DSTU2 FHIR Release 3 (STU)

This page is part of the FHIR Specification (v1.0.2: DSTU (v3.0.2: STU 2). 3). 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 R3 R2

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

Detailed Descriptions for the elements in the Encounter resource.

To Do Need a harmonization proposal for this.
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 | arrived | triaged | in-progress | onleave | finished | cancelled. cancelled +.

Control 1..1
Terminology Binding EncounterState: Current state of the encounter EncounterStatus ( Required )
Type code
Is Modifier true
Summary true
Comments

Note that internal business rules will detemine the appropraite 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
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

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

Control 1..1
Terminology Binding EncounterState: Current state of the encounter EncounterStatus ( Required )
Type code
Encounter.statusHistory.period
Definition

The time that the episode was in the specified status.

Control 1..1
Type Period
Encounter.class
Definition

inpatient | outpatient | ambulatory | emergency +.

Control 0..1
Terminology Binding EncounterClass: Classification of the encounter ActEncounterCode ( Required Extensible )
Type code Coding
Summary true
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 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 discharge from emergency to inpatient.

Control 0..*
Encounter.classHistory.class
Definition

inpatient | outpatient | ambulatory | emergency +.

Control 1..1
Terminology Binding ActEncounterCode ( Extensible )
Type Coding
Encounter.classHistory.period
Definition

The time that the episode was in the specified class.

Control 1..1
Type Period
Encounter.type
Definition

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

Control 0..*
Terminology Binding EncounterType: The type of encounter EncounterType ( Example )
Type CodeableConcept
Summary true
Comments

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

Encounter.priority
Definition

Indicates the urgency of the encounter.

Control 0..1
Terminology Binding Encounter Priority: Indicates the urgency of the encounter. v3 Code System ActPriority ( Example )
Type CodeableConcept
Encounter.patient Encounter.subject
Definition

The patient ro group present at the encounter.

Control 0..1
Type Reference ( Patient | Group )
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. 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
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 referral request this encounter satisfies (incoming referral).

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

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

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

Role of participant in encounter.

Control 0..*
Terminology Binding ParticipantType: Role of participant in encounter ParticipantType ( 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.period
Definition

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

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

Persons involved in the encounter other than the patient.

Control 0..1
Type Reference ( Practitioner | RelatedPerson )
Summary true
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..*
Terminology Binding Encounter Reason Codes: Encounter Reason why the encounter takes place. Codes ( Example 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.indication Encounter.diagnosis
Definition

The list of diagnosis relevant to this encounter.

Control 0..*
Summary true
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 0..* 1..1
Type Reference ( Condition | Procedure )
Alternate Names Admission diagnosis diagnosis; discharge diagnosis; indication
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
Definition

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

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

Ranking of the diagnosis (for each role type).

Control 0..1
Type positiveInt
Encounter.account
Definition

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

Control 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
Definition

Details about the admission to a 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 Reference ( Location )
Encounter.hospitalization.admitSource
Definition

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

Control 0..1
Terminology Binding AdmitSource: From where the patient was admitted. AdmitSource ( Preferred )
Type CodeableConcept
Encounter.hospitalization.admittingDiagnosis Definition The admitting diagnosis field is used to record the 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..* Type Reference ( Condition ) Encounter.hospitalization.reAdmission
Definition

Whether this hospitalization is a readmission and why if known.

Control 0..1
Terminology Binding ReAdmissionType : The reason for re-admission of this hospitalization encounter. v2 Re-Admission Indicator ( Example )
Type CodeableConcept
Encounter.hospitalization.dietPreference
Definition

Diet preferences reported by the patient.

Control 0..*
Terminology Binding Diet: Medical, cultural or ethical food preferences to help with catering requirements. 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 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..*
Terminology Binding SpecialCourtesy: Special courtesies SpecialCourtesy ( Preferred )
Type CodeableConcept
Encounter.hospitalization.specialArrangement
Definition

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

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

Location to which the patient is discharged.

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

Category or kind of location after discharge.

Control 0..1
Terminology Binding DischargeDisposition: Discharge Disposition DischargeDisposition ( Preferred Example )
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..* Type Reference ( Condition ) Encounter.location
Definition

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

Control 0..*
Comments

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

Encounter.location.location
Definition

The location where the encounter takes place.

Control 1..1
Type Reference ( Location )
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 0..1
Terminology Binding EncounterLocationStatus: The status of the location. 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.period
Definition

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

Control 0..1
Type Period
Encounter.serviceProvider
Definition

An organization that is in charge of maintaining the information of this Encounter (e.g. who maintains the report or 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 Reference ( Organization )
Encounter.partOf
Definition

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

Control 0..1
Type Reference ( Encounter )
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.