StructureDefinition-Discharge-Summary

Sourcehl7.fhir.us.ccda#current:C-CDA on FHIR (v4.0.1)
resourceTypeStructureDefinition
idDischarge-Summary
canonicalhttp://hl7.org/fhir/us/ccda/StructureDefinition/Discharge-Summary
version1.2.0-ballot
statusactive
publisherHL7 Structured Documents Working Group
nameDischargeSummary
titleDischarge Summary
date2023-03-27T20:25:00+00:00
descriptionThe 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 patients 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.
jurisdictionsus
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeComposition
derivationconstraint
basehttp://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header
Usages
Name Flags Card. Type Description & Constraints doco
. . Composition USRealmHeader
. . . type S Discharge Summary
Binding: DischargeSummaryDocumentTypeCode ( required )
. . . Slices for section Slice: Unordered, Open by value:code
. . . . section:allergies_and_intolerances_section S 1..1 Allergies and Intolerances Section
. . . . . title S 1.. title
. . . . . code S 1.. Allergies and adverse reactions
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:allergy_entry S Reference (US Core AllergyIntolerance Profile)
. . . . section:hospital_course_section S 1..1 Hospital Course Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8648-8
. . . . . text S 1.. This section contains only human readable content
. . . . section:discharge_diagnosis_section S 1..1 Discharge Diagnosis Section
. . . . . title S 1.. title
. . . . . code S 1.. Hospital discharge diagnosis
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11535-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:discharge_diagnosis_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:plan_of_treatment_section S ..1 Plan of Treatment Section
. . . . . title S 1.. title
. . . . . code S 1.. Plan of treatment
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:discharge_medications_section S ..1 Discharge Medications Section
. . . . . title S 1.. title
. . . . . code S 1.. Hospital discharge medications
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10183-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:discharge_medications_entry S Reference ( MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)
. . . . section:admission_diagnosis_section S ..1 Admission Diagnosis Section
. . . . . title S 1.. title
. . . . . code S 1.. Hospital admission diagnosis
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46241-6
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:admission_diagnosis_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:admission_medications_section S ..1 Admission Medications Section
. . . . . title S 1.. title
. . . . . code S 1.. Medications on admission
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 42346-7
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:admission_medications_entry S Reference ( MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)
. . . . section:chief_complaint_and_reason_for_visit_section S ..1 Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient’s own description) and/or the reason for the patient's visit (the provider’s description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46239-0
. . . . . text S 1.. This section contains only human readable content
. . . . section:chief_complaint_section S ..1 Chief Complaint Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
. . . . . text S 1.. This section contains only human readable content
. . . . section:family_history_section S ..1 Family History Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:family_history_entry S Reference ( FamilyMemberHistory ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:functional_status_section S ..1 Functional Status Section
. . . . . title S 1.. title
. . . . . code S 1.. Functional status
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47420-5
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:functional_status_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition | Observation | ClinicalImpression ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:history_of_present_illness_section S ..1 History of Present Illness Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
. . . . . text S 1.. This section contains only human readable content
. . . . section:hospital_consultations_section S ..1 Hospital Consultations Section
. . . . . title S 1.. title
. . . . . code S 1.. Hospital consultations
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18841-7
. . . . . text S 1.. This section contains only human readable content
. . . . section:hospital_discharge_instructions_section S ..1 Hospital Discharge Instructions Section
. . . . . title S 1.. title
. . . . . code S 1.. Hospital discharge instructions
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8653-8
. . . . . text S 1.. This section contains only human readable content
. . . . section:hospital_discharge_physical_section S ..1 Hospital Discharge Physical Section
. . . . . title S 1.. title
. . . . . code S 1.. Hospital discharge physical
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10184-0
. . . . . text S 1.. This section contains only human readable content
. . . . section:hospital_discharge_studies_section S ..1 Hospital Discharge Studies Section
. . . . . title S 1.. title
. . . . . code S 1.. Hospital discharge studies summary
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11493-4
. . . . . text S 1.. This section contains only human readable content
. . . . section:immunizations_section S ..1 Immunizations Section
. . . . . title S 1.. title
. . . . . code S 1.. Immunizations
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:immunizations_entry S Reference (US Core Immunization Profile)
. . . . section:nutrition_section S ..1 Nutrition Section
. . . . . title S 1.. title
. . . . . code S 1.. Diet and nutrition
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 61144-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:nutrition_entry S Reference ( Observation ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:past_medical_history_section S ..1 Past Medical History Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:past_medical_history_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:problem_section S ..1 Problem Section
. . . . . title S 1.. title
. . . . . code S 1.. Problem list
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:problem_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:procedures_section S ..1 Procedures Section
. . . . . title S 1.. title
. . . . . code S 1.. History of procedures
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:procedure_entry S Reference (US Core Procedure Profile)
. . . . section:reason_for_visit_section S ..1 Reason for Visit Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29299-5
. . . . . text S 1.. This section contains only human readable content
. . . . section:review_of_systems_section S ..1 Review of Systems Section
. . . . . title S 1.. title
. . . . . code S 1.. Review of systems
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
. . . . . text S 1.. This section contains only human readable content
. . . . section:social_history_section S ..1 Social History Section
. . . . . title S 1.. title
. . . . . code S 1.. Social history
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:smoking_status_entry S Reference (US Core Smoking Status Observation Profile) Smoking status
. . . . section:vital_signs_section S ..1 Vital Signs Section
. . . . . title S 1.. title
. . . . . code S 1.. Vital signs
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8716-3
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:vital_signs_entry S Reference ( Vital Signs Profile )
. . . . section:goals_section S 0..1 Goals Section
. . . . . title S 1.. title
. . . . . code S 1.. Goals
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 61146-7
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:goals_entry S Reference (US Core Goal Profile) entry
. . . . section:health_concerns_section S 0..1 Health Concerns Section
. . . . . title S 1.. title
. . . . . code S 1.. Health concerns section code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 75310-3
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:health_concerns_entry S Reference (US Core AllergyIntolerance Profile | http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition | US Core Laboratory Result Observation Profile | US Core Smoking Status Observation Profile | Vital Signs Profile | ClinicalImpression | Observation | RiskAssessment | List | DocumentReference ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

doco Documentation for this format

Produced 06 Apr 2023