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Template Discharge Summary 2013‑01‑31

Id2.16.840.1.113883.10.20.22.1.8Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameDischargeSummaryDisplay NameDischarge Summary
Description
The Discharge Summary is a document that is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The Joint Commission requires the following information to be included in the Discharge Summary: • The reason for hospitalization • The procedures performed • The care, treatment, and services provided • The patient’s condition and disposition at discharge • Information provided to the patient and family • Provisions for follow-up care
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 25 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.3Transactionfinal Discharge Summary (Release 1.1)2013‑01‑31
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1Containmentdraft Chief Complaint Section (1.1)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.4Containmentdraft History of Present Illness Section (1.1)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.5Containmentdraft Hospital Course Section (1.1)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.18Containmentdraft Review of Systems Section (1.1)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.26Containmentdraft Hospital Discharge Physical Section (1.1)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.33Containmentdraft Discharge Diet Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2Containmentdraft Immunizations Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.4Containmentdraft Vital Signs Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.5Containmentdraft Problem Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6Containmentdraft Allergies Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7Containmentdraft Procedures Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Care Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.11Containmentdraft Hospital Discharge Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.12Containmentdraft Reason for Visit Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.13Containmentdraft Chief Complaint and Reason for Visit Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.14Containmentdraft Functional Status Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.15Containmentdraft Family History Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.16Containmentdraft Hospital Discharge Studies Summary Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.17Containmentdraft Social History Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.20Containmentdraft History of Past Illness Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.24Containmentdraft Hospital Discharge Diagnosis Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.41Containmentdraft Hospital Discharge Instructions Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.42Containmentdraft Hospital Consultations Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.43Containmentdraft Hospital Admission Diagnosis Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.44Containmentdraft Hospital Admission Medications Section (entries optional) (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
Discdotsmary
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:8463) such that itconf‑8463
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.8confdots0044
cda:code
1 … 1SHALL contain exactly one [1..1] code (CONF:17178).confdots7178
cda:participant
0 … *MAY contain zero or more [0..*] participant (CONF:8467).

If present, the participant/associatedEntity element SHALL have an associatedPerson or scopingOrganization element.

b. When participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30		conf‑8467
cda:associatedEntity
1 … 1Mconf‑8467
Choice1 … 
If present, the participant/associatedEntity element SHALL have an associatedPerson or scopingOrganization element.
Elements to choose from:
  • cda:associatedPerson
  • cda:scopingOrganization
cda:associatedPerson
conf‑8467
cda:scopingOrganization
conf‑8467
cda:componentOf
1 … 1MSHALL contain exactly one [1..1] componentOf (CONF:8471).conf‑8471
cda:encompassingEncounter
1 … 1MThis componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8472).

The dischargeDispositionCode SHALL be present where the value of code SHOULD be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status DYNAMIC (www.nubc.org)

The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, SHALL be displayed when the document is rendered

The encounterParticipant elements MAY be present. If present, the encounterParticipant/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present.

The responsibleParty element MAY be present. If present, the responsibleParty/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present.		conf‑8472
cda:effectiveTime
1 … 1Mconf‑8472
cda:low
1 … 1RThis encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/low (CONF:8473).conf‑8473
cda:high
1 … 1RThis encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/high (CONF:8475).conf‑8475
cda:component
1 … 1MSHALL contain exactly one [1..1] component (CONF:9539).

A Discharge Summary can have either a structuredBody or a nonXMLBody.

A Discharge Summary can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.8), coded entries are optional.

If structuredBody, the component/structuredBody SHALL conform to the section constraints below

SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section		conf‑9539
Choice1 … 1
A Discharge Summary can have either a structuredBody or a nonXMLBody.
Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
cda:nonXMLBody
conf‑9539
cda:structuredBody
conf‑9539
 Schematron assertrolered error 
 testnot(.//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'] and (.//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] or .//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])) 
 MessageSHALL NOT contain a Chief Complaint and Reason for Visit Section when either a Chief Complaint Section or a Reason for Visit Section is present 
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (2013‑01‑31)conf‑9542
cda:component
1 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.5 Hospital Course Section (2013‑01‑31)conf‑9544
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.24 Hospital Discharge Diagnosis Section (2013‑01‑31)conf‑9546
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.11 Hospital Discharge Medications Section (entries optional) (2013‑01‑31)conf‑9548
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31)conf‑9550
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2013‑01‑31)conf‑9554
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2013‑01‑31)conf‑9556
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.33 Discharge Diet Section (2013‑01‑31)conf‑9558
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (2013‑01‑31)conf‑9560
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (2013‑01‑31)conf‑9562
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.20 History of Past Illness Section (2013‑01‑31)conf‑9564
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2013‑01‑31)conf‑9566
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.26 Hospital Discharge Physical Section (2013‑01‑31)conf‑9568
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.16 Hospital Discharge Studies Summary Section (2013‑01‑31)conf‑9570
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (2013‑01‑31)conf‑9572
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (2013‑01‑31)conf‑9574
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (2013‑01‑31)conf‑9576
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2013‑01‑31)conf‑9578
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2013‑01‑31)conf‑9580
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (2013‑01‑31)conf‑9582
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (2013‑01‑31)conf‑9584
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.42 Hospital Consultations Section (2013‑01‑31)conf‑9924
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.41 Hospital Discharge Instructions Section (2013‑01‑31)conf‑9926
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.43 Hospital Admission Diagnosis Section (2013‑01‑31)conf‑9928
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.44 Hospital Admission Medications Section (entries optional) (2013‑01‑31)confdots0111