18842-5  Discharge summaryDischarge summaryDischarge summary note: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Discharge summary note  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Discharge summary
  Short Name:  Discharge sum

PART DEFINITION/DESCRIPTION(S)
  Part: 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.
 
 

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 1.0l
  Last Updated in Version: 2.58
  Order vs. Obs.: Both
  HL7 Attachment Structure: IG exists
  Status: Active.
Change Reason: Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class. Changed Component from 'Discharge summarization note' per the Clinical LOINC Committee decision to harmonize existing terms in the LOINC Document Ontology.; 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.

ASSOCIATED OBSERVATIONS

Definition/Description: 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#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  81218-0   Discharge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:    
       48765-2   Allergies R    
       8648-8   Hospital course NarrativeHospital course NarrativeHospital course: Find: Pt: ^Patient: Nar: R    
       78375-3   Discharge diagnosis NarrativeDischarge diagnosis NarrativeDischarge diagnosis: Imp: Pt: ^Patient: Nar: R    
       75311-1   Discharge medications NarrativeDischarge medications NarrativeDischarge medications: Find: Pt: ^Patient: Nar: R    
       18776-5   Plan of care R    
       42347-5   Admission diagnosis (narrative)Admission diagnosis (narrative)Admission diagnosis: Find: Pt: ^Patient: Nar: O    
       42346-7   Medications on admission (narrative)Medications on admission (narrative)Medications on admission: Find: Pt: ^Patient: Nar: O    
       46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar: O    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported O    
       42344-2   Discharge diet (narrative)Discharge diet (narrative)Discharge diet: Find: Pt: ^Patient: Nar: O    
       10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar: O    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} O    
       11348-0   History of Past illness NarrativeHistory of Past illness NarrativePast illness: Hx: Pt: ^Patient: Nar: O    
       10164-2   History of Present illness NarrativeHistory of Present illness NarrativePresent illness: Hx: Pt: ^Patient: Nar: O    
       18841-7   Hospital consultations DocumentHospital consultations DocumentHospital consultations: Type: Pt: ^Patient: Doc: O    
       8653-8   Hospital Discharge instructionsHospital Discharge instructionsDischarge instructions: Find: Pt: Hospital: Doc: {Role} O    
       10184-0   Hospital discharge physical findings NarrativeHospital discharge physical findings NarrativeHospital discharge physical findings: Find: Pt: ^Patient: Nar: O    
       11493-4   Hospital discharge studies summary NarrativeHospital discharge studies summary NarrativeHospital discharge studies summary: Find: Pt: ^Patient: Nar: O    
       11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar: O    
       61144-2   Diet and nutrition NarrativeDiet and nutrition NarrativeDiet and nutrition: Find: Pt: ^Patient: Nar: O    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported O    
       47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role} O    
       29299-5   Reason for visit NarrativeReason for visit NarrativeReason for visit: Find: Pt: ^Patient: Nar: O    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported O    
       29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar: O    
       8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed O    
 

ASSOCIATED OBSERVATIONS

Definition/Description: 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#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:    
       48765-2   Allergies R    
       8648-8   Hospital course NarrativeHospital course NarrativeHospital course: Find: Pt: ^Patient: Nar: R    
       11535-2   Hospital discharge Dx NarrativeHospital discharge Dx NarrativeHospital discharge Dx: Imp: Pt: ^Patient: Nar: R    
       10183-2   Hospital discharge medications NarrativeHospital discharge medications NarrativeHospital discharge medications: Find: Pt: ^Patient: Nar: R    
       18776-5   Plan of care R    
       46241-6   Hospital admission diagnosis Narrative - ReportedHospital admission diagnosis Narrative - ReportedHospital admission Dx: Imp: Pt: ^Patient: Nar: Reported O    
       42346-7   Medications on admission (narrative)Medications on admission (narrative)Medications on admission: Find: Pt: ^Patient: Nar: R    
       46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar: O    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported O    
       42344-2   Discharge diet (narrative)Discharge diet (narrative)Discharge diet: Find: Pt: ^Patient: Nar: O    
       10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar: O    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} O    
       11348-0   History of Past illness NarrativeHistory of Past illness NarrativePast illness: Hx: Pt: ^Patient: Nar: O    
       10164-2   History of Present illness NarrativeHistory of Present illness NarrativePresent illness: Hx: Pt: ^Patient: Nar: O    
       18841-7   Hospital consultations DocumentHospital consultations DocumentHospital consultations: Type: Pt: ^Patient: Doc: O    
       8653-8   Hospital Discharge instructionsHospital Discharge instructionsDischarge instructions: Find: Pt: Hospital: Doc: {Role} O    
       10184-0   Hospital discharge physical findings NarrativeHospital discharge physical findings NarrativeHospital discharge physical findings: Find: Pt: ^Patient: Nar: O    
       11493-4   Hospital discharge studies summary NarrativeHospital discharge studies summary NarrativeHospital discharge studies summary: Find: Pt: ^Patient: Nar: O    
       11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar: O    
       61144-2   Diet and nutrition NarrativeDiet and nutrition NarrativeDiet and nutrition: Find: Pt: ^Patient: Nar: O    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported O    
       47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role} O    
       29299-5   Reason for visit NarrativeReason for visit NarrativeReason for visit: Find: Pt: ^Patient: Nar: O    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported O    
       29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar: O    
       8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed O    
 

