FHIR Server FHIR Server Version n/a

Resource StructureDefinition/FHIR Server from package hl7.cda.us.ccda#current (1843 ms)

Package

hl7.cda.us.ccda

Type

StructureDefinition

FHIR Version

Source

http://hl7.org/cda/us/ccda/https://build.fhir.org/ig/HL7/CDA-ccda/StructureDefinition-DischargeSummary.html

Url

http://hl7.org/cda/us/ccda/StructureDefinition/DischargeSummary

Version

3.0.0

Status

active

Date

2024-07-23T20:00:48+00:00

Name

DischargeSummary

Title

Discharge Summary

Experimental

False

Realm

Authority

hl7

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 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. #### Document Sections Although document templates may contain any section, the following sections are specifically called out by this template: **Required Sections** - [AllergiesAndIntolerancesSection](StructureDefinition-AllergiesAndIntolerancesSection.html) - [HospitalCourseSection](StructureDefinition-HospitalCourseSection.html) - [DischargeDiagnosisSection](StructureDefinition-DischargeDiagnosisSection.html) - [PlanofTreatmentSection](StructureDefinition-PlanofTreatmentSection.html) - [HospitalConsultationsSection](StructureDefinition-HospitalConsultationsSection.html) - [ProceduresSection](StructureDefinition-ProceduresSection.html) - [ResultsSection](StructureDefinition-ResultsSection.html) **Recommended Sections** - [DischargeMedicationsSection](StructureDefinition-DischargeMedicationsSection.html) **Additional Sections** - [ChiefComplaintSection](StructureDefinition-ChiefComplaintSection.html) - [ChiefComplaintandReasonforVisitSection](StructureDefinition-ChiefComplaintandReasonforVisitSection.html) - [NutritionSection](StructureDefinition-NutritionSection.html) - [FamilyHistorySection](StructureDefinition-FamilyHistorySection.html) - [FunctionalStatusSection](StructureDefinition-FunctionalStatusSection.html) - [PastMedicalHistory](StructureDefinition-PastMedicalHistory.html) - [HistoryofPresentIllnessSection](StructureDefinition-HistoryofPresentIllnessSection.html) - [AdmissionDiagnosisSection](StructureDefinition-AdmissionDiagnosisSection.html) - [AdmissionMedicationsSectionEntriesOptional](StructureDefinition-AdmissionMedicationsSectionEntriesOptional.html) - [HospitalDischargeInstructionsSection](StructureDefinition-HospitalDischargeInstructionsSection.html) - [HospitalDischargePhysicalSection](StructureDefinition-HospitalDischargePhysicalSection.html) - [HospitalDischargeStudiesSummarySection](StructureDefinition-HospitalDischargeStudiesSummarySection.html) - [ImmunizationsSection](StructureDefinition-ImmunizationsSection.html) - [ProblemSection](StructureDefinition-ProblemSection.html) - [ReasonforVisitSection](StructureDefinition-ReasonforVisitSection.html) - [ReviewofSystemsSection](StructureDefinition-ReviewofSystemsSection.html) - [SocialHistorySection](StructureDefinition-SocialHistorySection.html) - [VitalSignsSection](StructureDefinition-VitalSignsSection.html) - [AdvanceDirectivesSection](StructureDefinition-AdvanceDirectivesSection.html)

Type

http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument

Kind

logical

Resources that use this resource

No resources found

Resources that this resource uses

StructureDefinition

http://hl7.org/cda/stds/core/StructureDefinition/Section

Section (CDA Class)

AdmissionDiagnosisSection

Admission Diagnosis Section

AdmissionMedicationsSectionEntriesOptional

Admission Medications Section (entries optional)

AdvanceDirectivesSection

Advance Directives Section

AllergiesAndIntolerancesSection

Allergies and Intolerances Section

ChiefComplaintSection

Chief Complaint Section

ChiefComplaintandReasonforVisitSection

Chief Complaint and Reason for Visit Section

DischargeDiagnosisSection

Discharge Diagnosis Section

DischargeMedicationsSection

Discharge Medications Section

FamilyHistorySection

Family History Section

FunctionalStatusSection

Functional Status Section

HistoryofPresentIllnessSection

History of Present Illness Section

HospitalConsultationsSection

Hospital Consultations Section

HospitalCourseSection

Hospital Course Section

HospitalDischargeInstructionsSection

Hospital Discharge Instructions Section

HospitalDischargePhysicalSection

Hospital Discharge Physical Section

HospitalDischargeStudiesSummarySection

Hospital Discharge Studies Summary Section

ImmunizationsSection

Immunizations Section

NutritionSection

Nutrition Section

PastMedicalHistory

Past Medical History

PlanofTreatmentSection

Plan of Treatment Section

ProblemSection

Problem Section

ProceduresSection

Procedures Section

ReasonforVisitSection

Reason for Visit Section

ResultsSection

Results Section

ReviewofSystemsSection

Review of Systems Section

SocialHistorySection

Social History Section

USRealmHeader

US Realm Header

VitalSignsSection

Vital Signs Section

http://hl7.org/cda/stds/core/ValueSet/CDARoleClassAssociative

CDARoleClassAssociative

http://hl7.org/cda/us/ccda/ValueSet/2.16.840.1.113883.3.88.12.80.33

NUBC UB-04 FL17 Patient Status

http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.4.1

DischargeSummaryDocumentTypeCode

Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: StructureDefinition DischargeSummary

Description & Constraints

ClinicalDocument

1..1

USRealmHeader

XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)

templateId

2..*

Slices for templateId

Content/Rules for all slices

templateId:discharge-summary

1..1

@root

1..1

oid, uuid, ruid

Required Pattern: 2.16.840.1.113883.10.20.22.1.8

@extension

1..1

Required Pattern: 2024-05-01

code

1..1

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.
Binding: DischargeSummaryDocumentTypeCode

(required)

participant

0..*

Participant1

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.
1198-8469: 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:1198-8469).

associatedEntity

@classCode

1..1

Binding: CDARoleClassAssociative (required): See additional bindings

Additional Bindings

Purpose

Documentation

When typeCode=IND

1..1

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

encompassingEncounter

1..1

EncompassingEncounter

effectiveTime

1..1

USRealmDateTimeInterval

Base for all types and resources

low

1..1

IVXB_TS

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

high

1..1

IVXB_TS

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

dischargeDispositionCode

1..1

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.
Binding: NUBC UB-04 FL17 Patient Status (preferred)

responsibleParty

0..1