Template 2.16.840.1.113883.3.51.60.2.4.1

Template BC CDA ClinicalDocumentDischargeSummary (V3)

Id 2.16.840.1.113883.3.51.60.2.4.1 Effective Date 2019‑03‑19 14:15:51

Status Draft Version Label 2.1

Name BCCDADischargeSummaryV3 Display Name BC CDA ClinicalDocumentDischargeSummary (V3)

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 patient’s 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.

Context Pathname //

Classification CDA Document Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 1 transaction and 0 templates, Uses 27 templates

Used by	as	Name	Version
bccdapilot-transaction-17	Transaction	Create Discharge Summary	2019‑04‑01 07:32:17
Uses	as	Name	Version
2.16.840.1.113883.3.51.60.1.9.2	Include	BC CDA Ordering Provider	DYNAMIC
2.16.840.1.113883.10.20.22.2.62	Containment	BC CDA Allergies and Intolerances Section (entries optional) (V3) (2.1)	DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.5	Containment	Hospital Course Section (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.24	Containment	BC CDA Discharge Diagnosis Section (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.11	Containment	BC CDA Discharge Medications Section (entries optional) (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.10	Containment	Plan of Treatment Section (V2) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.45	Containment	Chief Complaint Section (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.46	Containment	Reason for Visit Section (2.1)	DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.33	Containment	Discharge Diet Section (1.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.15	Containment	Family History Section (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.14	Containment	Functional Status Section (V2) (2.1)	DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.4	Containment	History of Present Illness Section (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.43	Containment	Admission Diagnosis Section (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.44	Containment	BC CDA Admission Medications Section (entries optional) (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.42	Containment	Hospital Consultations Section (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.41	Containment	Hospital Discharge Instructions Section (2.1)	DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.26	Containment	Hospital Discharge Physical Section (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.16	Containment	Hospital Discharge Studies Summary Section (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.78	Containment	Immunizations Section (entries optional) (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.55	Containment	BC CDA Problem Section (entries optional) (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.7	Containment	Procedures Section (entries optional) (V2) (2.1)	DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.18	Containment	Review of Systems Section (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.17	Containment	Social History Section (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.4	Containment	Vital Signs Section (entries optional) (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.48	Containment	Advance Directives Section (entries optional) (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.47	Containment	BC CDA Results Section (entries optional) (V3) (2.1)	DYNAMIC
2.16.840.1.113883.10.20.22.2.49	Containment	BC CDA Complications DS Section (V3) (2.1)	DYNAMIC

Relationship

Specialization: template 2.16.840.1.113883.3.51.60.2.4.1 (2015‑08‑01)

ref

Specialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)

ref

ad1bbr-

Version: template 2.16.840.1.113883.3.51.60.2.4.1 (2013‑01‑31)

ref

Specialization: template 2.16.840.1.113883.3.51.60.2.0 BC CDA Clinical Document Header (DYNAMIC)

Item DT Card Conf Description Label

cda:ClinicalDocument

(BCCyV3)

cda:templateId

1 … 1

SHALL contain exactly one [1..1] templateId (CONF:1198-8463) such that it

CONF8463

@root

uid

1 … 1

2.16.840.1.113883.3.51.60.2.4.1

CONF0044

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.8" (CONF:1198-10044).

@extension

1 … 1

2015-08-01

CONF2517

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32517).

cda:code

1 … 1

SHALL contain exactly one [1..1] code (CONF:1198-17178).

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.

CONF7178

cda:participant

0 … *

MAY contain zero or more [0..*] participant (CONF:1198-8467).

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.

CONF8467

Constraint 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

cda:componentOf

1 … 1

SHALL contain exactly one [1..1] componentOf (CONF:1198-8471).

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

CONF8471

cda:encompassingEncounter

1 … 1

This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:1198-8472).

CONF8472

cda:effectiveTime

IVL_TS

1 … 1

This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:1198-32611).

CONF2611

cda:low

1 … 1

This effectiveTime SHALL contain exactly one [1..1] low (CONF:1198-8473).

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

CONF8473

cda:high

1 … 1

This effectiveTime SHALL contain exactly one [1..1] high (CONF:1198-8475).

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

CONF8475

cda:dischargeDispositionCode

1 … 1

This encompassingEncounter SHALL contain exactly one [1..1] dischargeDispositionCode, which SHOULD be selected from ValueSet NUBC UB-04 FL17 Patient Status urn:oid:2.16.840.1.113883.3.88.12.80.33 DYNAMIC (CONF:1198-8476).

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.

CONF8476

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17 Patient Status (DYNAMIC)

cda:responsibleParty

0 … 1

This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:1198-8479).

The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care.

CONF8479

cda:assignedEntity

1 … 1

The responsibleParty, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32613).

CONF2613

Schematron assert role error

test cda:assignedPerson | cda:representedOrganization

Message This assignedEntity *SHALL* contain an assignedPerson or a representedOrganization or both.

Included from 2.16.840.1.113883.3.51.60.1.9.2 BC CDA Ordering Provider (DYNAMIC)

hl7:participant

0 … *

CONF‑8504

@typeCode

1 … 1

REF

CONFR‑48

@contextControlCode

1 … 1

CONF‑8505

hl7:associatedEntity

1 … 1

CONF‑8507

@classCode

1 … 1

PROV

CONF‑8507

hl7:id

1 … 2

CONF‑BC0097, CONF‑BC0098

Constraint If the participant is a provider, the id elements SHALL conform to section 4.2.1.3.

