Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Discharge Summary

[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.8]

Discharge Summary Header Constraints

Discharge Summary Body Constraints

  1. SHALL contain exactly one [1..1] templateId ( ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.8"
  2. SHALL conform to General Header Constraints template (templateId: 2.16.840.1.113883.10.20.22.1.1)
  3. SHALL contain exactly one [1..1] code (CONF:17178), where the @code SHALL be selected from ValueSet DischargeSummaryDocumentTypeCode 2.16.840.1.113883.11.20.4.1 DYNAMIC (CONF:17179)
  4. MAY contain exactly one [1..1] component (CONF:10111)
    1. Contains exactly one [1..1] Hospital Admission Medications Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.44)
  5. SHALL contain exactly one [1..1] component (CONF:9928)
    1. Contains exactly one [1..1] Hospital Admission Diagnosis Section (templateId: 2.16.840.1.113883.10.20.22.2.43)
  6. SHALL contain exactly one [1..1] component (CONF:9546)
    1. Contains exactly one [1..1] Hospital Discharge Diagnosis Section (templateId: 2.16.840.1.113883.10.20.22.2.24)
  7. MAY contain zero or one [0..1] component (CONF:9558)
    1. Contains exactly one [1..1] Discharge Diet Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.33)
  8. SHALL contain exactly one [1..1] component (CONF:9548)
    1. Contains exactly one [1..1] Hospital Discharge Medications Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.11)
  9. MAY contain zero or one [0..1] component (CONF:9562)
    1. Contains exactly one [1..1] Functional Status Section (templateId: 2.16.840.1.113883.10.20.22.2.14)
  10. MAY contain exactly one [1..1] component (CONF:9566)
    1. Contains exactly one [1..1] History Of Present Illness Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.4)
  11. SHALL contain exactly one [1..1] component (CONF:9544)
    1. Contains exactly one [1..1] Hospital Course Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.5)
  12. SHALL contain exactly one [1..1] component (CONF:9550)
    1. Contains exactly one [1..1] Plan Of Care Section (templateId: 2.16.840.1.113883.10.20.22.2.10)
  13. MAY contain exactly one [1..1] component (CONF:9564)
    1. Contains exactly one [1..1] History Of Past Illness Section (templateId: 2.16.840.1.113883.10.20.22.2.20)
  14. SHALL contain exactly one [1..1] componentOf (CONF:9539)
    1. This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8472)
      1. This encompassingEncounter SHALL contain exactly one [1..1] dischargeDispositionCode, where the @code SHOULD be selected from ValueSet NUBC UB-04 FL17-Patient Status 2.16.840.1.113883.6.301.5 STATIC (CONF:8476)
      2. This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:8473, CONF:8475)
      3. This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:8479)
        1. This responsibleParty SHALL contain at least one [1..*] assignedEntity, where its type is CDA Assigned Entity (CONF:8479)
          1. Contains exactly one [1..1] CDA Assigned Entity
        2. This responsibleParty The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both. (CONF:8479)
      4. This encompassingEncounter MAY contain zero or one [0..1] encounterParticipant (CONF:8478)
        1. This encounterParticipant SHALL contain at least one [1..*] assignedEntity, where its type is CDA Assigned Entity (CONF:8478)
          1. Contains exactly one [1..1] CDA Assigned Entity
        2. This encounterParticipant The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both. (CONF:8478)
      5. This encompassingEncounter This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/low (CONF:8473)
      6. This encompassingEncounter This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime/high (CONF:8475)
  15. MAY contain zero or one [0..1] component (CONF:9556)
    1. Contains exactly one [1..1] Chief Complaint And Reason For Visit Section (templateId: 2.16.840.1.113883.10.20.22.2.13)
  16. MAY contain zero or one [0..1] component (CONF:9554)
    1. Contains exactly one [1..1] Chief Complaint Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1)
  17. MAY contain zero or one [0..1] component (CONF:9560)
    1. Contains exactly one [1..1] Family History Section (templateId: 2.16.840.1.113883.10.20.22.2.15)
  18. MAY contain zero or one [0..1] component (CONF:9924)
    1. Contains exactly one [1..1] Hospital Consultations Section (templateId: 2.16.840.1.113883.10.20.22.2.42)
  19. MAY contain zero or one [0..1] component (CONF:9926)
    1. Contains exactly one [1..1] Hospital Discharge Instructions Section (templateId: 2.16.840.1.113883.10.20.22.2.41)
  20. MAY contain zero or one [0..1] component (CONF:9568)
    1. Contains exactly one [1..1] Hospital Discharge Physical Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.26)
  21. MAY contain zero or one [0..1] component (CONF:9570)
    1. Contains exactly one [1..1] Hospital Discharge Studies Summary Section (templateId: 2.16.840.1.113883.10.20.22.2.16)
  22. MAY contain zero or one [0..1] component (CONF:9572)
    1. Contains exactly one [1..1] Immunizations Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.2)
  23. MAY contain zero or one [0..1] component (CONF:9574)
    1. Contains exactly one [1..1] Problem Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.5)
  24. MAY contain zero or one [0..1] component (CONF:9576)
    1. Contains exactly one [1..1] Procedures Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.7)
  25. MAY contain zero or one [0..1] component (CONF:9578)
    1. Contains exactly one [1..1] Reason For Visit Section (templateId: 2.16.840.1.113883.10.20.22.2.12)
  26. MAY contain zero or one [0..1] component (CONF:9580)
    1. Contains exactly one [1..1] Review Of Systems Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.18)
  27. MAY contain zero or one [0..1] component (CONF:9582)
    1. Contains exactly one [1..1] Social History Section (templateId: 2.16.840.1.113883.10.20.22.2.17)
  28. SHALL contain exactly one [1..1] component (CONF:9542)
    1. Contains exactly one [1..1] Allergies Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.6)
  29. MAY contain zero or one [0..1] component (CONF:9584)
    1. Contains exactly one [1..1] Vital Signs Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.4)
  30. SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section. (CONF:10055)

