Narrative patient data relevant to the context identified by note types.

  •  
  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 

Data Element
Transfer summary note
Submitted By: Swapna Abhyankar / Regenstrief Institute, LOINC Document Ontology Subcommittee
Data Element Information
Data Element Description A synopsis of a patient’s admission and clinical course in one setting when being transferred to another setting.
Rationale for Separate Consideration There are related data elements (e.g., Discharge summary note, History and Physical note), but none that capture the information in a transfer summary.
Use Case Description(s)
Use Case Description The set of proposed data elements are complementary to the existing Clinical Notes data elements in USCDI v1 and together, they better represent the broad scope of clinical documentation that occurs each day in the U.S. Healthcare system.
Estimate the breadth of applicability of the use case(s) for this data element These data elements are broadly used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders.
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC.
We recommend adding the new data elements with a LOINC term representing the most generic term for that particular data element, along with information about how to access the value set of more specific LOINC terms available for each note type. The Regenstrief LOINC team can provide FHIR ValueSets with associated OIDs and/or webpages with downloadable content for each note type. Both of these resources would include the same set of LOINC terms. These resources do not exist yet but can easily be created if approved as additions to the USCDI. The benefit of hosting these resources on the LOINC website or providing them via LOINC FHIR terminology services compared to VSAC or other value set repositories is that the resources will be updated automatically with every LOINC release and would not require a separate process.
https://loinc.org
Additional Specifications There are HL7 C-CDA implementation guides for several of these data elements (Transfer summary, Plan of care, Referral note). In addition, the FHIR DocumentReference and other resources across versions, including the US Core, utilize these data elements.
Current Use Extensively used in production environments
Supporting Artifacts These data elements are broadly used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders.
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts These data elements are broadly used every day across healthcare systems, settings, and specialties and would be used by a large proportion of USCDI stakeholders.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns None
Estimate of Overall Burden Minimal - already being used
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.

Comment

Submitted by ubackonja@mitre.org on

PACIO Recommends Advancement from Level 0 to Level 2

Recommendation: Advance the Transfer Summary Note data element from Level 0 to Level 2.

Rationale: The PACIO Project Community* recommends advancing the Transfer Summary Note data element from Level 0 to Level 2. The Transfer Summary Note is a synopsis of a patient’s admission and clinical course in one setting that is generated to facilitate the patient being transferred to another setting. It is a foundational clinical document for ensuring safe, timely, and effective transitions of care between healthcare settings.

CMS priority to improve care transitions: 

  • CMS has identified improving care transitions as a priority within its Quality Improvement Program — elevating the Transfer Summary Note to Level 2 would facilitate that work by making critical patient information gathered by a discharging organization available for the admitting organization.
  • The FY 2026 Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals (IPPS) and the Long-Term Care Hospital Prospective Payment System (IPPS/LTCH PPS) Final Rule maintains Medicare Promoting Interoperability Program requirements related to electronic health information exchange, including modification of the MORT-30-STK measure that “promotes successful transitions of care for stroke patients discharged from acute care settings...”
  • The Final Rule also establishes the Transforming Episode Accountability Model (TEAM) model, which seeks to “improve the beneficiary care experience during care transitions,” among other outcomes, by holding participating acute-care hospitals accountable for coordinating the quality and cost of care beyond hospitalization and into the post-acute period.
  • The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) “requires the submission of standardized data by Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs)” and includes a quality measure domain for “transfer of health information and care preferences when an individual transitions.”

  • "The 2020 CMS Interoperability and Patient Access final rule (CMS-9115-F) requires  hospitals, psychiatric hospitals, and  critical access hospitals (CAHs), that if such hospital utilizes a compliant electronic medical records system or other electronic administrative system as discussed above, the system should send notifications directly, or through an intermediary that facilitates exchange of health information at the time of: (i) The patient's registration in the hospital's emergency department (if applicable) or (ii) The patient's admission to the hospital's inpatient services (if applicable). The final rule also requires that if a hospital (or CAH) utilizes an electronic medical records system or other electronic administrative system, the system should send notifications directly, or through an intermediary that facilitates exchange of health information, either immediately prior to, or at the time of: (i) The patient's discharge or transfer from the hospital's emergency department (if applicable) or (ii) The patient's discharge or transfer from the hospital's inpatient services (if applicable).”

