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UEC Digital Integration Programme | Encounter implementation guidance

Encounter resource implementation guidance

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 COULD be populated, but is not expected to be for unscheduled care.
diagnosis 0..* BackboneElement The list of diagnoses relevant to this encounter This COULD 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
Tags: rest fhir api

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