If the participant is a not a Provider, associatedEntity/id.extension MAY be a locally assigned identifier

hl7:code

0 … 1

CONF‑8507

@codeSystem

CONF

0 … 1

2.16.840.1.113883.5.111 (Role Code)

hl7:addr

AD.CA

0 … *

CONF0101

hl7:telecom

TEL.CA.PHONE

0 … *

CONF0102

hl7:associatedPerson

1 … 1

Contains 2.16.840.1.113883.3.51.60.1.5.2 BC CDA Person (DYNAMIC)

CONF‑8508

where [not(@nullFlavor)] [@classCode = 'PSN'] [@determinerCode = 'INSTANCE']

cda:encounterParticipant

0 … *

This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:1198-8478).

The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.

CONF8478

cda:assignedEntity

1 … 1

The encounterParticipant, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1198-32615).

CONF2615

Schematron assert role error

test cda:assignedPerson | cda:representedOrganization

Message This assignedEntity *SHALL* contain an assignedPerson or a representedOrganization or both.

cda:component

1 … 1

SHALL contain exactly one [1..1] component (CONF:1198-9539).

CONF9539

cda:structuredBody

1 … 1

This component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30518).

In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional.

CONF0518

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.62 BC CDA Allergies and Intolerances Section (entries optional) (V3) (DYNAMIC)

CONF0519

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.62'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.62'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.62'] [@extension = '2015-08-01']]]

cda:component

1 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.5 Hospital Course Section (DYNAMIC)

CONF0521

where [cda:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.5'] and cda:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.5']]]

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.24 BC CDA Discharge Diagnosis Section (V3) (DYNAMIC)

CONF0519

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.24'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.24'] [@extension = '2015-08-01']]]

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.11 BC CDA Discharge Medications Section (entries optional) (V3) (DYNAMIC)

CONF0523

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.11'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.11'] [@extension = '2015-08-01']]]

cda:component

1 … 1

Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (DYNAMIC)

CONF0527

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.10'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.10'] [@extension = '2014-06-09']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.45 Chief Complaint Section (DYNAMIC)

CONF0529

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.45'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.45']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.46 Reason for Visit Section (DYNAMIC)

CONF0533

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.46'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.46']]]

cda:component

0 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.33 Discharge Diet Section (DYNAMIC)

CONF0533

where [cda:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.33'] and cda:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.33']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (DYNAMIC)

CONF0535

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.15'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.15'] [@extension = '2015-08-01']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (V2) (DYNAMIC)

CONF0537

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.14'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.14'] [@extension = '2014-06-09']]]

cda:component

0 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (DYNAMIC)

CONF0537

where [cda:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.4'] and cda:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.4']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.43 Admission Diagnosis Section (V3) (DYNAMIC)

CONF0543

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.43'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.43'] [@extension = '2015-08-01']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.44 BC CDA Admission Medications Section (entries optional) (V3) (DYNAMIC)

CONF0545

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.44'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.44'] [@extension = '2015-08-01']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.42 Hospital Consultations Section (DYNAMIC)

CONF0547

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.42'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.42']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.41 Hospital Discharge Instructions Section (DYNAMIC)

CONF0549

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.41'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.41']]]

cda:component

0 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.26 Hospital Discharge Physical Section (DYNAMIC)

CONF0551

where [cda:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.26'] and cda:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.26']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.16 Hospital Discharge Studies Summary Section (DYNAMIC)

CONF0553

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.16'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.16']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.78 Immunizations Section (entries optional) (V3) (DYNAMIC)

CONF0555

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.78'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.78'] [@extension = '2015-08-01']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.55 BC CDA Problem Section (entries optional) (V3) (DYNAMIC)

CONF0557

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.55'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.55'] [@extension = '2015-08-01']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (DYNAMIC)

CONF0559

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.7'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.7'] [@extension = '2014-06-09']]]

cda:component

0 … 1

Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (DYNAMIC)

CONF0563

where [cda:section [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.18'] and cda:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.18']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (DYNAMIC)

CONF0565

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.17'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.17'] [@extension = '2015-08-01']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (V3) (DYNAMIC)

CONF0567

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.4'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.4'] [@extension = '2015-08-01']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.48 Advance Directives Section (entries optional) (V3) (DYNAMIC)

CONF1586

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.48'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.48'] [@extension = '2015-08-01']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.47 BC CDA Results Section (entries optional) (V3) (DYNAMIC)

CONF1586

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.47'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.47'] [@extension = '2015-08-01']]]

cda:component

0 … 1

Contains 2.16.840.1.113883.10.20.22.2.49 BC CDA Complications DS Section (V3) (DYNAMIC)

CONF1586

where [cda:section [hl7:templateId [@root = '2.16.840.1.113883.10.20.22.2.49'] and cda:templateId [@root = '2.16.840.1.113883.10.20.22.2.49'] [@extension = '2015-08-01']]]

Schematron assert role 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 This structuredBody *SHALL NOT* contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present

Template BC CDA ClinicalDocumentDischargeSummary (V3)