DSTU2

This page is part of the FHIR Specification (v0.0.82: (v1.0.2: DSTU 1). 2). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

5.9.8 5.18.8 Resource Encounter - Formal Definitions Detailed Descriptions

Formal definitions Detailed Descriptions for the elements in the Encounter resource.

Aliases Aliases Aliases Encounter.priority Type Encounter.hospitalization.accomodation.bed Type
Encounter
Definition

An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

Control 1..1
Alternate Names Visit
Encounter.identifier
Definition

Identifier(s) by which this encounter is known.

Note This is a business identifer, not a resource identifier (see discussion )
Control 0..*
Type Identifier
Summary true
Encounter.status
Definition

planned | in progress arrived | in-progress | onleave | finished | cancelled.

Control 1..1
Binding EncounterState: Current state of the encounter (see http://hl7.org/fhir/encounter-state for values) ( Required )
Type code
Is Modifier true
Summary true
Encounter.class Encounter.statusHistory
Definition

The status history permits the encounter resource to contain the status history without needing to read through the historical versions of the resource, or even have the server store them.

Control 0..*
Comments

The current status is always found in the current version of the resource, not the status history.

Encounter.statusHistory.status
Definition inpatient

planned | outpatient arrived | ambulatory in-progress | emergency +. onleave | finished | cancelled.

Control 1..1
Binding EncounterClass: Classification EncounterState: Current state of the encounter (see http://hl7.org/fhir/encounter-class for values) ( Required )
Type code
Encounter.statusHistory.period
Definition Is Modifier

The time that the episode was in the specified status.

Control true 1..1
Type Period
Encounter.class
Definition

inpatient | outpatient | ambulatory | emergency +.

Control 0..1
Binding EncounterClass: Classification of the encounter ( Required )
Type code
Summary true
Encounter.type
Definition

Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation).

Control 0..*
Binding EncounterType: A specific code indicating The type of service provided encounter ( See http://hl7.org/fhir/vs/encounter-type Example )
Type CodeableConcept
Summary true
Comments

Since there are many ways to further classify encounters, this element is 0..*.

Encounter.subject Encounter.priority
Definition

Indicates the urgency of the encounter.

Control 0..1
Binding Encounter Priority: Indicates the urgency of the encounter. ( Example )
Type CodeableConcept
Encounter.patient
Definition

The patient present at the encounter.

Control 0..1
Type Resource Reference ( Patient )
Alternate Names patient
Summary true
Comments

While the encounter is always about the patient, the patient may not actually be known in all contexts of use.

Encounter.participant Encounter.episodeOfCare
Definition

Where a specific encounter should be classified as a part of a specific episode(s) of care this field should be used. This association can facilitate grouping of related encounters together for a specific purpose, such as government reporting, issue tracking, association via a common problem. The association is recorded on the encounter as these are typically created after the episode of care, and grouped on entry rather than editing the episode of care to append another encounter to it (the episode of care could span years).

Control 0..*
Type Reference ( EpisodeOfCare )
Summary true
Encounter.incomingReferral
Definition

The main practitioner responsible referral request this encounter satisfies (incoming referral).

Control 0..*
Type Reference ( ReferralRequest )
Encounter.participant
Definition

The list of people responsible for providing the service.

Control 0..*
Summary true
Encounter.participant.type
Definition

Role of participant in encounter.

Control 0..*
Binding ParticipantType: ( See http://hl7.org/fhir/vs/encounter-participant-type Role of participant in encounter ( Extensible )
Type CodeableConcept
Summary true
Comments

The participant type indicates how an individual partitipates in an encounter. It includes non-practitioner participants, and for practitioners this is to describe the action type in the context of this encounter (e.g. Admitting Dr, Attending Dr, Translator, Consulting Dr). This is different to the practitioner roles which are functional roles, derived from terms of employment, education, licensing, etc.

Encounter.participant.individual Encounter.participant.period
Definition

The period of time that the specified participant was present during the encounter. These can overlap or be sub-sets of the overall encounters period.

Control 0..1
Type Period
Encounter.participant.individual
Definition

Persons involved in the encounter other than the patient.

Control 0..1
Type Resource Reference ( Practitioner | RelatedPerson )
Summary true
Encounter.period Encounter.appointment
Definition

The appointment that scheduled this encounter.

Control 0..1
Type Reference ( Appointment )
Summary true
Encounter.period
Definition

The start and end time of the encounter.

Control 0..1
Type Period
Comments

If not (yet) known, the end of the Period may be omitted.

Encounter.length
Definition

Quantity of time the encounter lasted. This excludes the time during leaves of absence.

Control 0..1
Type Duration
Comments

May differ from the time the Encounter.period lasted because of leave of absence.

Encounter.reason
Definition

Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis.

Control 0..1 0..*
Binding EncounterReason: ( Encounter Reason Codes: See http://hl7.org/fhir/vs/encounter-reason Reason why the encounter takes place. ( Example )
Type CodeableConcept
Alternate Names Indication; Admission diagnosis
Summary true
Comments

For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).

Encounter.indication
Definition

Reason the encounter takes place, as specified using information from another resource. For admissions, this is the admission diagnosis. The indication will typically be a Condition (with other resources referenced in the evidence.detail), or a Procedure.

Control 0..1 0..*
Type Resource Reference ( Any Condition | Procedure )
Alternate Names Admission diagnosis
Definition Comments Indicates

For systems that need to know which was the urgency of primary diagnosis, these will be marked with the encounter. Control 0..1 Binding Priority: ( See http://hl7.org/fhir/vs/encounter-priority ) standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).

