Tuesday, June 15, 2010

Standards for Discharge Summaries

I was recently asked about the standards for representing a discharge summary.

HL7 completed and balloted an implementation guide for discharge summaries in the Fall of 2009. It's CDA based and includes structured data elements as well as free text. Here's a sample using the HL7 style sheet.

BIDMC has used a CCD for the past two years to communicate discharge data to primary care clinicians, skilled nursing facilities and long term acute care organizations. We also provide a copy to the patient. This discharge format of CCD uses the same standard, but different contents than our lifetime medical record summary CCD which is what we use for our social security administration data exchange and what we give to patients to comply with meaningful use patient summary requirements.

Thus, for discharge summaries, the HL7 discharge summary implementation guide using CDA is the right standard to use, with CCD as a reasonable intermediate step.
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5 comments:

  1. Health Story ProjectJune 18, 2010 at 4:57 AM

    For more information about the HL7 Discharge Summary project and to access the project zip files: http://www.healthstory.com/standards/sec/discharge.htm.

    ReplyDelete
  2. emt.danJune 21, 2010 at 4:47 PM

    Thanks for this. I am an EMT who frequents the BI transporting discharges, and am always impressed with the quality and comprehensiveness of your discharge summaries. One note, or question. It seems, whenever the unit coordinator prints the summary, there is an extra sheet of paper printed with just a "PRINT" radial button at the top. The sheet has no content, and is often wasteful.
    Consider reexamining the logistics of the actual discharge.

    Thanks!
    Dan

    ReplyDelete
  3. John HalamkaJune 21, 2010 at 6:12 PM

    We do a form feed in all our laser printers at the end of each print job to prevent patient content from remaining in the print queue and accidentally mixing two patients together on a single sheet, violating privacy policies.

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  4. emt.danJune 22, 2010 at 7:28 AM

    Interesting, thanks for explaining. Certainly there are other, less wasteful ways of performing the same task, no? How about adding a tray to the printer of colored paper that just prints between jobs and is constantly reused? Perhaps using the copier each floor uses, and separate trays for different print jobs?

    Thanks!

    ReplyDelete
  5. Sudha MantriJuly 8, 2010 at 9:25 AM

    John,

    Thank you. This is very useful information. I like the examples you have provided.

    Regards,
    Sudha

    ReplyDelete