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/):\n\n The reason for hospitalization (the admission) \n\n The procedures performed, as applicable\n\n The care, treatment, and services provided\n\n The patients condition and disposition at discharge\n\n Information provided to the patient and family\n\n Provisions for follow-up care\n\nThe best practice for a Discharge Summary is to include the discharge disposition in the display of the header. package_name: hl7.fhir.us.ccda derivation: constraint name: DischargeSummary type: Composition elements: type: label: Discharge Summary short: Discharge Summary binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.4.1'} mustSupport: true index: 0 section: index: 1 slicing: rules: open discriminator: - {path: code, type: value} min: null slices: functional_status_section: match: code: coding: - {code: 47420-5, system: 'http://loinc.org'} schema: label: Functional Status Section short: Functional Status Section mustSupport: true index: 56 elements: title: {short: title, mustSupport: true, index: 57} code: label: Functional status short: Functional status mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 47420-5, system: 'http://loinc.org'} index: 58 text: {short: text, mustSupport: true, index: 59} entry: short: entry index: 60 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: functional_status_entry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/ClinicalImpression', 'http://hl7.org/fhir/StructureDefinition/Observation', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition'] index: 61 required: [text, title, code] allergies_and_intolerances_section: match: code: coding: - {code: 48765-2, system: 'http://loinc.org'} schema: short: Allergies and Intolerances Section mustSupport: true _required: true label: Allergies and Intolerances Section index: 2 elements: title: {short: title, mustSupport: true, index: 3} code: label: Allergies and adverse reactions short: Allergies and adverse reactions mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 48765-2, system: 'http://loinc.org'} index: 4 text: {short: text, mustSupport: true, index: 5} entry: short: entry index: 6 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: allergy_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance'] index: 7 required: [text, title, code] chief_complaint_section: match: code: coding: - {code: 10154-3, system: 'http://loinc.org'} schema: label: Chief Complaint Section short: Chief Complaint Section mustSupport: true index: 46 elements: title: {short: title, mustSupport: true, index: 47} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10154-3, system: 'http://loinc.org'} index: 48 text: {short: This section contains only human readable content, mustSupport: true, index: 49} required: [text, title, code] nutrition_section: match: code: coding: - {code: 61144-2, system: 'http://loinc.org'} schema: label: Nutrition Section short: Nutrition Section mustSupport: true index: 88 elements: title: {short: title, mustSupport: true, index: 89} code: label: Diet and nutrition short: Diet and nutrition mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 61144-2, system: 'http://loinc.org'} index: 90 text: {short: text, mustSupport: true, index: 91} entry: short: entry index: 92 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: nutrition_entry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/Observation'] index: 93 required: [text, title, code] reason_for_visit_section: match: code: coding: - {code: 29299-5, system: 'http://loinc.org'} schema: label: Reason for Visit Section short: Reason for Visit Section mustSupport: true index: 112 elements: title: {short: title, mustSupport: true, index: 113} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 29299-5, system: 'http://loinc.org'} index: 114 text: {short: This section contains only human readable content, mustSupport: true, index: 115} required: [text, title, code] immunizations_section: match: code: coding: - {code: 11369-6, system: 'http://loinc.org'} schema: label: Immunizations Section short: Immunizations Section mustSupport: true index: 82 elements: title: {short: title, mustSupport: true, index: 83} code: label: Immunizations short: Immunizations mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11369-6, system: 'http://loinc.org'} index: 84 text: {short: text, mustSupport: true, index: 85} entry: short: entry index: 86 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: immunizations_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization'] index: 87 required: [text, title, code] past_medical_history_section: match: code: coding: - {code: 11348-0, system: 'http://loinc.org'} schema: label: Past Medical History Section short: Past Medical History Section mustSupport: true index: 94 elements: title: {short: