Narrative patient data relevant to the context identified by note types.

Data Element

Additional Information

Discharge Summary Note
Description
Synopsis of a patient’s admission and course in a hospital or post-acute care setting. Usage note: Must contain admission and discharge dates and locations, discharge instructions, and reason(s) for hospitalization. Examples include but are not limited to dermatology discharge summary, hematology discharge summary, and neurology discharge summary. 

Applicable Vocabulary Standard(s)

Applicable Standards
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
    • At minimum: Discharge Summary (LOINC code 18842-5)

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