    Distinct importance of Transfer Summary Note vs. Discharge Summary: 

  • The Transfer Summary Note serves a distinct and time-critical function that is not addressed by the Discharge Summary Note. The Transfer Summary Note must accompany the patient at the time of transfer to support patient safety and care decisions that must be immediately made at admission. In contrast, discharge summaries are often completed up to seven days after discharge and driven largely by billing and regulatory requirements. The content and timeliness of the Transfer Summary Note are essential for avoiding errors, providing appropriate care, and decreasing provider and patient burden; this note gives receiving providers immediate needed access to important patient information (e.g., C-CDA Transfer Summary required patient information), such as their clinical status, active problems, current medications, allergies, recent procedures, and ongoing treatment plans to safely assume care without interruption.

    Impact of transfer information in post-acute care (PAC): 

  • The distinction between the Transfer Summary Note and Discharge Summary Note is particularly important for PAC settings, where patients are frequently transferred between hospitals, skilled nursing facilities, inpatient rehabilitation facilities, long-term acute care hospitals, and home health agencies. In these transitions, the absence of a standardized, timely transfer summary can lead to medication errors, missed diagnoses, duplicative testing, and preventable readmissions. The Transfer Summary Note helps avoid these issues by helping bridge the information gap that exists between the point of transfer and the eventual availability of a complete discharge summary.

     

     

    Data Standard: The Transfer Summary Note data element is well represented by several established terminology and content standards.

  • LOINC provides “Transfer summary note” code (18761-7).
  • SNOMED CT provides a “Transfer summary report (record artifact)” code (371535009).

  • The HL7® C-CDA (Consolidated Clinical Document Architecture) includes a dedicated Transfer Summary document template, most recently published in C-CDA Edition 4 (on FHIR®).

     

    USCDI LEVELING CRITERIA:

    Current Standards: Level 2 – Transfer Summary Note is represented by multiple terminology standards and SDO-balloted technical specifications.

  • LOINC provides a “Transfer summary note” code (18761-7).
  • SNOMED CT provides a “Transfer summary report (record artifact)” code (371535009).
  • The C-CDA on FHIR Implementation Guide (STU 1, v.1.2) provides a FHIR-based Transfer Summary profile on the Composition resource, enabling interoperability between CDA and FHIR implementations. The Transfer Summary template defines required, recommended, and additional sections for structured clinical content exchange and uses the LOINC code 18761-7 for “Transfer Summary Note” as its required binding. C-CDA is one of the most widely implemented implementation guides for CDA and is used extensively for health information exchange across the United States.

  • The HL7 C-CDA v.2.0.0 (STU 2 Ballot) and C-CDA Edition 4 include a balloted Transfer Summary document template with defined required, recommended, and additional sections for structured clinical content.

    Current Use: Level 2 – Transfer Summary Note data are captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.

  • The C-CDA Transfer Summary template has been implemented in production EHR systems since its initial inclusion in C-CDA, supporting transitions of care documentation across healthcare organizations.
  • Epic Systems supports the creation, storage, and retrieval of C-CDA Documents through its FHIR R4 DocumentReference API. Epic’s publicly available FHIR APIs support interoperability with the comprehensive health record at clinics, hospitals, and health systems worldwide.

  • Oracle Health (Cerner) supports the ability to query document references, through its FHIR R4 APIs and Millennium platform. 

    Current Exchange: Level 2 – Transfer Summary Notes are electronically exchanged between production EHRs and HIT modules from different developers using available interoperability standards.