title, mustSupport: true, index: 95} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11348-0, system: 'http://loinc.org'} index: 96 text: {short: text, mustSupport: true, index: 97} entry: short: entry index: 98 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: past_medical_history_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition'] index: 99 required: [text, title, code] health_concerns_section: match: code: coding: - {code: 75310-3, system: 'http://loinc.org'} schema: short: Health Concerns Section mustSupport: true index: 138 elements: title: {short: title, mustSupport: true, index: 139} code: short: Health concerns section code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 75310-3, system: 'http://loinc.org'} index: 140 text: {short: text, mustSupport: true, index: 141} entry: short: entry index: 142 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: health_concerns_entry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/ClinicalImpression', 'http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/List', 'http://hl7.org/fhir/StructureDefinition/Observation', 'http://hl7.org/fhir/StructureDefinition/RiskAssessment', 'http://hl7.org/fhir/StructureDefinition/vitalsigns', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus'] index: 143 required: [text, title, code] hospital_discharge_physical_section: match: code: coding: - {code: 10184-0, system: 'http://loinc.org'} schema: label: Hospital Discharge Physical Section short: Hospital Discharge Physical Section mustSupport: true index: 74 elements: title: {short: title, mustSupport: true, index: 75} code: label: Hospital discharge physical short: Hospital discharge physical mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10184-0, system: 'http://loinc.org'} index: 76 text: {short: This section contains only human readable content, mustSupport: true, index: 77} required: [text, title, code] history_of_present_illness_section: match: code: coding: - {code: 10164-2, system: 'http://loinc.org'} schema: label: History of Present Illness Section short: History of Present Illness Section mustSupport: true index: 62 elements: title: {short: title, mustSupport: true, index: 63} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10164-2, system: 'http://loinc.org'} index: 64 text: {short: This section contains only human readable content, mustSupport: true, index: 65} required: [text, title, code] hospital_consultations_section: match: code: coding: - {code: 18841-7, system: 'http://loinc.org'} schema: label: Hospital Consultations Section short: Hospital Consultations Section mustSupport: true index: 66 elements: title: {short: title, mustSupport: true, index: 67} code: label: Hospital consultations short: Hospital consultations mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 18841-7, system: 'http://loinc.org'} index: 68 text: {short: This section contains only human readable content, mustSupport: true, index: 69} required: [text, title, code] hospital_course_section: match: code: coding: - {code: 8648-8, system: 'http://loinc.org'} schema: label: Hospital Course Section short: Hospital Course Section mustSupport: true _required: true index: 8 elements: title: {short: title, mustSupport: true, index: 9} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 8648-8, system: 'http://loinc.org'} index: 10 text: {short: This section contains only human readable content, mustSupport: true, index: 11} required: [text, title, code] hospital_discharge_studies_section: match: code: coding: - {code: 11493-4, system: 'http://loinc.org'} schema: label: Hospital Discharge Studies Section short: Hospital Discharge Studies Section mustSupport: true index: 78 elements: title: {short: title, mustSupport: true, index: 79} code: label: Hospital discharge studies summary short: Hospital discharge studies summary mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11493-4, system: 'http://loinc.org'} index: 80 text: {short: This section contains only human readable content, mustSupport: true, index: 81} required: [text, title, code] hospital_discharge_instructions_section: match: code: coding: - {code: 8653-8, system: 'http://loinc.org'} schema: label: Hospital Discharge Instructions Section short: Hospital Discharge Instructions Section mustSupport: true index: 70 elements: title: {short: title, mustSupport: true, index: 71} code: label: Hospital discharge instructions short: Hospital discharge instructions mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 8653-8, system: 'http://loinc.org'} index: 72 text: {short: This section contains only human readable content, mustSupport: true, index: 73} required: [text, title, code] social_history_section: match: code: coding: - {code: 29762-2, system: 'http://loinc.org'} schema: label: Social History Section short: Social History Section mustSupport: true index: 120 elements: title: {short: title, mustSupport: true, index: 121} code: label: Social history short: Social history mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 29762-2, system: 'http://loinc.org'} index: 122 text: {short: text, mustSupport: true, index: 123} entry: short: entry index: 124 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: smoking_status_entry: match: {} schema: type: Reference short: Smoking status mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus'] index: 125 required: [text, title, code] discharge_medications_section: match: code: coding: - {code: 10183-2, system: 'http://loinc.org'} schema: label: Discharge Medications Section short: Discharge Medications Section mustSupport: true index: 24 elements: title: {short: title, mustSupport: true, index: 25} code: label: Hospital discharge medications short: Hospital discharge medications mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10183-2, system: 'http://loinc.org'} index: 26 text: {short: text, mustSupport: true, index: 27} entry: short: entry index: 28 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: discharge_medications_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/MedicationStatement', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest'] index: 29 required: [text, title, code] procedures_section: match: code: coding: - {code: 47519-4, system: 'http://loinc.org'} schema: label: Procedures Section short: Procedures Section mustSupport: true index: 106 elements: title: {short: title, mustSupport: true, index: 107} code: label: History of procedures short: History of procedures mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 47519-4, system: 'http://loinc.org'} index: 108 text: {short: text, mustSupport: true, index: 109} entry: short: entry index: 110 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: procedure_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure'] index: 111 required: [text, title, code] chief_complaint_and_reason_for_visit_section: match: code: coding: - {code: 46239-0, system: 'http://loinc.org'} schema: label: Chief Complaint and Reason for Visit Section short: !!binary |- Q2hpZWYgQ29tcGxhaW50IGFuZCBSZWFzb24gZm9yIFZpc2l0IFNlY3Rpb24uIFRoaXMgc2VjdGlvbiByZWNvcmRzIHRoZSBwYXRpZW50J3MgY2hpZWYgY29tcGxhaW50ICh0aGUgcGF0aWVudMOiwoDCmXMgb3duIGRlc2NyaXB0aW9uKSBhbmQvb3IgdGhlIHJlYXNvbiBmb3IgdGhlIHBhdGllbnQncyB2aXNpdCAodGhlIHByb3ZpZGVyw6LCgMKZcyBkZXNjcmlwdGlvbiBvZiB0aGUgcmVhc29uIGZvciB2aXNpdCkuIExvY2FsIHBvbGljeSBkZXRlcm1pbmVzIHdoZXRoZXIgdGhlIGluZm9ybWF0aW9uIGlzIGRpdmlkZWQgaW50byB0d28gc2VjdGlvbnMgb3IgcmVjb3JkZWQgaW4gb25lIHNlY3Rpb24gc2VydmluZyBib3RoIHB1cnBvc2VzLg== mustSupport: true index: 42 elements: title: {short: title, mustSupport: true, index: 43} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 46239-0, system: 'http://loinc.org'} index: 44 text: {short: This section contains only human readable content, mustSupport: true, index: 45} required: [text, title, code] plan_of_treatment_section: match: code: coding: - {code: 18776-5, system: 'http://loinc.org'} schema: label: Plan of Treatment Section short: Plan of Treatment Section mustSupport: true index: 18 elements: title: {short: title, mustSupport: true, index: 19} code: label: Plan of treatment short: Plan of treatment mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 18776-5, system: 'http://loinc.org'} index: 20 text: {short: text, mustSupport: true, index: 21} entry: short: entry index: 22 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: sliceEntry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. refers: ['http://hl7.org/fhir/StructureDefinition/Appointment', 'http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/CommunicationRequest', 'http://hl7.org/fhir/StructureDefinition/DeviceRequest', 'http://hl7.org/fhir/StructureDefinition/NutritionOrder', 'http://hl7.org/fhir/StructureDefinition/RequestGroup', 'http://hl7.org/fhir/StructureDefinition/ServiceRequest', 'http://hl7.org/fhir/StructureDefinition/Task', 'http://hl7.org/fhir/StructureDefinition/VisionPrescription', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest'] index: 23 required: [text, title, code] problem_section: match: code: coding: - {code: 11450-4, system: 'http://loinc.org'} schema: label: Problem Section short: Problem Section mustSupport: true index: 100 elements: title: {short: title, mustSupport: true, index: 101} code: label: Problem list short: Problem list mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11450-4, system: 'http://loinc.org'} index: 102 text: {short: text, mustSupport: true, index: 103} entry: short: entry index: 104 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: problem_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition'] index: 105 required: [text, title, code] review_of_systems_section: match: code: coding: - {code: 10187-3, system: 'http://loinc.org'} schema: label: Review of Systems Section short: Review of Systems Section mustSupport: true index: 116 elements: title: {short: title, mustSupport: true, index: 117} code: label: Review of systems short: Review of systems mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10187-3, system: 'http://loinc.org'} index: 118 text: {short: This section contains only human readable content, mustSupport: true, index: 119} required: [text, title, code] vital_signs_section: match: code: coding: - {code: 8716-3, system: 'http://loinc.org'} schema: label: Vital Signs Section short: Vital Signs Section mustSupport: true index: 126 elements: title: {short: title, mustSupport: true, index: 127} code: label: Vital signs short: Vital signs mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 8716-3, system: 'http://loinc.org'} index: 128 text: {short: text, mustSupport: true, index: 129} entry: short: entry index: 130 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: vital_signs_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/vitalsigns'] index: 131 required: [text, title, code] admission_diagnosis_section: match: code: coding: - {code: 46241-6, system: 'http://loinc.org'} schema: label: Admission Diagnosis Section short: Admission Diagnosis Section mustSupport: true index: 30 elements: title: {short: title, mustSupport: true, index: 31} code: label: Hospital admission diagnosis short: Hospital admission diagnosis mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 46241-6, system: 'http://loinc.org'} index: 32 text: {short: text, mustSupport: true, index: 33} entry: short: entry index: 34 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: admission_diagnosis_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition'] index: 35 required: [text, title, code] goals_section: match: code: coding: - {code: 61146-7, system: 'http://loinc.org'} schema: short: Goals Section mustSupport: true index: 132 elements: title: {short: title, mustSupport: true, index: 133} code: short: Goals mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 61146-7, system: 'http://loinc.org'} index: 134 text: {short: text, mustSupport: true, index: 135} entry: short: entry index: 136 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: goals_entry: match: {} schema: type: Reference short: entry mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal'] index: 137 required: [text, title, code] family_history_section: match: code: coding: - {code: 10157-6, system: 'http://loinc.org'} schema: label: Family History Section short: Family History Section mustSupport: true index: 50 elements: title: {short: title, mustSupport: true, index: 51} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10157-6, system: 'http://loinc.org'} index: 52 text: {short: text, mustSupport: true, index: 53} entry: short: entry index: 54 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: family_history_entry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory'] index: 55 required: [text, title, code] admission_medications_section: match: code: coding: - {code: 42346-7, system: 'http://loinc.org'} schema: label: Admission Medications Section short: Admission Medications Section mustSupport: true index: 36 elements: title: {short: title, mustSupport: true, index: 37} code: label: Medications on admission short: Medications on admission mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 42346-7, system: 'http://loinc.org'} index: 38 text: {short: text, mustSupport: true, index: 39} entry: short: entry index: 40 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: admission_medications_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/MedicationStatement', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest'] index: 41 required: [text, title, code] discharge_diagnosis_section: match: code: coding: - {code: 11535-2, system: 'http://loinc.org'} schema: label: Discharge Diagnosis Section short: Discharge Diagnosis Section mustSupport: true _required: true index: 12 elements: title: {short: title, mustSupport: true, index: 13} code: label: Hospital discharge diagnosis short: Hospital discharge diagnosis mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11535-2, system: 'http://loinc.org'} index: 14 text: {short: text, mustSupport: true, index: 15} entry: short: entry index: 16 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: discharge_diagnosis_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition'] index: 17 required: [text, title, code] package_version: 1.2.0 class: profile kind: resource url: http://hl7.org/fhir/us/ccda/StructureDefinition/Discharge-Summary base: http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header version: 1.2.0