CodeableConcept Encounter.hospitalization
Definition

Details about an the admission to a clinic. healthcare service.

Control 0..1
Comments

An Encounter may cover more than just the inpatient stay. Contexts such as outpatients, community clinics, and aged care facilities are also included.

The duration recorded in the period of this encounter covers the entire scope of this hospitalization record.

Encounter.hospitalization.preAdmissionIdentifier
Definition

Pre-admission identifier.

Control 0..1
Type Identifier
Encounter.hospitalization.origin
Definition

The location from which the patient came before admission.

Control 0..1
Type Resource Reference ( Location )
Encounter.hospitalization.admitSource
Definition

From where patient was admitted (physician referral, transfer).

Control 0..1
Binding AdmitSource: ( See http://hl7.org/fhir/vs/encounter-admit-source From where the patient was admitted. ( Preferred )
Type CodeableConcept
Encounter.hospitalization.period Encounter.hospitalization.admittingDiagnosis
Definition Period during which

The admitting diagnosis field is used to record the patient was admitted. diagnosis codes as reported by admitting practitioner. This could be different or in addition to the conditions reported as reason-condition(s) for the encounter.

Control 0..1 0..*
Type Period Reference Comments May differ from start + length, since length excludes leaves of absence. ( Condition )
Encounter.hospitalization.accomodation Encounter.hospitalization.reAdmission
Definition Where the patient stays during

Whether this encounter. hospitalization is a readmission and why if known.

Control 0..* 0..1
Binding Definition ReAdmissionType : The bed that is assigned to the patient. Control 0..1 reason for re-admission of this hospitalization encounter.
Type Resource ( Location ) Encounter.hospitalization.accomodation.period CodeableConcept
Definition Period during which the patient was assigned the bed. Control To Do 0..1 Need a harmonization proposal for this.
Period Encounter.hospitalization.diet Encounter.hospitalization.dietPreference
Definition Dietary restrictions for

Diet preferences reported by the patient.

Control 0..1 0..*
Binding PatientDiet: ( Diet: See http://hl7.org/fhir/vs/encounter-diet Medical, cultural or ethical food preferences to help with catering requirements. ( Example )
Type CodeableConcept
Requirements Track patients reported dietary

Used to track patient's diet restrictions and/or preference. For a complete description of the nutrition needs of a patient during their stay, one should use the nutritionOrder resource which links to help with catering requirements. Encounter.

Comments

For example a patient may request both a dairy-free and nut-free diet preference (not mutually exclusive).

Encounter.hospitalization.specialCourtesy
Definition

Special courtesies (VIP, board member).

Control 0..*
Binding Courtesies: ( SpecialCourtesy: See http://hl7.org/fhir/vs/encounter-special-courtesy Special courtesies ( Preferred )
Type CodeableConcept
Encounter.hospitalization.specialArrangement
Definition

Wheelchair, translator, stretcher, etc.

Control 0..*
Binding Arrangements: ( SpecialArrangements: See http://hl7.org/fhir/vs/encounter-special-arrangements Special arrangements ( Preferred )
Type CodeableConcept
Encounter.hospitalization.destination
Definition

Location to which the patient is discharged.

Control 0..1
Type Resource Reference ( Location )
Encounter.hospitalization.dischargeDisposition
Definition

Category or kind of location after discharge.

Control 0..1
Binding DischargeDisp: ( DischargeDisposition: See http://hl7.org/fhir/vs/encounter-discharge-disposition Discharge Disposition ( Preferred )
Type CodeableConcept
Encounter.hospitalization.dischargeDiagnosis
Definition

The final diagnosis given a patient before release from the hospital after all testing, surgery, and workup are complete.

Control 0..1 0..*
Type Resource Reference ( Any Condition )
Encounter.hospitalization.reAdmission Encounter.location
Definition Whether

List of locations where the patient has been during this hospitalization is a readmission. encounter.

Control 0..1 0..*
Type boolean Comments To Do Need

Virtual encounters can be recorded in the Encounter by specifying a harmonization proposal for this. location reference to a location of type "kind" such as "client's home" and an encounter.class = "virtual".

Encounter.location Encounter.location.location
Definition List of locations at which

The location where the patient has been. encounter takes place.

Control 0..* 1..1
Type Reference ( Location )
Encounter.location.location Encounter.location.status
Definition

The status of the participants' presence at the specified location where during the encounter takes place. period specified. If the participant is is no longer at the location, then the period will have an end date/time.

Control 1..1 0..1
Type Binding Resource EncounterLocationStatus: The status of the location. ( Location Required )
Type code
Comments

When the patient is no longer active at a location, then the period end date is entered, and the status may be changed to completed.

Encounter.location.period
Definition

Time period during which the patient was present at the location.

Control 1..1 0..1
Type Period
Encounter.serviceProvider
Definition Department

An organization that is in charge of maintaining the information of this Encounter (e.g. who maintains the report or team providing care. the master service catalog item, etc.). This MAY be the same as the organization on the Patient record, however it could be different. This MAY not be not the Service Delivery Location's Organization.

Control 0..1
Type Resource Reference ( Organization )
Encounter.partOf
Definition

Another Encounter of which this encounter is a part of (administratively or in time).

Control 0..1
Type Resource Reference ( Encounter )
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