolved Problems R 1.3.6.1.4.1.19376.1.5.3.1.3.8
Discharge Diagnosis R 1.3.6.1.4.1.19376.1.5.3.1.3.7
Admitting Diagnosis R 1.3.6.1.4.1.19376.1.5.3.1.3.3
Selected Meds Administered R2 1.3.6.1.4.1.19376.1.5.3.1.3.21
Discharge Meds R 1.3.6.1.4.1.19376.1.5.3.1.3.22
Admission Medications R2 1.3.6.1.4.1.19376.1.5.3.1.3.20
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Hospital Course R 1.3.6.1.4.1.19376.1.5.3.1.3.5
Advance Directives O 1.3.6.1.4.1.19376.1.5.3.1.3.34
History of Present Illness R2 1.3.6.1.4.1.19376.1.5.3.1.3.4
Functional Status O 1.3.6.1.4.1.19376.1.5.3.1.3.17
Review of Systems O 1.3.6.1.4.1.19376.1.5.3.1.3.18
Physical Examination O 1.3.6.1.4.1.19376.1.5.3.1.3.24
Vital Signs O 1.3.6.1.4.1.19376.1.5.3.1.3.25
Discharge Procedures Tests, Reports O 1.3.6.1.4.1.19376.1.5.3.1.3.29
Plan of Care R 1.3.6.1.4.1.19376.1.5.3.1.3.31
Discharge Diet O 1.3.6.1.4.1.19376.1.5.3.1.3.33

Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Discharge Summary Document
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.4'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Discharge Summary</title> <effectiveTime value='20190920012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/>  : <component><structuredBody>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <!-- Required Active Problems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/> <!-- Required Resolved Problems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.7'/> <!-- Required Discharge Diagnosis Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.3'/> <!-- Required Admitting Diagnosis Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/> <!-- Required if known Selected Meds Administered Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.22'/> <!-- Required Discharge Meds Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.20'/> <!-- Required if known Admission Medications Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/> <!-- Required Allergies Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.5'/> <!-- Required Hospital Course Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/> <!-- Optional Advance Directives Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/> <!-- Required if known History of Present Illness Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/> <!-- Optional Functional Status Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/> <!-- Optional Review of Systems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/> <!-- Optional Physical Examination Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/> <!-- Optional Vital Signs Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.29'/> <!-- Optional Discharge Procedures Tests, Reports Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <!-- Required Plan of Care Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.33'/> <!-- Optional Discharge Diet Section content --> </section> </component>
    </structuredBody></component> </ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.4'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.4"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Discharge Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for Discharge Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Discharge Summary must be {{{LOINC}}}
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Resolved Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Discharge Diagnosis Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Admitting Diagnosis Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Discharge Summary Document should contain a(n) Selected Meds Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.22"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Discharge Meds Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.20"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Discharge Summary Document should contain a(n) Admission Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Hospital Course Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Discharge Summary Document should contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Functional Status Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.24"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.29"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Discharge Procedures Tests, Reports Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Discharge Summary Document must contain a(n) Plan of Care Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.33"]'> 
     <!-- Note any missing optional elements -->
     Note: This Discharge Summary Document does not contain a(n) Discharge Diet Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.4
   </assert> 
 </rule>
</pattern>