Encounter resource implementation guidance
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Encounter: Implementation Guidance
Usage
The Encounter resource is used to carry information arising from 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.
In the scope of this implementation guide, an encounter occurs for the duration of a patient’s interaction with a single service provider.
The Encounter resource uses the CareConnect Encounter profile.
Detailed implementation guidance for an Encounter resource in the context of an $evaluate interaction is given below:
| Name | Cardinality | Type | FHIR Documentation | CDS Implementation Guidance |
|---|---|---|---|---|
id |
0..1 |
id | Logical id of this artifact | |
meta |
0..1 |
Meta | Metadata about the resource | |
implicitRules |
0..1 |
uri | A set of rules under which this content was created | |
language |
0..1 |
code | Language of the resource content. (Common Languages (Extensible but limited to All Languages) |
|
text |
0..1 |
Narrative | Text summary of the resource, for human interpretation | |
contained |
0..* |
Resource | Contained, inline Resources | |
extension (encounterTransport) |
0..1 |
Extension | An extension to the Encounter resource to include the Transport used by the subject for an encounter. | |
extension (outcomeOfAttendance) |
0..1 |
Extension | An extension to the Encounter resource to record the outcome of an Out-Patient attendance. | |
extension (emergencyCareDischargeStatus) |
0..1 |
Extension | An extension to the Encounter resource which is used indicate the status of the Patient on discharge from an Emergency Care Department. | |
modifierExtension |
0..* |
Extension | Extensions that cannot be ignored | |
identifier |
0..* |
Identifier | Identifier(s) by which this encounter is known | Business identifier for the Encounter, assigned by the EMS. |
status |
1..1 |
code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + EncounterStatus (Required). | |
statusHistory |
0..* |
BackboneElement | List of past encounter statuses | To be populated when the status changes |
status |
1..1 |
code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + EncounterStatus (Required) | |
period |
1..1 |
Period | The time that the episode was in the specified status | |
class |
0..1 |
Coding | inpatient | outpatient | ambulatory | emergency + ActEncounterCode (Extensible) | This MUST NOT be populated. |
classHistory |
0..* |
BackboneElement | List of past encounter classes | This MUST NOT be populated |
type |
0..* |
CodeableConcept | Specific type of encounter EncounterType (Example) | This SHOULD be populated. |
priority |
0..1 |
CodeableConcept | Indicates the urgency of the encounter v3 Code System ActPriority (Example) | This MUST NOT be populated. |
subject |
0..1 |
Reference (Patient | Group) |
The patient or group present at the encounter | This MUST be populated with a reference to the Patient resource. |
episodeOfCare |
0..* |
Reference (EpisodeOfCare) |
Episode(s) of care that this encounter should be recorded against | If this is a continuation of a prior episode, this Encounter MUST reference that episode.
If not a continuation, this MUST be populated with a new episode. |
incomingReferral |
0..* |
Reference (ReferralRequest) |
The ReferralRequest that initiated this encounter | This SHOULD be populated where this is a continuation of a patient journey from a different provider. |
participant |
0..* |
BackboneElement | List of participants involved in the encounter | This SHOULD be populated with the details of the EMS system users (Practitioner) during this Encounter,
and any third parties answering questions on behalf of the patient. (RelatedPerson). Note that the patient is NOT an appropriate participant, as the element should only record third-parties paticipating in the encounter. |
type |
0..* |
CodeableConcept | Role of participant in encounter ParticipantType (Extensible) | |
period |
0..1 |
Period | Period of time during the encounter that the participant participated | |
individual |
0..1 |
Reference (Practitioner | RelatedPerson) |
Persons involved in the encounter other than the patient | |
appointment |
0..1 |
Reference (UEC Appointment) |
The appointment that scheduled this encounter | This MAY be populated, but is not expected to be for unscheduled care |
period |
0..1 |
Period | The start and end time of the encounter | This SHOULD be populated. |
length |
0..1 |
Duration | Quantity of time the encounter lasted (less time absent) | This SHOULD be populated. |
reason |
0..* |
CodeableConcept | Reason the encounter takes place (code) Encounter Reason Codes (Preferred) | This MAY be populated, but is not expected to be for unscheduled care. |
diagnosis |
0..* |
BackboneElement | The list of diagnoses relevant to this encounter | This MAY be populated, but is not expected to be for unscheduled care. |
condition |
1..1 |
Reference (Condition | Procedure) |
Reason the encounter takes place (resource) | |
role |
0..1 |
CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge) DiagnosisRole (Preferred) |
|
rank |
0..1 |
positiveInt | Ranking of the diagnosis (for each role type) | |
account |
0..* |
Reference (Account) |
The set of accounts that may be used for billing for this Encounter | This SHOULD NOT be populated. |
hospitalization |
0..1 |
BackboneElement | Details about the admission to a healthcare service | This SHOULD NOT be populated – if the patient is admitted, this will be a separate encounter. |
preAdmissionIdentifier |
0..1 |
Identifier | Pre-admission identifier | |
origin |
0..1 |
Reference (Location) |
The location from which the patient came before admission | |
admitSource |
0..1 |
CodeableConcept | From where patient was admitted (physician referral, transfer) AdmitSource (Preferred) | |
reAdmission |
0..1 |
CodeableConcept | The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission v2 Re-Admission Indicator (Example) | |
dietPreference |
0..* |
CodeableConcept | Diet preferences reported by the patient Diet (Example) | |
specialCourtesy |
0..* |
CodeableConcept | Special courtesies (VIP, board member) SpecialCourtesy (Preferred) | |
specialArrangement |
0..* |
CodeableConcept | Wheelchair, translator, stretcher, etc. SpecialArrangements (Preferred) | |
destination |
0..1 |
Reference (Location) |
Location to which the patient is discharged | |
dischargeDisposition |
0..1 |
CodeableConcept | Category or kind of location after discharge DischargeDisposition (Example) | |
location |
0..* |
BackboneElement | List of locations where the patient has been | This SHOULD be populated where the patient has physically attended the provider service. |
location |
1..1 |
Reference (Location) |
Location the encounter takes place | |
status |
0..1 |
code | planned | active | reserved | completed EncounterLocationStatus (Required) | |
period |
0..1 |
Period | Time period during which the patient was present at the location | |
serviceProvider |
0..1 |
Reference (Organization) |
The custodian organization of this Encounter record | This MUST be populated with a reference to the Service Provider Organization responsible for the encounter |
partOf |
0..1 |
Reference (Encounter) |
Another Encounter this encounter is part of | This MUST NOT be populated |