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 CDS context, an encounter occurs for the duration of a patient’s interaction with a single service provider.
Detailed implementation guidance for an Encounter resource in the CDS context is given below:
| Name | Cardinality | Type | FHIR Documentation | CDS Implementation Guidance |
|---|---|---|---|---|
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). | During a triage journey this will carry the value 'triaged'. When the Encounter has a result, this will update to 'finished'. |
statusHistory |
0..* |
BackboneElement | List of past encounter statuses | To be populated when the status changes |
statusHistory.status |
1..1 |
code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + EncounterStatus (Required) | |
statusHistory.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 SHOULD be populated with the value 'unscheduled'. |
classHistory |
0..* |
BackboneElement | List of past encounter classes | |
classHistory.class |
1..1 |
coding | inpatient | outpatient | ambulatory | emergency + ActEncounterCode (Extensible) | |
classHistory.period |
1..1 |
Period | The time that the episode was in the specified class | |
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 SHOULD be populated. |
subject |
0..1 |
Reference (Patient | Group) |
The patient or group present at the encounter | This SHOULD 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 should reference that episode. If not a continuation, this should 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 during this Encounter. |
participant.type |
0..* |
CodeableConcept | Role of participant in encounter ParticipantType (Extensible) | |
participant.period |
0..1 |
Period | Period of time during the encounter that the participant participated | |
participant.individual |
0..1 |
Reference (Practitioner | RelatedPerson) |
Persons involved in the encounter other than the patient | |
appointment |
0..1 |
Reference (Appointment) |
The appointment that scheduled this encounter | |
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. |
diagnosis.condition |
1..1 |
Reference (Condition | Procedure) |
Reason the encounter takes place (resource) | |
diagnosis.role |
0..1 |
CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge) DiagnosisRole (Preferred) |
|
diagnosis.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. |
hospitalization.preAdmissionIdentifier
|
0..1 |
Identifier | Pre-admission identifier | |
hospitalization.origin |
0..1 |
Reference (Location) |
The location from which the patient came before admission | |
hospitalization.admitSource
|
0..1 |
CodeableConcept | From where patient was admitted (physician referral, transfer) AdmitSource (Preferred) | |
hospitalization.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) | |
hospitalization.dietPreference
|
0..* |
CodeableConcept | Diet preferences reported by the patient Diet (Example) | |
hospitalization.specialCourtesy
|
0..* |
CodeableConcept | Special courtesies (VIP, board member) SpecialCourtesy (Preferred) | |
hospitalization.specialArrangement
|
0..* |
CodeableConcept | Wheelchair, translator, stretcher, etc. SpecialArrangements (Preferred) | |
hospitalization.destination
|
0..1 |
Reference (Location) |
Location to which the patient is discharged | |
hospitalization.dischargeDisposition
|
0..1 |
CodeableConcept | Category or kind of location after discharge DischargeDisposition (Example) | This SHOULD NOT be populated. |
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.location |
1..1 |
Reference (Location) |
Location the encounter takes place | |
location.status |
0..1 |
code | planned | active | reserved | completed EncounterLocationStatus (Required) | |
location.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 | The service provider |
partOf |
0..1 |
Reference (Encounter) |
Another Encounter this encounter is part of |