ASSOCIATED OBSERVATIONS

Definition/Description: 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#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:    
       48765-2   Allergies R    
       8648-8   Hospital course NarrativeHospital course NarrativeHospital course: Find: Pt: ^Patient: Nar: R    
       11535-2   Hospital discharge Dx NarrativeHospital discharge Dx NarrativeHospital discharge Dx: Imp: Pt: ^Patient: Nar: R    
       10183-2   Hospital discharge medications NarrativeHospital discharge medications NarrativeHospital discharge medications: Find: Pt: ^Patient: Nar: R    
       18776-5   Plan of care R    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported O    
       46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar: O    
       42344-2   Discharge diet (narrative)Discharge diet (narrative)Discharge diet: Find: Pt: ^Patient: Nar: O    
       10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar: O    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} O    
       10164-2   History of Present illness NarrativeHistory of Present illness NarrativePresent illness: Hx: Pt: ^Patient: Nar: O    
       46241-6   Hospital admission diagnosis Narrative - ReportedHospital admission diagnosis Narrative - ReportedHospital admission Dx: Imp: Pt: ^Patient: Nar: Reported O    
       18841-7   Hospital consultations DocumentHospital consultations DocumentHospital consultations: Type: Pt: ^Patient: Doc: O    
       8653-8   Hospital Discharge instructionsHospital Discharge instructionsDischarge instructions: Find: Pt: Hospital: Doc: {Role} O    
       10184-0   Hospital discharge physical findings NarrativeHospital discharge physical findings NarrativeHospital discharge physical findings: Find: Pt: ^Patient: Nar: O    
       11348-0   History of Past illness NarrativeHistory of Past illness NarrativePast illness: Hx: Pt: ^Patient: Nar: O    
       47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role} O    
       11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar: O    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported O    
       11493-4   Hospital discharge studies summary NarrativeHospital discharge studies summary NarrativeHospital discharge studies summary: Find: Pt: ^Patient: Nar: O    
       29299-5   Reason for visit NarrativeReason for visit NarrativeReason for visit: Find: Pt: ^Patient: Nar: O    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported O    
       29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar: O    
       8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed O    
 

