Template 2.16.840.1.113883.10.20.22.1.8 Discharge Summary

2012‑01‑12

Template 2.16.840.1.113883.10.20.22.1.8 - DischargeSummary
Id 2.16.840.1.113883.10.20.22.1.8
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑738
Version valid from 2012‑01‑12 status draft
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
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-738
treetree cda:templateId
II 1..1 M conf‑9479
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8463
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.8
treetree cda:code
1..1 M conf‑8466
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.4.1 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.4.1"
treetree cda:componentOf
1..1 M conf‑8471
treeblank treetree cda:encompassingEncounter
1..1 M 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 responsibleParty element MAY be present. If present, the responsibleParty/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present.
The encounterParticipant elements MAY be present. If present, the encounterParticipant/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present.
conf‑8472
treeblank treeblank treetree cda:effectiveTime
_cda:low
TS 1..1 M conf‑8473
treeblank treeblank treetree cda:effectiveTime
_cda:high
TS 1..1 M conf‑8475
treetree cda:component
1..1 M 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
conf‑9539
Schematron assert Role red error
Test count(//cda:structuredBody | //cda:nonXMLBody)=1
Message
A Discharge Summary can have either a structuredBody or a nonXMLBody.
Schematron assert Role red error
Test count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])<=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=0)
Message
SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section