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Template IHE Discharge Summary Specification 2017‑03‑20 14:34:30

Id	1.3.6.1.4.1.19376.1.5.3.1.1.4 ref IHE-PCC-	Effective Date	2017‑03‑20 14:34:30
Status	Active	Version Label	2016
Name	IHEDischargeSummarySpecification	Display Name	IHE Discharge Summary Specification
Description This use case is described fully in the XDS-MS Profile found in IHE 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.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.1.4
Label	6.3.1.4
Classification	CDA Document Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 0 templates, Uses 18 templates Uses as Name Version 1.3.6.1.4.1.19376.1.5.3.1.3.3 Containment IHE Hospital Admission Diagnosis Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.4 Containment IHE History of Present Illness Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.5 Containment IHE Hospital Course Section (2016) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.6 Containment IHE Active Problems Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.7 Containment IHE Discharge Diagnosis Section (2016) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.8 Containment IHE History of Past Illness Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.13 Containment IHE Allergies and Other Adverse Reactions Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.17 Containment IHE Functional Status Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.18 Containment IHE Review of Systems Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.20 Containment IHE Admission Medication History Section (2016) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.21 Containment IHE Medications Administered Section (2016) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.22 Containment IHE Hospital Discharge Medications Section (2016) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.24 Containment IHE Physical Examination Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.25 Containment IHE Vital Signs Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.29 Containment IHE Hospital Studies Summary Section (2016) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.31 Containment IHE Care Plan Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.33 Containment IHE Discharge Diet Section (2016) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.34 Containment IHE Advance directives section (2014) DYNAMIC
Relationship	Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.1.2 (2005‑09‑07) ref IHE-PCC-
Example	Example <ClinicalDocument>   <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.4"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.2"/>  <id extension="--TODO--" root="1.2.3.999"/>  <component>     <structuredBody>       <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.8 'IHE History of Past Illness Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.7 'IHE Discharge Diagnosis Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.3 'IHE Hospital Admission Diagnosis Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.21 'IHE Medications Administered Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.22 'IHE Hospital Discharge Medications Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.20 'IHE Admission Medication History Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.13 'IHE Allergies and Other Adverse Reactions Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.5 'IHE Hospital Course Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.34 'IHE Advance directives section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'IHE History of Present Illness Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.17 'IHE Functional Status Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.18 'IHE Review of Systems Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.24 'IHE Physical Examination Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.25 'IHE Vital Signs Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.29 'IHE Hospital Studies Summary Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.31 'IHE Care Plan Section' (dynamic) -->       </component>      <component>         <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.33 'IHE Discharge Diet Section' (dynamic) -->       </component>    </structuredBody>  </component></ClinicalDocument>
Expand AllCollapse All Item DT Card Conf Description Label hl7:ClinicalDocument 6.3.1.4 hl7:templateId II 1 … 1 M 6.3.1.4 @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.4 hl7:templateId II 1 … 1 M 6.3.1.4 @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.2 hl7:id II 1 … 1 R 6.3.1.4 @root uid 0 … 1   @extension st 0 … 1   hl7:component 1 … 1 R 6.3.1.4 hl7:structuredBody 1 … 1 R 6.3.1.4 hl7:component 1 … * R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (DYNAMIC) 6.3.1.4 hl7:component 1 … * R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.8 IHE History of Past Illness Section (DYNAMIC) 6.3.1.4 hl7:component 1 … * R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.7 IHE Discharge Diagnosis Section (DYNAMIC) 6.3.1.4 hl7:component 1 … * R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.3 IHE Hospital Admission Diagnosis Section (DYNAMIC) 6.3.1.4 hl7:component 0 … * Contains 1.3.6.1.4.1.19376.1.5.3.1.3.21 IHE Medications Administered Section (DYNAMIC) 6.3.1.4 hl7:component 1 … * R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.22 IHE Hospital Discharge Medications Section (DYNAMIC) 6.3.1.4 hl7:component 0 … * Contains 1.3.6.1.4.1.19376.1.5.3.1.3.20 IHE Admission Medication History Section (DYNAMIC) 6.3.1.4 hl7:component 1 … * R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.13 IHE Allergies and Other Adverse Reactions Section (DYNAMIC) 6.3.1.4 hl7:component 1 … * R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.5 IHE Hospital Course Section (DYNAMIC) 6.3.1.4 hl7:component 0 … * Contains 1.3.6.1.4.1.19376.1.5.3.1.3.34 IHE Advance directives section (DYNAMIC) 6.3.1.4 hl7:component 0 … * Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 IHE History of Present Illness Section (DYNAMIC) 6.3.1.4 hl7:component 0 … * Contains 1.3.6.1.4.1.19376.1.5.3.1.3.17 IHE Functional Status Section (DYNAMIC) 6.3.1.4 hl7:component 0 … * Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 IHE Review of Systems Section (DYNAMIC) 6.3.1.4 hl7:component 0 … * Contains 1.3.6.1.4.1.19376.1.5.3.1.3.24 IHE Physical Examination Section (DYNAMIC) 6.3.1.4 hl7:component 0 … * Contains 1.3.6.1.4.1.19376.1.5.3.1.3.25 IHE Vital Signs Section (DYNAMIC) 6.3.1.4 hl7:component 0 … * Contains 1.3.6.1.4.1.19376.1.5.3.1.3.29 IHE Hospital Studies Summary Section (DYNAMIC) 6.3.1.4 hl7:component 1 … * R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.31 IHE Care Plan Section (DYNAMIC) 6.3.1.4 hl7:component 0 … * Contains 1.3.6.1.4.1.19376.1.5.3.1.3.33 IHE Discharge Diet Section (DYNAMIC) 6.3.1.4