  • Epic includes “Transfer Summarization Note” as one type of document being stored within its EHI Export Specification regarding received documents.  
  • https://pointclickcare.com/wp-content/uploads/2024/09/PointClickCare-Solution-Sheet-SNF-Stay-Summary-Alert.pdfPointClickCare (PCC) Emergency Department IQ delivers a SNF Stay Summary from post-acute care into receiving ED workflows, including diagnoses, medications, code status, recent clinical context, and an AI-generated Reason for Transfer. PCC integrates with Epic and Oracle Health/Cerner via SMART on FHIR and uses cross-EHR data, demonstrating production exchange of information substantially similar to a Transfer Summary Note across post-acute and acute-care systems.
  • Health information exchange networks, including those participating in eHealth Exchange, routinely exchange C-CDA documents including Transfer Summaries. The eHealth Exchange supports the exchange of billions of CDA documents annually across participating organizations. 
  • The US Government supports use of C-CDA to facilitate health data exchange between different systems and providers, including C-CDA testing and support within its suite of ONC Certification tools. 

  • Oracle Health Clinical Data Exchange uses C-CDA documents to deliver clinical event information including admit and discharge messages.

    Breadth of Applicability: Level 2 – Use cases for Transfer Summary Note apply to most care settings.

  • Transfer Summary Notes are used when patients move between acute care hospitals, emergency departments, skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term acute care hospitals (LTACHs), home health agencies, as well as hospice, home-based care, ambulatory care settings, behavioral health facilities, and medical transport between settings. These transitions are among the most clinically significant events in a patient’s care journey, as they are particularly vulnerable time, which apply across virtually all care settings and specialties.
  • The CMS Discharge Planning Final Regulation and the CMS Interoperability and Patient Access Final Rule require that all of a patient’s necessary medical information, including post-discharge goals of care and treatment preferences, must be documented and transferred along with the patient at the time of discharge to an appropriate receiving healthcare facility. The Transfer Summary Note serves as the standardized vehicle for this information exchange.

* The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, which aims to advance interoperable health information exchange between post-acute care (PAC) providers, patients, and other key stakeholders across health care.

Submitted by ubackonja@mitre.org on

PACIO recommends advancing Transfer Summary Note to Level 2

Recommendation: Advance the Transfer Summary Note data element from Level 0 to Level 2.

 

Rationale: The PACIO Project Community* recommends advancing the Transfer Summary Note data element from Level 0 to Level 2. The Transfer Summary Note is a synopsis of a patient’s admission and clinical course in one setting that is generated to facilitate the patient being transferred to another setting. It is a foundational clinical document for ensuring safe, timely, and effective transitions of care between healthcare settings.

  • Distinct importance of Transfer Summary Note vs. Discharge Summary: The Transfer Summary Note serves a distinct and time-critical function that is not addressed by the Discharge Summary Note. Transfer Summary Note must accompany the patient at the time of transfer to support patient safety and care decisions that must be immediately made at admission. In contrast, discharge summaries are often completed up to seven days after discharge and driven largely by billing and regulatory requirements. The content and timeliness of the Transfer Summary Note is essential for avoiding errors, providing appropriate care, and decreasing provider and patient burden; this note gives receiving providers needed immediate access to important patient information (e.g., C-CDA Transfer Summaryrequired patient information), such as their clinical status, active problems, current medications, allergies, recent procedures, and ongoing treatment plans to safely assume care without interruption.

  • Impact of transfer information in post-acute care (PAC): The distinction between Transfer Summary Note and Discharge Summary Note is particularly important for PAC settings, where patients are frequently transferred between hospitals, skilled nursing facilities, inpatient rehabilitation facilities, long-term acute care hospitals, and home health agencies. In these transitions, the absence of a standardized, timely transfer summary can lead to medication errors, missed diagnoses, duplicative testing, and preventable readmissions. The Transfer Summary Note helps avoid these issues by helping bridge the information gap that exists between the point of transfer and the eventual availability of a complete discharge summary.

     

    Data Standard: The Transfer Summary Note data element is well represented by several established terminology and content standards.

  • LOINC provides “Transfer summary note” code (18761-7).
  • SNOMED-CT provides a “Transfer summary report (record artifact)” code (371535009).

  • The HL7® C-CDA (Consolidated Clinical Document Architecture) includes a dedicated Transfer Summary document template, most recently published in C-CDA Edition 4 (on FHIR®). 

     

    USCDI Level Criteria

     

    Current Standards: Level 2 – Transfer Summary Note is represented by multiple terminology standards and SDO-balloted technical specifications.

