34105-7
Hospital Discharge Summary
Active
Part Description
LP72467-1 Discharge summary note
Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The summary may include the reason for hospitalization, procedures performed, the care, treatment and services provided, the patient's condition and disposition at discharge, information provided to the patient and family, and provisions for follow-up care.
Source: HL7
LOINC Names Get Info
- Fully-Specified Name
- Discharge summary note:
Find: Pt: Hospital: Doc: {Role} - Long Common Name
- Hospital Discharge Summary
- Short Name
- Hosp D/C Sum
Part Model Get Info
Associated Observations
81218-0 Discharge summary - recommended C-CDA R2.1 sections
This panel contains the recommended sections for discharge summary notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.1.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81218-0 | Discharge summary - recommended C-CDA R2.1 sections | |||
| Indent48765-2 | Allergies | R | ||
| Indent8648-8 | Hospital course note | R | ||
| Indent78375-3 | Discharge diagnosis Narrative | R | ||
| Indent75311-1 | Discharge medications note | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent42347-5 | Admission diagnosis (narrative) | O | ||
| Indent42346-7 | Medications on admission (narrative) | O | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | O | ||
| Indent10154-3 | Chief complaint Narrative - Reported | O | ||
| Indent42344-2 | Discharge diet (narrative) | O | ||
| Indent10157-6 | History of family member diseases note | O | ||
| Indent47420-5 | Functional Status Assessment Note | O | ||
| Indent11348-0 | History of Past illness note | O | ||
| Indent10164-2 | History of Present illness Narrative | O | ||
| Indent18841-7 | Hospital consultations Document | O | ||
| Indent8653-8 | Hospital Discharge Instructions | O | ||
| Indent10184-0 | Hospital discharge physical findings Narrative | O | ||
| Indent11493-4 | Hospital discharge studies summary Narrative | O | ||
| Indent11369-6 | History of Immunization note | O | ||
| Indent61144-2 | Diet and nutrition Narrative | O | ||
| Indent11450-4 | Problem list - Reported | O | ||
| Indent47519-4 | History of Procedures Document | O | ||
| Indent29299-5 | Reason for visit Narrative | O | ||
| Indent10187-3 | Review of systems Narrative - Reported | O | ||
| Indent29762-2 | Social history note | O | ||
| Indent8716-3 | Vital signs note | O |
81219-8 Discharge summary - recommended C-CDA R2.0 sections
This panel contains the recommended sections for discharge summary notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.0.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81219-8 | Discharge summary - recommended C-CDA R2.0 sections | |||
| Indent48765-2 | Allergies | R | ||
| Indent8648-8 | Hospital course note | R | ||
| Indent11535-2 | Hospital discharge diagnosis note | R | ||
| Indent10183-2 | Hospital discharge medications Narrative | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent46241-6 | Hospital admission diagnosis Narrative - Reported | O | ||
| Indent42346-7 | Medications on admission (narrative) | R | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | O | ||
| Indent10154-3 | Chief complaint Narrative - Reported | O | ||
| Indent42344-2 | Discharge diet (narrative) | O | ||
| Indent10157-6 | History of family member diseases note | O | ||
| Indent47420-5 | Functional Status Assessment Note | O | ||
| Indent11348-0 | History of Past illness note | O | ||
| Indent10164-2 | History of Present illness Narrative | O | ||
| Indent18841-7 | Hospital consultations Document | O | ||
| Indent8653-8 | Hospital Discharge Instructions | O | ||
| Indent10184-0 | Hospital discharge physical findings Narrative | O | ||
| Indent11493-4 | Hospital discharge studies summary Narrative | O | ||
| Indent11369-6 | History of Immunization note | O | ||
| Indent61144-2 | Diet and nutrition Narrative | O | ||
| Indent11450-4 | Problem list - Reported | O | ||
| Indent47519-4 | History of Procedures Document | O | ||
| Indent29299-5 | Reason for visit Narrative | O | ||
| Indent10187-3 | Review of systems Narrative - Reported | O | ||
| Indent29762-2 | Social history note | O | ||
| Indent8716-3 | Vital signs note | O |
72229-8 Discharge summary - recommended C-CDA R1.1 sections
This panel contains the recommended sections for discharge summary notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 72229-8 | Discharge summary - recommended C-CDA R1.1 sections | |||
| Indent48765-2 | Allergies | R | ||
| Indent8648-8 | Hospital course note | R | ||
| Indent11535-2 | Hospital discharge diagnosis note | R | ||
| Indent10183-2 | Hospital discharge medications Narrative | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent10154-3 | Chief complaint Narrative - Reported | O | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | O | ||
| Indent42344-2 | Discharge diet (narrative) | O | ||
| Indent10157-6 | History of family member diseases note | O | ||
| Indent47420-5 | Functional Status Assessment Note | O | ||
| Indent10164-2 | History of Present illness Narrative | O | ||
| Indent46241-6 | Hospital admission diagnosis Narrative - Reported | O | ||
| Indent18841-7 | Hospital consultations Document | O | ||
| Indent8653-8 | Hospital Discharge Instructions | O | ||
| Indent10184-0 | Hospital discharge physical findings Narrative | O | ||
| Indent11348-0 | History of Past illness note | O | ||
| Indent47519-4 | History of Procedures Document | O | ||
| Indent11369-6 | History of Immunization note | O | ||
| Indent11450-4 | Problem list - Reported | O | ||
| Indent11493-4 | Hospital discharge studies summary Narrative | O | ||
| Indent29299-5 | Reason for visit Narrative | O | ||
| Indent10187-3 | Review of systems Narrative - Reported | O | ||
| Indent29762-2 | Social history note | O | ||
| Indent8716-3 | Vital signs note | O |
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
This panel contains the recommended sections for an enhanced discharge summary note based on the HL7 Clinical Documents for Payers - Set 1, Release 1.0 (US Realm).
