Hospital Discharge Instructions Section¶

OID: 2.16.840.1.113883.10.20.22.2.41 Version: (No extension) Badge: Administrative Section

Overview¶

The Hospital Discharge Instructions Section records instructions provided to the patient at hospital discharge. This narrative-only section contains guidance for patient self-care after leaving the hospital, including medication instructions, dietary restrictions, activity limitations, follow-up appointments, and warning signs to watch for.

This section contains only narrative text - no structured entries are required or typically used. Instructions can be provided as general text or organized by category (e.g., Medications, Diet, Activity, Follow-up Care).

Template Details¶

Template ID: 2.16.840.1.113883.10.20.22.2.41
Extension: None
Conformance: SHALL
Cardinality: 0..1 (Optional in documents)
LOINC Code: 8653-8 "Hospital Discharge Instructions"

Protocol Requirements¶

DischargeInstructionProtocol¶

from typing import Protocol, Optional

class DischargeInstructionProtocol(Protocol):
    instruction_text: str                   # The instruction content
    instruction_category: Optional[str]     # Category (e.g., "Medications", "Diet", "Activity", "Follow-up")

Code Example¶

Simple Narrative Text¶

from ccdakit import HospitalDischargeInstructionsSection, CDAVersion

# Create section with simple narrative
section = HospitalDischargeInstructionsSection(
    narrative_text="Follow discharge care plan. Take all medications as prescribed. "
                   "Follow up with your primary care physician within 7 days. "
                   "Call 911 if you experience chest pain or difficulty breathing.",
    version=CDAVersion.R2_1
)

xml_element = section.build()

Categorized Instructions¶

from ccdakit import HospitalDischargeInstructionsSection, CDAVersion

# Define categorized instructions
instructions = [
    {
        "instruction_text": "Take Lisinopril 10mg once daily in the morning",
        "instruction_category": "Medications"
    },
    {
        "instruction_text": "Take Aspirin 81mg once daily with food",
        "instruction_category": "Medications"
    },
    {
        "instruction_text": "Follow a low-sodium diet (less than 2000mg per day)",
        "instruction_category": "Diet"
    },
    {
        "instruction_text": "Avoid heavy lifting for 2 weeks",
        "instruction_category": "Activity"
    },
    {
        "instruction_text": "Walk for 10-15 minutes twice daily",
        "instruction_category": "Activity"
    },
    {
        "instruction_text": "Schedule appointment with Dr. Smith within 7 days",
        "instruction_category": "Follow-up"
    },
    {
        "instruction_text": "Call 911 if you experience chest pain or shortness of breath",
        "instruction_category": "Warning Signs"
    }
]

# Create section with categorized instructions
section = HospitalDischargeInstructionsSection(
    instructions=instructions,
    narrative_text="The following instructions should be followed after discharge:",
    version=CDAVersion.R2_1
)

xml_element = section.build()

Combined Approach¶

from ccdakit import HospitalDischargeInstructionsSection, CDAVersion

# Use both narrative preamble and structured instructions
section = HospitalDischargeInstructionsSection(
    narrative_text="You are being discharged after successful treatment. "
                   "Please follow these important instructions:",
    instructions=[
        {"instruction_text": "Take all medications exactly as prescribed", "instruction_category": None},
        {"instruction_text": "Monitor your blood pressure daily", "instruction_category": None},
        {"instruction_text": "Return to emergency department if symptoms worsen", "instruction_category": None}
    ],
    version=CDAVersion.R2_1
)

xml_element = section.build()

Official Reference¶

HL7 C-CDA Hospital Discharge Instructions Section Specification

Best Practices¶

Be Specific and Clear: Write instructions in plain language that patients can easily understand. Avoid medical jargon.
Organize by Category: Group related instructions together (Medications, Diet, Activity, Follow-up, Warning Signs).
Include Key Information: Always cover medications, activity restrictions, dietary guidance, follow-up appointments, and emergency warning signs.
Make It Actionable: Use clear action verbs (Take, Avoid, Call, Schedule, Monitor).
Specify Timing: Include specific timeframes (e.g., "within 7 days", "for 2 weeks").
Highlight Critical Items: Emphasize important warning signs and when to seek immediate medical attention.
Include Contact Information: Provide phone numbers for follow-up appointments and questions.
Keep It Concise: While being thorough, keep instructions concise and easy to follow.
Patient-Centered Language: Use "you" and "your" to make instructions personal and direct.
Verify Understanding: Instructions should be written at a 5th-8th grade reading level for best patient comprehension.