Discharge Summary profile

This profile defines constraints that represent common administrative and demographic concepts for VN clinical documents' header. Further specification, such as type, are provided in document profiles that conform to this profile.

The Data Enterer Extension represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author’s information to the electronic system.

Informant Extension describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.

The Information Recipient Extension records the intended recipient of the information at the time the document was created.

The Order Extension represents orders that are fulfilled by this document such as a radiologists report of an x-ray.

Participant Extension identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).

The Performer Extension represents clinicians who actually and principally carry out the clinical services being documented. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patients key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.

VersionNumber Extension represents a numeric value used to version successive replacement documents.

(Clinical Focus: Kind of discharge summary document classified by author role),(Data Element Scope: ),(Inclusion Criteria: A list of LOINC terms, intended to identify Discharge Summary Notes where component contains "Discharge Summary Note", Timing = "Patient", Property = Find" , scale = "Doc"),(Exclusion Criteria: )

This value set was imported on 6/24/2019 with a version of 20190425.