Clinical discharge summary document profile
Index source-stated episode summaries.
The Clinical discharge summary profile helps you index source-stated episode summaries. It belongs to the research and health family.
Recognize the source
Episode discharge narrative, not generic progress note or new clinical advice. Keep identity references minimal.
Review the document itself before applying the profile. Similar labels, dates, parties, or amounts can appear in another document type with a different meaning. Use the source context to distinguish them.
Expected fields
Core fields form the profile’s main structure. Recommended and optional fields add supported detail. None of these designations permits guessing a value that is absent or ambiguous.
| Field | Type | Inclusion | Meaning and extraction rule |
|---|---|---|---|
| Patient reference | text | Core | The source-stated patient reference for this document and its identified subject. Copy exact source spans for this one scalar field, preserving their order, ownership and qualifications. Ordered spans may continue across segments. Do not synthesize a summary or combine unrelated fields or repeated records; return unresolved when the scalar meaning is ambiguous. |
| Care provider | text | Core | The source-stated care provider for this document and its identified subject. Copy exact source spans for this one scalar field, preserving their order, ownership and qualifications. Ordered spans may continue across segments. Do not synthesize a summary or combine unrelated fields or repeated records; return unresolved when the scalar meaning is ambiguous. |
| Admission date | date | Core | The source-stated admission date for this document and its identified subject. Normalize an explicitly stated date only when unambiguous. Do not infer missing day, month, year or timezone. |
| Discharge date | date | Core | The source-stated discharge date for this document and its identified subject. Normalize an explicitly stated date only when unambiguous. Do not infer missing day, month, year or timezone. |
| Documented diagnoses excerpt | text | Core | The source-stated documented diagnoses excerpt for this document and its identified subject. Copy exact source spans for this one scalar field, preserving their order, ownership and qualifications. Ordered spans may continue across segments. Do not synthesize a summary or combine unrelated fields or repeated records; return unresolved when the scalar meaning is ambiguous. |
| Treatment excerpt | text | Optional | The source-stated treatment excerpt for this document and its identified subject. Copy exact source spans for this one scalar field, preserving their order, ownership and qualifications. Ordered spans may continue across segments. Do not synthesize a summary or combine unrelated fields or repeated records; return unresolved when the scalar meaning is ambiguous. |
| Follow up stated | text | Optional | The source-stated follow up stated for this document and its identified subject. Copy exact source spans for this one scalar field, preserving their order, ownership and qualifications. Ordered spans may continue across segments. Do not synthesize a summary or combine unrelated fields or repeated records; return unresolved when the scalar meaning is ambiguous. |
| Discharge destination | text | Optional | The source-stated discharge destination for this document and its identified subject. Copy exact source spans for this one scalar field, preserving their order, ownership and qualifications. Ordered spans may continue across segments. Do not synthesize a summary or combine unrelated fields or repeated records; return unresolved when the scalar meaning is ambiguous. |
Missing, ambiguous, and repeated values
Missing or ambiguous fields remain null with a reason. Null is not zero, false, an empty statement, or proof that a document-wide fact does not exist. Inspect unresolved states and their supporting passages before accepting the table. This document type can contain repeated records such as medications, diagnoses and follow-up actions. The profile uses one row per document; do not compress repeated records into a scalar field or confuse a line value with a document-level total. Additional supported fields can be considered when the extraction experience allows them. Review their definitions and types explicitly; changing a field’s meaning requires a new extraction preview.
Review the result
Select evidence-backed cells and read the retained source. Text should preserve the relevant source spans and qualifications. Numbers and dates must be stated unambiguously and normalized safely; do not calculate unstated values or infer missing units, currency, scale, date parts, or time zones.
Verify the result against the captured document before acceptance. Source support does not independently establish perfect OCR, exhaustive field discovery, or correct domain interpretation.
See profile modes, table review, and captured evidence.