DischargeSummaryV3

Template Discharge Summary (V3) 2015‑08‑01

2.16.840.1.113883.10.20.22.1.8

Effective Date

2015‑08‑01

Status

Draft

Version Label

2.1

Name

DischargeSummaryV3

Display Name

Discharge Summary (V3)

Description

The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge. The Joint Commission requires the following information to be included in the Discharge Summary (http://www.jointcommission.org/): • The reason for hospitalization (the admission) • The procedures performed, as applicable • 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 The best practice for a Discharge Summary is to include the discharge disposition in the display of the header.

Context

Pathname //

Classification

CDA Document Level Template

Open/Closed

Open (other than defined elements are allowed)

Used by / Uses

Used by 1 transaction and 0 templates, Uses 26 templates

Used by	as	Name	Version
2.16.840.1.113883.3.1937.99.3.4.25	Transaction	Discharge Summary (V3)	2015‑08‑01
Uses	as	Name	Version
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1	Containment	Chief Complaint Section (2.1)	2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.4	Containment	History of Present Illness Section (2.1)	2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.5	Containment	Hospital Course Section (2.1)	2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.18	Containment	Review of Systems Section (2.1)	2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.26	Containment	Hospital Discharge Physical Section (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.2.2	Containment	Immunizations Section (entries optional) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.4	Containment	Vital Signs Section (entries optional) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.5	Containment	Problem Section (entries optional) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.6	Containment	Allergies and Intolerances Section (entries optional) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.7	Containment	Procedures Section (entries optional) (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.2.10	Containment	Plan of Treatment Section (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.2.11	Containment	Discharge Medications Section (entries optional) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.11.1	Containment	Discharge Medications Section (entries required) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.12	Containment	Reason for Visit Section (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.2.13	Containment	Chief Complaint and Reason for Visit Section (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.2.14	Containment	Functional Status Section (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.2.15	Containment	Family History Section (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.16	Containment	Hospital Discharge Studies Summary Section (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.2.17	Containment	Social History Section (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.20	Containment	Past Medical History (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.24	Containment	Discharge Diagnosis Section (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.41	Containment	Hospital Discharge Instructions Section (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.2.42	Containment	Hospital Consultations Section (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.2.43	Containment	Admission Diagnosis Section (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.44	Containment	Admission Medications Section (entries optional) (V3) (2.1)	2015‑08‑01
2.16.840.1.113883.10.20.22.2.57	Containment	Nutrition Section (2.1)	2015‑08‑13

Relationship

Specialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)

ref

ad1bbr-

Specialization: template 2.16.840.1.113883.10.20.22.1.1 US Realm Header (V3) (2015‑08‑01)
Version: template 2.16.840.1.113883.10.20.22.1.8 Discharge Summary (2013‑01‑31)

Item

Card

Conf

Description

Label

cda:ClinicalDocument

When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 SHALL include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32938).

DiscryV3

cda:templateId

1 … 1

C-CDA R1.1 templateId root without an extension

CONF2936

@root

uid

1 … 1

2.16.840.1.113883.10.20.22.1.8

cda:templateId

1 … 1

SHALL contain exactly one [1..1] templateId (CONF:1198-8463) such that it

CONF8463

@root

uid

1 … 1

2.16.840.1.113883.10.20.22.1.8

CONF0044

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.8" (CONF:1198-10044).

@extension

1 … 1

2015-08-01

CONF2517

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32517).

cda:code

1 … 1

SHALL contain exactly one [1..1] code (CONF:1198-17178).

The Discharge Summary recommends use of a single document type code, 18842-5 "Discharge summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.

CONF7178

cda:participant

0 … *

MAY contain zero or more [0..*] participant (CONF:1198-8467).

The participant element in the Discharge Summary header follows the General Header Constraints for participants. Discharge Summary does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations.

CONF8467

Constraint

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

cda:componentOf

1 … 1

SHALL contain exactly one [1..1] componentOf (CONF:1198-8471).

