1.3.6.1.4.1.19376.1.5.3.1.1.4

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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']

-->>Data<<--

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.

Sample Discharge Summary Document

<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.4'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Discharge Summary</title> <effectiveTime value='20240424012005'/> <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>