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.