FHIR Release 3 (STU) 4

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Patient Administration Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Encounter , Patient , Practitioner , RelatedPerson

Detailed Descriptions for the elements in the Encounter resource.

Encounter
Element Id 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 Cardinality 1..1 0..*
Type DomainResource
Alternate Names Visit
Encounter.identifier
Element Id Encounter.identifier
Definition

Identifier(s) by which this encounter is known.

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

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

Control Cardinality 1..1
Terminology Binding EncounterStatus ( Required )
Type code
Is Modifier true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summary true
Comments

Note that internal business rules will detemine determine the appropraite appropriate transitions that may occur between statuses (and also classes).

This element is labeled as a modifier because the status contains codes that mark the encounter as not currently valid.
Encounter.statusHistory
Element Id 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 Cardinality 0..*
Comments

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

Encounter.statusHistory.status
Element Id Encounter.statusHistory.status
Definition

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

Control Cardinality 1..1
Terminology Binding EncounterStatus ( Required )
Type code
Encounter.statusHistory.period
Element Id Encounter.statusHistory.period
Definition

The time that the episode was in the specified status.

Control Cardinality 1..1
Type Period
Encounter.class
Element Id Encounter.class
Definition

inpatient | outpatient | Concepts representing classification of patient encounter such as ambulatory | emergency +. (outpatient), inpatient, emergency, home health or others due to local variations.

Control Cardinality 0..1 1..1
Terminology Binding ActEncounterCode V3 Value SetActEncounterCode ( Extensible )
Type Coding
Summary true
Encounter.classHistory
Element Id Encounter.classHistory
Definition

The class history permits the tracking of the encounters transitions without needing to go through the resource history. This would be used for a case where an admission starts of as an emergency encounter, then transisions transitions into an inpatient scenario. Doing this and not restarting a new encounter ensures that any lab/diagnostic results can more easily follow the patient and not require re-processing and not get lost or cancelled during a kindof kind of discharge from emergency to inpatient.

Control Cardinality 0..*
Encounter.classHistory.class
Element Id Encounter.classHistory.class
Definition

inpatient | outpatient | ambulatory | emergency +.

Control Cardinality 1..1
Terminology Binding ActEncounterCode V3 Value SetActEncounterCode ( Extensible )
Type Coding
Encounter.classHistory.period
Element Id Encounter.classHistory.period
Definition

The time that the episode was in the specified class.

Control Cardinality 1..1
Type Period
Encounter.type
Element Id Encounter.type
Definition

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

Control Cardinality 0..*
Terminology Binding EncounterType Encounter type ( Example )
Type CodeableConcept
Summary true
Comments

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

Encounter.serviceType
Element Id Encounter.serviceType
Definition

Broad categorization of the service that is to be provided (e.g. cardiology).

Cardinality 0..1
Terminology Binding Service type ( Example )
Type CodeableConcept
Summary true
Encounter.priority
Element Id Encounter.priority
Definition

Indicates the urgency of the encounter.

Control Cardinality 0..1
Terminology Binding v3 Code System ActPriority ( Example )
Type CodeableConcept
Encounter.subject
Element Id Encounter.subject
Definition

The patient ro or group present at the encounter.

Control Cardinality 0..1
Type Reference ( Patient | Group )
Alternate Names patient
Summary true
Comments

While the encounter is always about the patient, the patient may might not actually be known in all contexts of use, and there may be a group of patients that could be anonymous (such as in a group therapy for Alcoholics Anonymous - where the recording of the encounter could be used for billing on the number of people/staff and not important to the context of the specific patients) or alternately in veterinary care a herd of sheep receiving treatment (where the animals are not individually tracked).

Encounter.episodeOfCare
Element Id 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, 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 Cardinality 0..*
Type Reference ( EpisodeOfCare )
Summary true
Encounter.incomingReferral Encounter.basedOn
Element Id Encounter.basedOn
Definition

The referral request this encounter satisfies (incoming referral). (e.g. incoming referral or procedure request).

Control Cardinality 0..*
Type Reference ( ReferralRequest ServiceRequest )
Alternate Names incomingReferral
Encounter.participant
Element Id Encounter.participant
Definition

The list of people responsible The list of people responsible for providing the service.

Control Cardinality 0..*
Summary true
Encounter.participant.type
Element Id Encounter.participant.type
Definition

Role of participant in encounter.

Control Cardinality 0..*
Terminology Binding ParticipantType Participant type ( Extensible )
Type CodeableConcept
Summary true
Comments

The participant type indicates how an individual partitipates participates 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.period
Element Id Encounter.participant.period
Definition

The period of time that the specified participant participated in the encounter. These can overlap or be sub-sets of the overall encounter's period.

Control Cardinality 0..1
Type Period
Encounter.participant.individual
Element Id Encounter.participant.individual
Definition

Persons involved in the encounter other than the patient.

Control Cardinality 0..1
Type Reference ( Practitioner | PractitionerRole | RelatedPerson )
Summary true
Encounter.appointment
Element Id Encounter.appointment
Definition

The appointment that scheduled this encounter.

Control Cardinality 0..1 0..*
Type Reference ( Appointment )
Summary true
Encounter.period
Element Id Encounter.period
Definition

The start and end time of the encounter.

Control Cardinality 0..1
Type Period
Comments

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

Encounter.length
Element Id Encounter.length
Definition

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

Control Cardinality 0..1
Type Duration
Comments

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

Encounter.reason Encounter.reasonCode
Element Id Encounter.reasonCode
Definition

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

Control Cardinality 0..*
Terminology Binding Encounter Reason Codes ( Preferred )
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.reasonReference
Element Id Encounter.reasonReference
Definition

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

Cardinality 0..*
Type Reference ( Condition | Procedure | Observation | ImmunizationRecommendation )
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.diagnosis
Element Id Encounter.diagnosis
Definition

The list of diagnosis relevant to this encounter.