Discharge Summary Example

<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
  <typeId root="2.16.840.1.113883.1.3"/>
  <id root="MDHT" extension="1477736030"/>
  <code code="467202907"/>
  <title>TEXT FOR TITLE</title>
  <effectiveTime/>
  <confidentialityCode code="1124086430"/>
  <setId root="MDHT" extension="58a500d3-d9be-438c-8132-da61015f6813"/>
  <versionNumber value="1"/>
  <recordTarget>
    <typeId root="2.16.840.1.113883.1.3"/>
    <patientRole/>
  </recordTarget>
  <author>
    <typeId root="2.16.840.1.113883.1.3"/>
    <time/>
    <assignedAuthor/>
  </author>
  <custodian/>
  <componentOf>
    <encompassingEncounter>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <dischargeDispositionCode codeSystem="2.16.840.1.113883.12.112" codeSystemName="HL7DischargeDisposition"/>
      <responsibleParty/>
      <encounterParticipant/>
    </encompassingEncounter>
  </componentOf>
  <component>
    <structuredBody>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="2143241607"/>
          <code code="1663297042"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1846593212"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="313827286"/>
              <code code="680888243"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <substanceAdministration classCode="SBADM"/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="2041887241"/>
          <code code="1568878486"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1699091110"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1741947981"/>
              <code code="580193498"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1482650199"/>
          <code code="1776206732"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1534736076"/>
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              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1039989226"/>
              <code code="37493975"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
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              <entryRelationship>
                <observation/>
              </entryRelationship>
            </act>
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        </section>
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          <id root="MDHT" extension="1108479390"/>
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          <confidentialityCode code="318962281"/>
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          <id root="MDHT" extension="1168233350"/>
          <code code="1927019208"/>
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          <confidentialityCode code="2128077620"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1786158220"/>
              <code code="1217007050"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <substanceAdministration classCode="SBADM"/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1938366028"/>
          <code code="570650716"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="499272252"/>
          <entry>
            <organizer>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="112240994"/>
              <code code="1634552062"/>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <component>
                <observation/>
              </component>
            </organizer>
          </entry>
          <entry>
            <organizer>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1497605888"/>
              <code code="1390233542"/>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
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              <component>
                <observation/>
              </component>
            </organizer>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="191961161"/>
              <code code="369092814"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <author/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <referenceRange/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="354595539"/>
              <code code="843582008"/>
              <effectiveTime>
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                <high value="2013"/>
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              <author/>
              <entryRelationship>
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              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <referenceRange/>
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          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1106195867"/>
              <code code="962586752"/>
              <effectiveTime>
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              <entryRelationship>
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              <entryRelationship>
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          <entry>
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              <effectiveTime>
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              <entryRelationship>
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              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
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          <entry>
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              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="488645285"/>
              <code code="379227142"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <participant/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1896893654"/>
              <code code="1737260509"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <author/>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <referenceRange/>
            </observation>
          </entry>
          <entry>
            <supply classCode="SPLY">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1677154938"/>
              <code code="171575004"/>
              <effectiveTime value="20130627"/>
            </supply>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="421767418"/>
              <code code="515061444"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship typeCode="COMP"/>
              <entryRelationship typeCode="COMP"/>
              <entryRelationship typeCode="COMP"/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1236619646"/>
              <code code="538296493"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <author/>
              <entryRelationship typeCode="SUBJ"/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="501902982"/>
              <code code="1156682460"/>
              <effectiveTime>
                <low value="2013"/>
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        </section>
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      <component>
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          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="247837368"/>
          <code code="1324702735"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="420541802"/>
        </section>
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        <section>
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          <code code="147224590"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="701718108"/>
        </section>
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      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="542507106"/>
          <code code="459122082"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="430500546"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="558841816"/>
              <code code="1109028564"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </act>
          </entry>
          <entry>
            <encounter>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="5947779"/>
              <code code="2011706559"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </encounter>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="315467505"/>
              <code code="745398817"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </observation>
          </entry>
          <entry>
            <procedure>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1533836568"/>
              <code code="1958279244"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </procedure>
          </entry>
          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1564868656"/>
              <code code="2104947360"/>
              <effectiveTime value="20130627"/>
              <consumable/>
            </substanceAdministration>
          </entry>
          <entry>
            <supply classCode="SPLY">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="667540632"/>
              <code code="294231376"/>
              <effectiveTime value="20130627"/>
            </supply>
          </entry>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="981325524"/>
              <code code="1287320450"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="742820786"/>
          <code code="810499094"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="977883645"/>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1372838625"/>
              <code code="1128302449"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </observation>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="470490590"/>
          <code code="871062038"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="476286261"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1717999766"/>
          <code code="1455194317"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1336088070"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1627074523"/>
          <code code="1442049672"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="555022279"/>
          <entry>
            <organizer>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="741255028"/>
              <code code="1289345180"/>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <subject/>
              <component>
                <observation/>
              </component>
            </organizer>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1089976122"/>
          <code code="252576738"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="392722231"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1097050508"/>
          <code code="399208261"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="2141298676"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="569017439"/>
          <code code="1815963117"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1174053341"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1776666274"/>
          <code code="94403627"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1048346921"/>
        </section>
      </component>
      <component>
        <section>
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