Dataset for Clinical Summary:
Ref.
Section
Content
Notes by Discharge Instructions SWG
Comments from Audrey
T.CC.1 Personal
Name, DOB, Next of
Information Kin, Address, Phone
Number, Gender,
Marital Status,
Religion, Race,
Ethnicity
Has this list been standardized?
T.CC.2 Contact
Contact Name,
Information Contact Number
Would this be the power of healthcare attorney?
T.CC.3 Insurance
Insurance Name,
Information Phone #, Group #,
Type, Member #,
Subscriber Name,
Financial
responsibility
I would add Medicare/Medicaid to the section name.
T.CC.4 Healthcare
Provider
Provider Name,
Address, Phone
Number, Type
Would this be the provider who sent the referral form
to the specialist? Or the specialist? or the healthcare
entity the patient has been admitted from or is going
to?
T.CC.5 Allergies
Allergy Type; and
Date
Substance
intolerance
Associated Adverse
Events
List of allergies which might include allergy to what (e.g., To have an allergic response to a medication, food or
medication. food, environment)
the environment does not automatically mean the
person had an adverse event. Example: If the patient
has an allergic response to a medication, and has a
case of hives. The medication is stopped and the
patient takes Benadryl or similar. Does not mean an
adverse event has occurred.
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T.CC.5 Other
Adverse
Reactions
T.CC.6
Allergy Type; and
Date
Substance
intolerance
Associated Adverse
Events
Problem List
Active Problems (R/N)/Chief Complaint
(overriding problem at the time of
discharge) - chronic illness
and congenital problems



Yes/No/Unknown, and if Yes or Unknown how
does it affect care.
Other history that guide care.
Patient supplied information about reaction
Current Diseases &
Conditions monitored for the patient
and status



If a patient is allergic to latex or tape, this is a
product allergy. An adverse event would be if
the patient was listed as having a latex allergy
and latex was used in the care of the patient
and the patient had a skin reaction. This is an
adverse event because it could have been
prevented. In some places these events are
called “never events” because they are
preventable.
List of problems/complaints (what was diagnosis,
complaint and/or descriptor of problem/complaints,
symptoms). Is a list, of diagnosis, complaints some of
these may have been resolved and some are active.
How do these problems/complaints impact
interventions, orders or instructions. Discharge
instructions usually are for the encounter just ending.
Patient's perception or description of
problems/complaints Is usually in notes or history. Not
part of a formal problem list.
T.CC.7
History of Past Illness
Diseases & Conditions Patient has
suffered in the past
May be a list with dates onset and/or resolution
T.CC.8
Chief Complaint (see change in T.CC.6
Problem List)
Description of Patient's Complaint
(narrative)
If not listed in the problem list.
T.CC.9
Reason for Transfer
Reason Patient is being referred
May come from Utilization Review (UR) or Medicare rules,
insurance or HMO rules or the patient may be well.
T.CC.10 History of Present Illness
Sequence of events that occurred to
change the state of the patient’s
health proceeding patient's
disease/condition
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T.CC.11 List of Surgeries
List of types of surgeries and dates
T.CC.12 Hospital Admission Diagnosis
List of Hospital Diagnosis and dates
Hosp Adm diagnosis is different for list of hosp diagnosis and
dates. This should be the current encounter adm date
T.CC.13 Discharge Diagnosis
Conditions/Diseases identified during
hospital stay and dates
Current encounter list only
T.CC.14 Medications
List of Current Medication Names ;
date, route, dose, frequency



