Discharge Summary

Type: Information Object

Status: Planned
Industry Sector: Healthcare
Sensitivity Level: Confidential
Personal Information: Sensitive PII

Description:
A clinical document summarizing a patient's episode of inpatient care for communication to the receiving provider.

Accessed by Application(s):

• Electronic Health Record System
• Patient Administration System

 Yes

Attributes

Order	Name	Description	Type	Cardinality	Example value
1	Summary ID	Unique identifier for the discharge summary	GUID	Mandatory
2	Patient ID	Reference to the patient being discharged	Reference	Mandatory
3	Admission Date	Date the patient was admitted	Date	Mandatory
4	Discharge Date	Date the patient was discharged	Date	Mandatory
5	Primary Diagnosis	Primary diagnosis for the episode	Reference	Mandatory
6	Authored By	Reference to the clinician who produced the summary	Reference	Mandatory
7	Discharge Destination	Where the patient was discharged to	Enumeration	Mandatory	Home
8	Procedures Performed	Clinical procedures carried out during the episode	String	Optional
9	Medications on Discharge	Medications prescribed at discharge	String	Optional
10	Follow-up Required	Indicates whether follow-up care has been arranged	Boolean	Mandatory

 Yes
 
 Planned
 Sensitive PII
 Confidential
 Healthcare
 A clinical document summarizing a patient's episode of inpatient care for communication to the receiving provider.

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