Version 2.78

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

Fully-Specified Name

Component
Discharge summary note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
General medicine

Additional Names

Short Name
General medicine D/C sum

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 Narrative R
Indent78375-3 Discharge diagnosis Narrative R
Indent75311-1 Discharge medications Narrative 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 Narrative O
Indent47420-5 Functional status assessment note O
Indent11348-0 History of Past illness Narrative 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 Narrative 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 Narrative O
Indent8716-3 Vital signs 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 Narrative R
Indent11535-2 Hospital discharge Dx Narrative 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 Narrative O
Indent47420-5 Functional status assessment note O
Indent11348-0 History of Past illness Narrative 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 Narrative 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 Narrative O
Indent8716-3 Vital signs 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 Narrative R
Indent11535-2 Hospital discharge Dx Narrative 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 Narrative 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 Narrative O
Indent47519-4 History of Procedures Document O
Indent11369-6 History of Immunization Narrative 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 Narrative O
Indent8716-3 Vital signs 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 Narrative 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 Dx Narrative R
Indent10183-2 Hospital discharge medications Narrative R
Indent10157-6 History of family member diseases Narrative 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 Narrative R
Indent10164-2 History of Present illness Narrative R
Indent18841-7 Hospital consultations Document R
Indent8648-8 Hospital course Narrative 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 Narrative 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 Narrative 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 Narrative R
Indent10187-3 Review of systems Narrative - Reported R
Indent8716-3 Vital signs R

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.54
Last Updated
Version 2.73
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38746-0 Discharge summary note|ANYRole|ANYSetting
LG38960-7 General medicine|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Entlassungsbrief Ärztlich:Ergebnis:Zeitpunkt:{Setting}:Dokument:Allgemeinmedizin
Synonyms: Bericht Entlassungsbrief aus stationärer Behandlung (Arzt); Ärztlicher Entlassungsbrief
es-MX Spanish (Mexico) Nota de resumen de alta:Tipo:Punto temporal:{Configuración}:Documento:General medicine
fr-BE French (Belgium) Note résumée de sortie:Observation:Temps ponctuel:{réglages}:Document:Médecine Générale
it-IT Italian (Italy) Lettera di dimissione ospedaliera:Osservazione:Pt:{Setting}:Doc:Medicina generale
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) samenvattende ontslagbrief:bevinding:moment:{instelling}:document:algemene geneeskunde
Synonyms: huisartsenzorg
zh-CN Chinese (China) 出院摘要记录:发现:时间点:{环境}:文档型:普通内科学
Synonyms: 一般内科;一般内科学;普通内科;内科 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 允许...离开(医院、军队);(从监狱)释放 出院（离院）摘要（小结、概要、总结、梗概、概括、总汇）记录;出院总结记录;出院概要记录;出院概括记录;出院摘要;出院小结 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 小结;概要;概括;总汇;总结 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 笔记;按语;注释;说明;票据;单据;证明书

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=78264-9