1.3.6.1.4.1.19376.1.5.3.1.1.2

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Medical Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.2

A medical summary contains a snapshot of the patient's medical information.

Standards

CDAR2	Clinical Document Architecture, Release 2.0, 2005, HL7
CRS	Implementation Guide for CDA Release 2 – Level 1 and 2 – Care Record Summary (US realm), 2006, HL7.

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.

Sample Medical 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'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Medical Summary</title> <effectiveTime value='20260408012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/>  : <component><structuredBody>     </structuredBody></component> </ClinicalDocument>

 

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Medical 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>

Document Specification

A medical summary is a type of medical document, and incorporates the constraints defined for Medical Documents(1.3.6.1.4.1.19376.1.5.3.1.1.1) .

The medical summary further constrains CDA Release 2.0 by adopting all Level 1 and Level 2 constraints of the HL7 Care Record Summary.