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Discharge Summary

HL7 Implementation Guide for CDA R2
Care Record Summary, Release 2: Discharge Summary

Draft Standard for Trial Use
Published December 2009

The Care Record Summary (CRS), issued in June 23, 2006, was the first balloted Implementation Guide for Clinical Document Architecture (CDA) Release 2 (R2). CRS covered CDA Levels 1 and 2, however, did not specify Level 3 templates (CDA entries). Continuity of Care Document (CCD), meanwhile, developed a rich set of Level 3 templates, however, CCD is not a Discharge Summary and does not specify a hospital course. The purpose of this update was to issue a Discharge Summary-specific CRS updated for compliance with the current approach to CDA templates in CCD and the HL7 Health Story implementation guides. The resulting specification is consistent with IHE XDS-MS for Discharge Summary and HITSP C48 and does not introduce conflicting requirements.

This project was sponsored by the HL7 Structured Documents Work Group. The project team balloted the CRS Release 2.0: Discharge Summary through HL7.

According to Dr. John Halamka, "...for discharge summaries, the HL7 discharge summary implementation guide using CDA is the right standard to use, with CCD as a reasonable intermediate step." Dr. Halamka is Chief Information Officer of Beth Israel Deaconess Medical Center, Chief Information Officer at Harvard Medical School, Chairman of the New England Healthcare Exchange Network (NEHEN), Chair of the US Healthcare Information Technology Standards Panel (HITSP)/Co-Chair of the HIT Standards Committee, and a practicing Emergency Physician. Access Dr. Halamka's complete blog post.

» Project Wiki Site

» Access Discharge Summary DSTU

» Download Discharge Summary Validating Rule Set (xpath/Schematron)

» Access HL7 CDA Release 2 through the Clinical Document Architecture section of the HL7 online store