The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header.

CONF8471

cda:encompassingEncounter

1 … 1

This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:1198-8472).

CONF8472

cda:effectiveTime

IVL_TS

1 … 1

This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:1198-32611).

CONF2611

cda:low

1 … 1

This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-8473).

The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low.

CONF8473

cda:high

1 … 1

This effectiveTime SHALL contain exactly one [1..1] high (CONF:1198-8475).

The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high.

CONF8475

cda:dischargeDispositionCode

1 … 1

This encompassingEncounter SHALL contain exactly one [1..1] dischargeDispositionCode, which SHOULD be selected from ValueSet NUBC UB-04 FL17 Patient Status urn:oid:2.16.840.1.113883.3.88.12.80.33 DYNAMIC (CONF:1198-8476).

The dischargeDispositionCode records the disposition of the patient at time of discharge. Access to the National Uniform Billing Committee (NUBC) code system requires a membership. The following conformance statement aligns with HITSP C80 requirements. The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, must be displayed when the document is rendered.

CONF8476

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17 Patient Status (DYNAMIC)

cda:responsibleParty

0 … 1

This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:1198-8479).

The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care.

CONF8479

cda:assignedEntity

1 … 1

The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32613).

CONF2613

Schematron assert

role

error

test

cda:assignedPerson | cda:representedOrganization

Message

This assignedEntity *SHALL* contain an assignedPerson or a representedOrganization or both.

cda:encounterParticipant

0 … *

This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:1198-8478).

The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.

CONF8478

cda:assignedEntity

1 … 1

The encounterParticipant, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32615).

CONF2615

Schematron assert

role

error

test

cda:assignedPerson | cda:representedOrganization

Message

This assignedEntity *SHALL* contain an assignedPerson or a representedOrganization or both.

cda:component

1 … 1

SHALL contain exactly one [1..1] component (CONF:1198-9539).

CONF9539

cda:structuredBody

1 … 1

This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30518).

In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional.

CONF0518

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.6 Allergies and Intolerances Section (entries optional) (V3) (2015‑08‑01)

CONF0519

cda:component

1 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.5 Hospital Course Section (2015‑08‑13)

CONF0521

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.24 Discharge Diagnosis Section (V3) (2015‑08‑01)

CONF0523

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.11 Discharge Medications Section (entries optional) (V3) (2015‑08‑01)

CONF0525

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09)

CONF0527

cda:component

0 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2015‑08‑13)

CONF0529

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2015‑08‑13)

CONF0531

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13)

CONF0533

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01)

CONF0535

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (2014‑06‑09)

CONF0537

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01)

CONF0539

cda:component

0 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2015‑08‑13)

CONF0541

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.43 Admission Diagnosis Section (V3) (2015‑08‑01)

CONF0543

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.44 Admission Medications Section (entries optional) (V3) (2015‑08‑01)

CONF0545

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.42 Hospital Consultations Section (2015‑08‑13)

CONF0547

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.41 Hospital Discharge Instructions Section (2015‑08‑13)

CONF0549

cda:component

0 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.26 Hospital Discharge Physical Section (2015‑08‑13)

CONF0551

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.16 Hospital Discharge Studies Summary Section (2015‑08‑13)

CONF0553

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (2015‑08‑01)

CONF0555

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (V3) (2015‑08‑01)

CONF0557

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2014‑06‑09)

CONF0559

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2015‑08‑13)

CONF0561

cda:component

0 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2015‑08‑13)

CONF0563

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01)

CONF0565

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (V3) (2015‑08‑01)

CONF0567

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.11.1 Discharge Medications Section (entries required) (V3) (2015‑08‑01)

CONF1586

Schematron assert

role

error

test

not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13']) or //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']

Message

This structuredBody *SHALL NOT* contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present

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Template

Template Discharge Summary (V3) 2015‑08‑01