1.3.6.1.4.1.19376.1.5.3.1.1.4
Development Only
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
Discharge Summary Specification 1.3.6.1.4.1.19376.1.5.3.1.1.4
This use case is described fully in PCC TF-1: 3.2.2. 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 found in section 5.4.1.2 above.
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.
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. |
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[@roleCode='HLD'] | ||||
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[@roleCode='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.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.4'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Discharge Summary</title> <effectiveTime value='20241017012005'/> <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 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>
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