DISCHARGE SUMMARY SCENARIO – C-CDA 2.1 FULL (VERSION 2)
Introduction
This scenario is an example referral note where the content of the referral note which includes
"full" C-CDA 2.1 content.
Kai Bergman is a 56-year-old lady who has been admitted this autumn (2015) to Good Health
University Hospital (GHUH) for a knee replacement; her left knee joint has been steadily
deteriorating and causing increasing pain since an accident 5 years ago. Kai has been using
regular analgesia for the knee pain for some time. This is her second knee replacement as her
right knee was previously replaced.
Header Data
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Patient
Kai Bergman
Race: White
Ethnicity: Not Hispanic or Latin
Language: English
DOB: June 11, 1959
ID: 647-386-2748
Address: 677 Schoolhouse Lane, West Chicago, IL 60185
Home Phone: (630) 555-3286
Attending Physician
o Dr. Shira Blackman
o Address: 150 W Roosevelt Rd., West Chicago, IL 60185
o Phone: (331) 555-9545
Admission Date: October 15, 2015
Discharge Date: October 28, 2015
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Sections
Allergies and Intolerances
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Ampicillin Sodium (Hives) since October 2, 2008
Clindamycin Hydrochloride (No allergy/completed)
Hospital Course
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Patient was admitted for a knee replacement for her left knee.
X-Rays on Left knee showed space narrowing
After replacement surgery, patient was released after 5 days with care instructions.
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DISCHARGE SUMMARY SCENARIO – C-CDA 2.1 FULL (VERSION 2)
Discharge Diagnosis
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October 28, 2015 - Left Knee Replacement
Plan of Treatment
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Follow occupational therapist recommended exercises for knee surgery recovery
Continue Enoxaparin 40mg tablet - 1 daily for 5 days
Continue use of Paracetamol for pain relief
Admission Diagnosis
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Pain in left knee
Admission Medications
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July 23, 2010 - Paracetamol 500mg tablets - 2 tablets up to 4 times daily as needed for
pain relief
Chief Complaint and Reason for Visit
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Decreased mobility and pain in left knee
Left knee replacement surgery
Discharge Medications (with entries)
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October 28, 2015 - Paracetamol 500mg tablets - 2 tablets up to 4 times daily as needed
for pain relief
October 28, 2015 - Enoxaparin 40mg tablet - 1 daily for 5 days
Family History
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No History taken
Functional Status
As determined during admission interview on October 15, 2015:
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Uses a cane for walking
Decreased mobility due to pain in left knee
Right knee was previously replaced
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DISCHARGE SUMMARY SCENARIO – C-CDA 2.1 FULL (VERSION 2)
History of Past Illness
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Car accident in 2010 caused lacerations and pain in knees
Right knee was replaced due to pain in 2013
History of Present Illness
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Left knee has experienced increasing pain since 2013 and the joint is steadily
deteriorating
Hospital Consultations
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None
Hospital Discharge Instructions
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Make appointment for followup with family doctor in 7 days and 21 days
Follow occupational therapist recommended exercises for knee surgery recovery
If swelling or redness occurs, visit emergency room
Continue Enoxaparin 40mg tablet - 1 daily for 5 days
Continue use of Paracetamol for pain relief
Hospital Discharge Physical
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Decreased mobility in left knee
Surgery to replace left knee
Walking with crutches and cane
Immunizations
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No history
Nutrition
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General diet as of October 15, 2015
Problem
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Pain in left knee (October 15, 2015)
Procedures
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Knee replacement surgery on left knee - October 28, 2015
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DISCHARGE SUMMARY SCENARIO – C-CDA 2.1 FULL (VERSION 2)
Review of Systems
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Pain in left knee
Decreased mobility due to pain
Social History
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Non-Smoker
Vital Signs
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October 27, 2015 - Height: 5'4"; Weight: 145lbs
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