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections | |||
| Indent77599-9 | Additional documentation | R | ||
| Indent77598-1 | Externally defined clinical data elements Document | R | ||
| Indent47420-5 | Functional Status Assessment Note | R | ||
| Indent77597-3 | Orders placed Document | R | ||
| Indent18776-5 | Plan of Care Note | R | ||
| Indent29762-2 | Social history note | R | ||
| Indent77596-5 | Transportation summary Document | R | ||
| Indent46241-6 | Hospital admission diagnosis Narrative - Reported | R | ||
| Indent42346-7 | Medications on admission (narrative) | R | ||
| Indent48765-2 | Allergies | R | ||
| Indent51847-2 | Evaluation + Plan Note | R | ||
| Indent51848-0 | Evaluation Note | R | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | R | ||
| Indent10154-3 | Chief complaint Narrative - Reported | R | ||
| Indent11535-2 | Hospital discharge diagnosis note | R | ||
| Indent10183-2 | Hospital discharge medications Narrative | R | ||
| Indent10157-6 | History of family member diseases note | R | ||
| Indent47420-5 | Functional Status Assessment Note | R | ||
| Indent10210-3 | Physical findings of General status Narrative | R | ||
| Indent61146-7 | Goals Narrative | R | ||
| Indent75310-3 | Health concerns Document | R | ||
| Indent11383-7 | Patient problem outcome Narrative | R | ||
| Indent11348-0 | History of Past illness note | R | ||
| Indent10164-2 | History of Present illness Narrative | R | ||
| Indent18841-7 | Hospital consultations Document | R | ||
| Indent8648-8 | Hospital course note | R | ||
| Indent8653-8 | Hospital Discharge Instructions | R | ||
| Indent10184-0 | Hospital discharge physical findings Narrative | R | ||
| Indent11493-4 | Hospital discharge studies summary Narrative | R | ||
| Indent11369-6 | History of Immunization note | R | ||
| Indent69730-0 | Instructions | R | ||
| Indent11329-0 | History general Narrative - Reported | R | ||
| Indent46264-8 | History of medical device use | R | ||
| Indent10160-0 | History of Medication use Narrative | R | ||
| Indent10190-7 | Mental status Narrative | R | ||
| Indent61144-2 | Diet and nutrition Narrative | R | ||
| Indent48768-6 | Payment sources Document | R | ||
| Indent29545-1 | Physical findings note | R | ||
| Indent11450-4 | Problem list - Reported | R | ||
| Indent47519-4 | History of Procedures Document | R | ||
| Indent29299-5 | Reason for visit Narrative | R | ||
| Indent30954-2 | Relevant diagnostic tests/laboratory data note | R | ||
| Indent10187-3 | Review of systems Narrative - Reported | R | ||
| Indent8716-3 | Vital signs note | R |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.09
- Last Updated
- Version 2.73 (MIN)
- Change Reason
- Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- Implementation guide exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 59271-7 | Hospital discharge summary panel |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG38746-0 | Discharge summary note| |
| LG41829-9 | Hospital| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| cs-CZ | Czech (Czechia) | propouštěcí zpráva: |
| de-DE | German (Germany) | Krankenhausentlassbericht - Dokumentation: |
| el-GR | Greek (Greece) | Συνοπτικό σημείωμα εξιτηρίου: Synonyms: {Ρόλος} Doc DOC.ONTOLOGY Pt Εύρεση Νοσοκομείο Περίληψη σημειώματος Σημείωση Συνοπτικό σημείωμα εξιτηρίου |
| es-AR | Spanish (Argentina) | nota de resumen en el momento del alta: |
| es-MX | Spanish (Mexico) | Nota de resumen de alta: |
| it-IT | Italian (Italy) | Lettera di dimissione ospedaliera: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | samenvattende ontslagbrief: |
| zh-CN | Chinese (China) | 出院摘要记录: Synonyms: 临床文档型; |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
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LOINC Copyright
Copyright © Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://