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pending Template  Discharge Summary

Template 2.16.840.1.113883.10.20.22.1.8 - DischargeSummary
Id 2.16.840.1.113883.10.20.22.1.8
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Document Level Template
Context Pathname //
Open/Closed Open (other than defined elements are allowed)
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
Used by / Uses
Used by / Uses 25 templates
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.2.6 Containment AllergiesSectionentriesoptional DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.5 Containment HospitalCourseSection DYNAMIC
2.16.840.1.113883.10.20.22.2.24 Containment HospitalDischargeDiagnosisSection DYNAMIC
2.16.840.1.113883.10.20.22.2.11 Containment HospitalDischargeMedicationsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.10 Containment PlanofCareSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Containment ChiefComplaintSection DYNAMIC
2.16.840.1.113883.10.20.22.2.13 Containment ChiefComplaintandReasonforVisitSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.33 Containment DischargeDietSection DYNAMIC
2.16.840.1.113883.10.20.22.2.15 Containment FamilyHistorySection DYNAMIC
2.16.840.1.113883.10.20.22.2.14 Containment FunctionalStatusSection DYNAMIC
2.16.840.1.113883.10.20.22.2.20 Containment HistoryofPastIllnessSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.4 Containment HistoryofPresentIllnessSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.26 Containment HospitalDischargePhysicalSection DYNAMIC
2.16.840.1.113883.10.20.22.2.16 Containment HospitalDischargeStudiesSummarySection DYNAMIC
2.16.840.1.113883.10.20.22.2.2 Containment ImmunizationsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.5 Containment ProblemSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.7 Containment ProceduresSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.12 Containment ReasonforVisitSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.18 Containment ReviewofSystemsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.17 Containment SocialHistorySection DYNAMIC
2.16.840.1.113883.10.20.22.2.4 Containment VitalSignsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.42 Containment HospitalConsultationsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.41 Containment HospitalDischargeInstructionsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.43 Containment HospitalAdmissionDiagnosisSection DYNAMIC
2.16.840.1.113883.10.20.22.2.44 Containment HospitalAdmissionMedicationsSectionentriesoptional DYNAMIC
Item DT Card Conf Description Label
cda:ClinicalDocument
(DischargeSummary)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8463) such that it conf‑8463
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.1.8
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:17178). conf‑17178
treetree cda:participant
0 .. * MAY contain zero or more [0..*] participant (CONF:8467).

If present, the participant/associatedEntity element SHALL have an associatedPerson or scopingOrganization element.

b. 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‑8467
  Schematron assert role red error
  test cda:associatedEntity[cda:associatedPerson | cda:scopingOrganization]
  Message If present, the participant/associatedEntity element SHALL have an associatedPerson or scopingOrganization element.
treetree cda:componentOf
1 .. 1 M SHALL contain exactly one [1..1] componentOf (CONF:8471). conf‑8471
treeblank treetree cda:encompassingEncounter
1 .. 1 M This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8472).

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 encounterParticipant elements MAY be present. If present, the encounterParticipant/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present.

The responsibleParty element MAY be present. If present, the responsibleParty/assignedEntity element SHALL have at least one assignedPerson or representedOrganization element present.
conf‑8472
treeblank treeblank treetree cda:effectiveTime/low
1 .. 1 M This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/low (CONF:8473). conf‑8473
  Schematron assert role red error
  test cda:componentOf/cda:encompassingEncounter[count(cda:effectiveTime/cda:low)=1]
  Message This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/low (CONF:8473).
treeblank treeblank treetree cda:effectiveTime/high
1 .. 1 M This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/high (CONF:8475). conf‑8475
  Schematron assert role red error
  test cda:componentOf/cda:encompassingEncounter[count(cda:effectiveTime/cda:high)=1]
  Message This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/high (CONF:8475).
treetree cda:component
1 .. 1 M SHALL contain exactly one [1..1] component (CONF:9539).

A Discharge Summary can have either a structuredBody or a nonXMLBody.

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

SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section
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.
Choice min 1 element(s) and max 1 element(s). Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
treeblank treeblank treetree cda:nonXMLBody
conf‑9539
treeblank treeblank treetree cda:structuredBody
conf‑9539
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.6']]
1 .. 1 M conf‑9542
  Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.5']]
1 .. 1 M conf‑9544
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.5 Hospital Course Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.24']]
1 .. 1 M conf‑9546
  Contains 2.16.840.1.113883.10.20.22.2.24 Hospital Discharge Diagnosis Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.11']]
1 .. 1 M conf‑9548
  Contains 2.16.840.1.113883.10.20.22.2.11 Hospital Discharge Medications Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.10']]
1 .. 1 M conf‑9550
  Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1']]
0 .. 1 conf‑9554
  Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.13']]
0 .. 1 conf‑9556
  Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.33']]
0 .. 1 conf‑9558
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.33 Discharge Diet Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.15']]
0 .. 1 conf‑9560
  Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.14']]
0 .. 1 conf‑9562
  Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.20']]
0 .. 1 conf‑9564
  Contains 2.16.840.1.113883.10.20.22.2.20 History of Past Illness Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.4']]
0 .. 1 conf‑9566
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.26']]
0 .. 1 conf‑9568
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.26 Hospital Discharge Physical Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.16']]
0 .. 1 conf‑9570
  Contains 2.16.840.1.113883.10.20.22.2.16 Hospital Discharge Studies Summary Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.2']]
0 .. 1 conf‑9572
  Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.5']]
0 .. 1 conf‑9574
  Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.7']]
0 .. 1 conf‑9576
  Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12']]
0 .. 1 conf‑9578
  Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.18']]
0 .. 1 conf‑9580
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.17']]
0 .. 1 conf‑9582
  Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.4']]
0 .. 1 conf‑9584
  Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.42']]
0 .. 1 conf‑9924
  Contains 2.16.840.1.113883.10.20.22.2.42 Hospital Consultations Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.41']]
0 .. 1 conf‑9926
  Contains 2.16.840.1.113883.10.20.22.2.41 Hospital Discharge Instructions Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.43']]
0 .. 1 conf‑9928
  Contains 2.16.840.1.113883.10.20.22.2.43 Hospital Admission Diagnosis Section (DYNAMIC)
  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:templateId[@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:templateId[@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
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.44']]
0 .. 1 conf‑10111
  Contains 2.16.840.1.113883.10.20.22.2.44 Hospital Admission Medications Section (entries optional) (DYNAMIC)