97704-1Radiation oncology Discharge summaryActive
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
- Radiation oncology
Additional Names
- Short Name
- Radiation Onc Discharge sum
Associated Observations
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 |
Associated Observations
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 |
Associated Observations
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 |
Associated Observations
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 2.70
- Last Updated
- Version 2.70
- Order vs. Observation
- Both
- HL7 Attachment Structure
- Implementation guide exists
Member of these Groups
| LG41826-5 | {Setting}| |
| LG38746-0 | Discharge summary note| |
| LG38990-4 | Radiation oncology| |
Language Variants Get Info
- zh-CNChinese (China)
- 出院摘要记录:
发现: 时间点: {环境}: 文档型: 放射肿瘤学 - nl-NLDutch (Netherlands)
- samenvattende ontslagbrief:
bevinding: moment: {instelling}: document: radiotherapie - fr-BEFrench (Belgium)
- Note résumée de sortie:
Observation: Temps ponctuel: {réglages}: Document: Irradiation oncologique - de-ATGerman (Austria)
- Entlassungsbrief Ärztlich:
Ergebnis: Zeitpunkt: {Setting}: Dokument: Strahlentherapie-Radioonkologie - it-ITItalian (Italy)
- Lettera di dimissione ospedaliera:
Osservazione: Pt: {Setting}: Doc: Radioterapia oncologica
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