Narrative patient data relevant to the context identified by note types.
- Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.
Data Element |
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Discharge Summary Note
Description
A synopsis of a patient’s admission and course in a hospital or post-acute care setting. Applicable Vocabulary Standard(s) Applicable Standards (*Please confirm or update this field for the new USCDI version*)
Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
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Submitted by NCQA on
NCQA USCDI v6 recommendation- Discharge Summary
Discharge Summary Note
Recommendation type: Modification to existing USCDI element.
Recommendation: Update the required components of a discharge summary note to include: practitioner responsible for the care, reason for hospitalization, diagnoses at discharge, procedures or treatment provided (including test results), current medication list, instructions for patient care post-discharge, and pending tests.
Rationale: High-quality discharge summaries are considered essential for promoting patient safety during transitions between care settings. The recommended required components of the discharge summary align to requirements set by NCQA’s HEDIS measure (Transitions of Care) used in CMS Medicare Advantage Stars and aligns to The Joint Commission requirements. Aligning USCDI requirements to industry standards supports reinforcement of high quality discharge summaries to support transitions of care.