ASSOCIATED OBSERVATIONS

Definition/Description: 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#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:    
       77599-9   Additional documentationAdditional documentationAdditional documentation: Find: Pt: {Setting}: Doc: {Role} R    
       77598-1   Externally defined clinical data elements DocumentExternally defined clinical data elements DocumentExternally defined clinical data elements: Find: Pt: {Setting}: Doc: {Role} R    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} R    
       77597-3   Orders placed DocumentOrders placed DocumentOrders placed: Find: Pt: {Setting}: Doc: {Role} R    
       18776-5   Plan of care notePlan of care notePlan of care note: Find: Pt: {Setting}: Doc: {Role} R    
       29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar: R    
       77596-5   Transportation summary DocumentTransportation summary DocumentTransportation summary: Find: Pt: {Setting}: Doc: {Role} R    
       46241-6   Hospital admission diagnosis Narrative - ReportedHospital admission diagnosis Narrative - ReportedHospital admission Dx: Imp: Pt: ^Patient: Nar: Reported R    
       42346-7   Medications on admission (narrative)Medications on admission (narrative)Medications on admission: Find: Pt: ^Patient: Nar: R    
       48765-2   Allergies R    
       51847-2   Evaluation +​ Plan noteEvaluation +​ Plan noteEvaluation+​Plan note: Find: Pt: {Setting}: Doc: {Role} R    
       51848-0   Evaluation noteEvaluation noteEvaluation note: Find: Pt: {Setting}: Doc: {Role} R    
       46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar: R    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported R    
       11535-2   Hospital discharge Dx NarrativeHospital discharge Dx NarrativeHospital discharge Dx: Imp: Pt: ^Patient: Nar: R    
       10183-2   Hospital discharge medications NarrativeHospital discharge medications NarrativeHospital discharge medications: Find: Pt: ^Patient: Nar: R    
       10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar: R    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} R    
       10210-3   Physical findings of General status NarrativePhysical findings of General status NarrativePhysical findings: Find: Pt: General status: Nar: Observed R    
       61146-7   Goals NarrativeGoals NarrativeGoals: Find: Pt: ^Patient: Nar: R    
       75310-3   Health concerns DocumentHealth concerns DocumentHealth concerns: Find: Pt: ^Patient: Doc: R    
       11383-7   Patient problem outcome NarrativePatient problem outcome NarrativePatient problem outcome: Find: Pt: ^Patient: Nar: R    
       11348-0   History of Past illness NarrativeHistory of Past illness NarrativePast illness: Hx: Pt: ^Patient: Nar: R    
       10164-2   History of Present illness NarrativeHistory of Present illness NarrativePresent illness: Hx: Pt: ^Patient: Nar: R    
       18841-7   Hospital consultations DocumentHospital consultations DocumentHospital consultations: Type: Pt: ^Patient: Doc: R    
       8648-8   Hospital course NarrativeHospital course NarrativeHospital course: Find: Pt: ^Patient: Nar: R    
       8653-8   Hospital Discharge instructionsHospital Discharge instructionsDischarge instructions: Find: Pt: Hospital: Doc: {Role} R    
       10184-0   Hospital discharge physical findings NarrativeHospital discharge physical findings NarrativeHospital discharge physical findings: Find: Pt: ^Patient: Nar: R    
       11493-4   Hospital discharge studies summary NarrativeHospital discharge studies summary NarrativeHospital discharge studies summary: Find: Pt: ^Patient: Nar: R    
       11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar: R    
       69730-0   InstructionsInstructionsInstructions: Find: Pt: {Setting}: Doc: {Role} R    
       11329-0   History general Narrative - ReportedHistory general Narrative - ReportedHistory general: Find: Pt: ^Patient: Nar: Reported R    
       46264-8   History of medical device useHistory of medical device useHistory of medical device use: Find: Pt: {Setting}: Doc: {Role} R    
       10160-0   History of Medication use NarrativeHistory of Medication use NarrativeMedication use: Hx: Pt: ^Patient: Nar: R    
       10190-7   Mental status NarrativeMental status NarrativeMental status: Find: Pt: ^Patient: Nar: Observed R    
       61144-2   Diet and nutrition NarrativeDiet and nutrition NarrativeDiet and nutrition: Find: Pt: ^Patient: Nar: R    
       48768-6   Payment sources DocumentPayment sources DocumentPayment sources: Find: Pt: ^Patient: Doc: R    
       29545-1   Physical findings NarrativePhysical findings NarrativePhysical findings: Find: Pt: ^Patient: Nar: Observed R    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported R    
       47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role} R    
       29299-5   Reason for visit NarrativeReason for visit NarrativeReason for visit: Find: Pt: ^Patient: Nar: R    
       30954-2   Relevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar: R    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported R    
       8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed R    
 

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  26443-2 Clinical reports.non lab claims attachment
  

MEMBER OF THESE EQUIVALENCE GROUPS
  LG38746-0  Discharge summary note|ANYRole|ANYSetting
  LG41826-5  {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

PARTS

Part Type    Part No.  Part Name   
Component   LP72467-1  Discharge summary note 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP100598-4  Discharge 
Fragments for synonyms   LP183649-5  note 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  出院摘要记录:发现:时间点:{环境}:文档型:{角色}出院摘要记录:发现:时间点:{环境}:文档型:{角色}
  German (AUSTRIA)  (From: Regenstrief-generated full translation based on part translation provided by ELGA, Austria)
 
  Entlassungsbrief Ärztlich:Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}Entlassungsbrief Ärztlich:Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Lettera di dimissione ospedaliera:Osservazione:Pt:{Setting}:Doc:{Role}Lettera di dimissione ospedaliera:Osservazione:Pt:{Setting}:Doc:{Role}
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Anotação resumo de alta médica:Achado:Pt:{Fixação}:Doc:{Fornecedor}Anotação resumo de alta médica:Achado:Pt:{Fixação}:Doc:{Fornecedor}
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  nota de resumen en el momento del alta:hallazgo:punto en el tiempo:{contexto}:Documento:{proveedor}nota de resumen en el momento del alta:hallazgo:punto en el tiempo:{contexto}:Documento:{proveedor}

RELATED NAMES
  Disch Evaluation and management Point in time
  Discharge summary Evaluation and management note Random
  DOC.ONT Finding Visit note
  Document Findings  
  Encounter notes  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 7:12:05 PM
  Long Common Name: Discharge summary
  Shortname: Discharge sum
  Fully Specified Name: Discharge summary note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 3
  ID: 9751
  # of Panel Elements: 45
  Status (Raw): ACTIVE