Control Cardinality 0..*
Summary true
Encounter.diagnosis.condition
Element Id Encounter.diagnosis.condition
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 Cardinality 1..1
Type Reference ( Condition | Procedure )
Alternate Names Admission diagnosis; discharge diagnosis; indication
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.diagnosis.role Encounter.diagnosis.use
Element Id Encounter.diagnosis.use
Definition

Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …).

Control Cardinality 0..1
Terminology Binding DiagnosisRole ( Preferred )
Type CodeableConcept
Encounter.diagnosis.rank
Element Id Encounter.diagnosis.rank
Definition

Ranking of the diagnosis (for each role type).

Control Cardinality 0..1
Type positiveInt
Encounter.account
Element Id Encounter.account
Definition

The set of accounts that may be used for billing for this Encounter.

Control Cardinality 0..*
Type Reference ( Account )
Comments

The billing system may choose to allocate billable items associated with the Encounter to different referenced Accounts based on internal business rules.

Encounter.hospitalization
Element Id Encounter.hospitalization
Definition

Details about the admission to a healthcare service.

Control Cardinality 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
Element Id Encounter.hospitalization.preAdmissionIdentifier
Definition

Pre-admission identifier.

Control Cardinality 0..1
Type Identifier
Encounter.hospitalization.origin
Element Id Encounter.hospitalization.origin
Definition

The location location/organization from which the patient came before admission.

Control Cardinality 0..1
Type Reference ( Location | Organization )
Encounter.hospitalization.admitSource
Element Id Encounter.hospitalization.admitSource
Definition

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

Control Cardinality 0..1
Terminology Binding AdmitSource Admit source ( Preferred )
Type CodeableConcept
Encounter.hospitalization.reAdmission
Element Id Encounter.hospitalization.reAdmission
Definition

Whether this hospitalization is a readmission and why if known.

Control Cardinality 0..1
Terminology Binding v2 Re-Admission Indicator RE-ADMISSION INDICATOR ( Example )
Type CodeableConcept
Encounter.hospitalization.dietPreference
Element Id Encounter.hospitalization.dietPreference
Definition

Diet preferences reported by the patient.

Control Cardinality 0..*
Terminology Binding Diet ( Example )
Type CodeableConcept
Requirements

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 Encounter.

Comments

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

Encounter.hospitalization.specialCourtesy
Element Id Encounter.hospitalization.specialCourtesy
Definition

Special courtesies (VIP, board member).

Control Cardinality 0..*
Terminology Binding SpecialCourtesy Special courtesy ( Preferred )
Type CodeableConcept
Encounter.hospitalization.specialArrangement
Element Id Encounter.hospitalization.specialArrangement
Definition

Any special requests that have been made for this hospitalization encounter, such as the provision of specific equipment or other things.

Control Cardinality 0..*
Terminology Binding SpecialArrangements Special arrangements ( Preferred )
Type CodeableConcept
Encounter.hospitalization.destination
Element Id Encounter.hospitalization.destination
Definition

Location Location/organization to which the patient is discharged.

Control Cardinality 0..1
Type Reference ( Location | Organization )
Encounter.hospitalization.dischargeDisposition
Element Id Encounter.hospitalization.dischargeDisposition
Definition

Category or kind of location after discharge.

Control Cardinality 0..1
Terminology Binding DischargeDisposition Discharge disposition ( Example )
Type CodeableConcept
Encounter.location
Element Id Encounter.location
Definition

List of locations where the patient has been during this encounter.

Control Cardinality 0..*
Comments

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

Encounter.location.location
Element Id Encounter.location.location
Definition

The location where the encounter takes place.

Control Cardinality 1..1
Type Reference ( Location )
Encounter.location.status
Element Id Encounter.location.status
Definition

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

Control Cardinality 0..1
Terminology Binding EncounterLocationStatus ( 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.physicalType
Element Id Encounter.location.physicalType
Definition

This will be used to specify the required levels (bed/ward/room/etc.) desired to be recorded to simplify either messaging or query.

Cardinality 0..1
Terminology Binding Location type ( Example )
Type CodeableConcept
Comments

This information is de-normalized from the Location resource to support the easier understanding of the encounter resource and processing in messaging or query.

There may be many levels in the hierachy, and this may only pic specific levels that are required for a specific usage scenario.

Encounter.location.period
Element Id Encounter.location.period
Definition

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

Control Cardinality 0..1
Type Period
Encounter.serviceProvider
Element Id Encounter.serviceProvider
Definition

An The organization that is in charge of maintaining the information of primarily responsible for this Encounter (e.g. who maintains the report or the master service catalog item, etc.). Encounter's services. This MAY be the same as the organization on the Patient record, however it could be different. This MAY not different, such as if the actor performing the services was from an external organization (which may be not billed seperately) for an external consultation. Refer to the Service Delivery Location's Organization. example bundle showing an abbreviated set of Encounters for a colonoscopy.

Control Cardinality 0..1
Type Reference ( Organization )
Encounter.partOf
Element Id Encounter.partOf
Definition

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

Control Cardinality 0..1
Type Reference ( Encounter )
Hierarchy This reference is part of a strict Hierarchy
Comments

This is also used for associating a child's encounter back to the mother's encounter.

Refer to the Notes section in the Patient resource for further details.