  • LOINC provides a “Transfer summary note” code (18761-7).
  • SNOMED-CT provides a “Transfer summary report (record artifact)” code (371535009).
  • The C-CDA on FHIR Implementation Guide (STU 1, v.1.2) provides a FHIR-based Transfer Summary profile on the Composition resource, enabling interoperability between CDA and FHIR implementations. The Transfer Summary template defines required, recommended, and additional sections for structured clinical content exchange and uses the document type code LOINC code 18761-7 for “Transfer Summary Note” as its required binding. C-CDA is one of the most widely implemented implementation guides for CDA and is used extensively for health information exchange across the United States.

  • The HL7 C-CDA v.2.0.0 (STU 2 Ballot) and C-CDA Edition 4 include a balloted Transfer Summary document template with defined required, recommended, and additional sections for structured clinical content.

     

    Current Use: Level 2 – Transfer Summary Note data are captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.

  • The C-CDA Transfer Summary template has been implemented in production EHR systems since its initial inclusion in C-CDA, supporting transitions of care documentation across healthcare organizations.
  • Epic Systems supports the creation, storage, and retrieval of CCDA Documents through its FHIR R4 DocumentReference API. Epic’s publicly available FHIR APIs support interoperability with the comprehensive health record at clinics, hospitals, and health systems worldwide.

  • Oracle Health (Cerner) supports operation for querying document references, through its FHIR R4 APIs and Millennium platform.

     

    Current Exchange: Level 2 – Transfer Summary Notes are electronically exchanged between production EHRs and HIT modules of different developers using available interoperability standards.

  • Health information exchange networks, including those participating in eHealth Exchange, routinely exchange C-CDA documents including Transfer Summaries. The eHealth Exchange supports the exchange of billions of CDA documents annually across participating organizations.
  • The US Government supports use of C-CDA to support health data exchange between different systems and providers, including C-CDA testing and support within its suite of ONC Certification tools. 

  • Oracle Health Clinical Data Exchange uses C-CDA documents to deliver clinical event information including admit and discharge messages.

     

    Breadth of Applicability: Level 2 – Use cases for Transfer Summary Note apply to most care settings.

  • Transfer Summary Notes are used when patients move between acute care hospitals, emergency departments, skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term acute care hospitals (LTACHs), home health agencies, as well as hospice, home-based care, ambulatory care settings, behavioral health facilities, and medical transport between settings. These transitions are among the most clinically significant events in a patient’s care journey, as it is a particularly vulnerable time, that apply across virtually all care settings and specialties.
  • The CMS Discharge Planning Final Regulation and the CMS Interoperability and Patient Access Final Rule require that all of a patient’s necessary medical information, including post-discharge goals of care and treatment preferences, must be documented and transferred along with the patient at the time of discharge to an appropriate receiving healthcare facility. The Transfer Summary Note serves as the standardized vehicle for this information exchange.

 

* The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, that aims to advance interoperable health information exchange between post-acute care (PAC) providers, patients, and other key stakeholders across health care.

Submitted by Katherine.Lusk… on

Transfer Summary Note Content Recommendations

1.Transfer Reason – Course of care

2.Medications, last dose and schedule

3.Allergies

4.Admission Diagnosis

5.Discharge Diagnosis

6.Procedures:  including Interventional Radiology, Cardiac Cath, operative procedures

7.Diagnostic Imaging – Advanced imaging for example:  MRI, CT, PET, Nuclear Imaging, Ultrasound, Echo, & Venous Doppler

8.Laboratory – Recommend 1st and last laboratory result for every test.  On those rare tests – they are only done once so would be included (ANA Rheumatoid)

9.Consultations

10.Assessment 

11.Active Problem List

Submitted by Katherine.Lusk… on

Behavioral Health Transitions of Care

The following elements should be included:  

·Medications given and discharged on

·History & Physical

·Discharge Summary

·Test and studies that are pending

·Basic labs (hemoglobin)

·When is the next appointment

·Who is going to follow up with them – PCP or psychiatrist

·Education on Medication and Diagnoses

·Safety plan & crisis number

·Psychiatrist Evaluation

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