Package | hl7.fhir.us.ccda |
Type | StructureDefinition |
Id | Id |
FHIR Version | R4 |
Source | http://hl7.org/fhir/us/ccda/https://build.fhir.org/ig/HL7/ccda-on-fhir/StructureDefinition-Discharge-Summary.html |
Url | http://hl7.org/fhir/us/ccda/StructureDefinition/Discharge-Summary |
Version | 1.2.0 |
Status | active |
Date | 2024-03-12T16:03:19+00:00 |
Name | DischargeSummary |
Title | Discharge Summary |
Experimental | False |
Realm | us |
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. |
Type | Composition |
Kind | resource |
CapabilityStatement | |
CcdaOnFhirClient | CCDA on FHIR Client |
CcdaOnFhirServer | CCDA on FHIR Server |
Note: links and images are rebased to the (stated) source
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
type | S | 1..1 | CodeableConcept | Discharge Summary Binding: DischargeSummaryDocumentTypeCode (required) |
Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
section:allergies_and_intolerances_section | S | 1..1 | BackboneElement | Allergies and Intolerances Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | 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..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:allergy_entry | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
section:hospital_course_section | S | 1..1 | BackboneElement | Hospital Course Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | 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..1 | Narrative | This section contains only human readable content |
section:discharge_diagnosis_section | S | 1..1 | BackboneElement | Discharge Diagnosis Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | 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..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:discharge_diagnosis_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
section:plan_of_treatment_section | S | 0..1 | BackboneElement | Plan of Treatment Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | 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..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:sliceEntry | 0..* | 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 | 0..1 | BackboneElement | Discharge Medications Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | 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..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:discharge_medications_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
section:admission_diagnosis_section | S | 0..1 | BackboneElement | Admission Diagnosis Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | 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..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:admission_diagnosis_entry | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
section:admission_medications_section | S | 0..1 | BackboneElement | Admission Medications Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | 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..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:admission_medications_entry | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
section:chief_complaint_and_reason_for_visit_section | S | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patientâs own description) and/or the reason for the patient's visit (the providerâs 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..1 | string | title |
code | S | 1..1 | CodeableConcept | 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..1 | Narrative | This section contains only human readable content |
section:chief_complaint_section | S | 0..1 | BackboneElement | Chief Complaint Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | 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..1 | Narrative | This section contains only human readable content |
section:family_history_section | S | 0..1 | BackboneElement | Family History Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | 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..1 | Narrative | text |
Slices for entry | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
entry:family_history_entry | S | 0..* | 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 | 0..1 | BackboneElement | Functional Status Section |
title | S | 1..1 | string | title |
code | S | 1..1 | CodeableConcept | 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 | |