list of prescribed medications or other medications.
Should be the reconciled list (which should have been
done on admission)
If to be reconciled then list needs to be inclusive of self
administered medications (herbals, over the counter)
See notes on medication reconciliation regarding
expectations such as discontinued medications from
inpatient if not included in discharge summary
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T.CC.15 Admission Medications History
List of historical medication
names, dose, route, frequency,
date patient has taken prior
T.CC.16 Hospital Discharge Medications
Medications names, doses,
frequency, route ordered for the
patient for after discharge
T.CC.17 Medications Administered
Medications administered to
patient during the course of an
encounter; name, dose, route,
frequency
T.CC.18 Advanced Directives
A summary of patient's
expectations for care
T.CC.19 Pregnancy
Pregnant, Yes/NO
T.CC.20 Immunizations
Immunizations name, dose,
route, date administered to the
patient
T.CC.21 Physical Examination
Physical Findings of the Patient;
VS, Biometrics, Review of
Systems
T.CC.22 Vital Signs
Vital Signs (R/N) including Pain Scale
Assessment, Smoking Status
Patient's Vital Signs ; Heart rate, Instructions regarding the capture of vital signs at points along
Resp Rate, Pulse Ox, Temp, B/P, the care plan and any special instructions regarding how to
Pain
capture
T.CC.23 Review of Systems
Functions of various body
systems; Neuro, Derm, GI, GU,
Cardiac, Pulmonary, MS, Repro,
Nervous, Endocrine




Yes/No
Yes/No if POLST form returned
Where is last known version/original is located
Going forward how the "state" and how it affects care
Comprehensive list of immunizations (have - patient reported,
got, need):* list of immunizations necessary to get after
discharge.* list of education or information about
immunizations they received while hospitalization
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T.CC.24 Hospital Course
Sequence of (name, diagnosis
associated with) events and
dates from admission to
discharge of hospital stay
T.CC.25 Diagnostic Results
Results and dates of Diagnostic
Procedures
T.CC.26 Assessment and Plan
Assessment of patients
conditions and
expectations/goals of care
T.CC.27 Plan of Care
Plan of Treatment/Treatment Plan/Care Plan
(R/N) - Covers the considerations that encompass
a range of scopes and/or timeframe (could be a
description of a single encounter or across
multiple encounters
Proposed interventions and
procedures for patient
Corresponding results to the scheduled procedures and
interventions.
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
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
T.CC.28 Family History
Dates with Disease Suffered,
Age of Death, other genetic
information
T.CC.29 Social History
Patient's beliefs, home life,
social/risky habits, family life,
work history
T.CC.30 Encounters
Current and historical
encounters; dates
T.CC.31 Medical Equipment
Medical Devices (C/N) - includes assistive
devices and is related to functional status
Implanted and External Medical
Devices; Dates



Goals.
Active interventions and orders (short term direct
instructions - in the long run as validated by the
patient and those contributed by the patient/caregiver).
Yes/No - has the discharge instruction been reviewed
with the patient.
Yes/No - has the discharge instruction been accepted
by the patient, if no then how addressed
List of devices and where the device is to be
secured/prescribed/embedded.
Duration of medical devices.
History of devices for this patient.
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T.CC.32
Preoperative Diagnosis
Diagnosis ( Date) assigned to
patient prior to surgery
T.CC.33
Postoperative Diagnosis
Diagnosis ( Date) assigned to
patient after surgery
T.CC.34
Surgery Description
Particulars of Surgery
(narrative) (images)
T.CC.35
Surgical Operation Note Findings
Clinically significant
observations found during
surgery
T.CC.36
Complications Section
Known risks or unidentified
problems
T.CC.37
Operative Note Surgical Procedure
Date and Description of
Procedure Performed
ADDED
Education
Patient education provided or
needed. To included classes,
educational sessions, printed
materials.
ADDED
Electronic Links
How to get to future results,
summaries, etc.
Updated PHR
ADDED
Facility Checklist
List of facility dependent items
(e.g., pain scale at discharge,
last ECG, etc.
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ADDED
Diet/Diet Restrictions (R/N
Diet:
- All instructions that describe the expected diet.
Restrictions:
- List of limitations being placed on the diet
ADDED
Fluids Management (C/N)
Fluids:
- All instructions that describe the expected fluids and method of
administration.
Restrictions:
- List of limitations being placed on fluids
ADDED
Functional Status (O/N) - Might be Smoking
SHOULD be present when any assessments of
functional status are performed on the patien
Baseline, current and desired:* Functional status* End state/goal
expressed/Projected change in functional status (will relate to the
goals identified)
ADDED
Procedures and Interventions (C/N)
Scheduled procedures and interventions, such as labs, etc.
(procedure/intervention, schedule, etc.
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