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StructureDefinition-us-core-encounter

This profile sets minimum expectations for the Encounter resource to record, search and fetch basic encounter information for an individual patient. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile.

Example Usage Scenarios:

The following are example usage scenarios for the US Core Encounter profile:

  • Query for a specific patient encounter
  • Query for recent patient encounters
  • Record or update an encounter
Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Encounter must have:

  1. a status
  2. an encounter type
  3. a patient

Additionally your system Must Support:

  1. An encounter identifier
  2. Providers involved in the encounter
  3. Where the encounter occurred
  4. When the encounter occurred
  5. The discharge disposition
  6. Reason for the visit
  7. Diagnosis
  8. Indication of the principle diagnosis

Profile specific implementation guidance:

  • none
Examples

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/us/core-r4/StructureDefinition/us-core-encounter

Published on Sun Dec 10 00:00:00 PST 2017 as a active by HL7 US Realm Steering Committee.

This profile builds on Encounter

Complete Summary of the Mandatory Requirements
  1. One status in Encounter.status
  2. A class in Encounter.class from EncounterCode value set.
  3. At least one type in Encounter.type from US Core Encounter Type value set.
  4. One patient reference in Encounter.subject
Summary of the Must Support Requirements

Additionally your system must Support:

  1. One or more Encounter numbers in Encounter.identifier
  2. One or more participants in Encounter.participant
  3. An Encounter.period
  4. One or more reasons in Encounter.reason from EncounterReason value set.
  5. One or more Encounter.diagnosis.condition
  6. An Encounter.diagnosis.rank
  7. A disposition in Encounter.hospitlization.dischargeDisposition from example dischargeDisposition value set.
  8. One or more locations in Encounter.location
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter I0..*US Core Encounter Profile
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierIdentifier(s) by which this encounter is known
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system SΣ1..1uriThe namespace for the identifier value
Example General': http://www.acme.com/identifiers/patient
.... value SΣ1..1stringThe value that is unique
Example General': 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣ1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required)
... statusHistory I0..*BackboneElementList of past encounter statuses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... status 1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required)
.... period 1..1PeriodThe time that the episode was in the specified status
... class SΣ1..1CodingClassification of patient encounter
Binding: V3 Value SetActEncounterCode (extensible)
... classHistory I0..*BackboneElementList of past encounter classes
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... class 1..1Codinginpatient | outpatient | ambulatory | emergency +
Binding: V3 Value SetActEncounterCode (extensible)
.... period 1..1PeriodThe time that the episode was in the specified class
... type SΣ1..*CodeableConceptSpecific type of encounter
Binding: US Core Encounter Type (extensible)
... serviceType Σ0..1CodeableConceptSpecific type of service
Binding: ServiceType (example)
... priority 0..1CodeableConceptIndicates the urgency of the encounter
Binding: v3 Code System ActPriority (example)
... subject SΣ1..1Reference(US Core Patient Profile)The patient or group present at the encounter
... episodeOfCare Σ0..*Reference(EpisodeOfCare)Episode(s) of care that this encounter should be recorded against
... basedOn 0..*Reference(ServiceRequest)The ServiceRequest that initiated this encounter
... participant SΣI0..*BackboneElementList of participants involved in the encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ0..*CodeableConceptRole of participant in encounter
Binding: ParticipantType (extensible)
.... period S0..1PeriodPeriod of time during the encounter that the participant participated
.... individual SΣ0..1Reference(US Core Practitioner Profile)Persons involved in the encounter other than the patient
... appointment Σ0..*Reference(Appointment)The appointment that scheduled this encounter
... period S0..1PeriodThe start and end time of the encounter
... length 0..1DurationQuantity of time the encounter lasted (less time absent)
... reasonCode SΣ0..*CodeableConceptCoded reason the encounter takes place
Binding: EncounterReasonCodes (preferred)
... reasonReference Σ0..*Reference(Condition | Procedure | Observation | ImmunizationRecommendation)Reason the encounter takes place (reference)
... diagnosis SΣI0..*BackboneElementThe list of diagnosis relevant to this encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... condition SΣ1..1Reference(US Core Condition Profile | US Core Procedure Profile)The diagnosis or procedure relevant to the encounter
.... use 0..1CodeableConceptRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred)
.... rank S0..1positiveIntRanking of the diagnosis (for each role type)
... account 0..*Reference(Account)The set of accounts that may be used for billing for this Encounter
... hospitalization SI0..1BackboneElementDetails about the admission to a healthcare service
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... preAdmissionIdentifier 0..1IdentifierPre-admission identifier
.... origin 0..1Reference(Location | Organization)The location/organization from which the patient came before admission
.... admitSource 0..1CodeableConceptFrom where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred)
.... reAdmission 0..1CodeableConceptThe type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
Binding: v2 RE-ADMISSION INDICATOR (example)
.... dietPreference 0..*CodeableConceptDiet preferences reported by the patient
Binding: Diet (example)
.... specialCourtesy 0..*CodeableConceptSpecial courtesies (VIP, board member)
Binding: SpecialCourtesy (preferred)
.... specialArrangement 0..*CodeableConceptWheelchair, translator, stretcher, etc.
Binding: SpecialArrangements (preferred)
.... destination 0..1Reference(Location | Organization)Location/organization to which the patient is discharged
.... dischargeDisposition S0..1CodeableConceptCategory or kind of location after discharge
Binding: DischargeDisposition (example)
... location SI0..*BackboneElementList of locations where the patient has been
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... location S1..1Reference(US Core Location Profile)Location the encounter takes place
.... status 0..1codeplanned | active | reserved | completed
Binding: EncounterLocationStatus (required)
.... physicalType 0..1CodeableConceptThe physical type of the location (usually the level in the location heirachy - bed room ward etc)
Binding: LocationType (example)
.... period 0..1PeriodTime period during which the patient was present at the location
... serviceProvider 0..1Reference(Organization)The organization (facility) responsible for this encounter
... partOf 0..1Reference(Encounter)Another Encounter this encounter is part of

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter I0..*US Core Encounter Profile
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierIdentifier(s) by which this encounter is known
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system SΣ1..1uriThe namespace for the identifier value
Example General': http://www.acme.com/identifiers/patient
.... value SΣ1..1stringThe value that is unique
Example General': 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣ1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required)
... statusHistory I0..*BackboneElementList of past encounter statuses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... status 1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required)
.... period 1..1PeriodThe time that the episode was in the specified status
... class SΣ1..1CodingClassification of patient encounter
Binding: V3 Value SetActEncounterCode (extensible)
... classHistory I0..*BackboneElementList of past encounter classes
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... class 1..1Codinginpatient | outpatient | ambulatory | emergency +
Binding: V3 Value SetActEncounterCode (extensible)
.... period 1..1PeriodThe time that the episode was in the specified class
... type SΣ1..*CodeableConceptSpecific type of encounter
Binding: US Core Encounter Type (extensible)
... serviceType Σ0..1CodeableConceptSpecific type of service
Binding: ServiceType (example)
... priority 0..1CodeableConceptIndicates the urgency of the encounter
Binding: v3 Code System ActPriority (example)
... subject SΣ1..1Reference(US Core Patient Profile)The patient or group present at the encounter
... episodeOfCare Σ0..*Reference(EpisodeOfCare)Episode(s) of care that this encounter should be recorded against
... basedOn 0..*Reference(ServiceRequest)The ServiceRequest that initiated this encounter
... participant SΣI0..*BackboneElementList of participants involved in the encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ0..*CodeableConceptRole of participant in encounter
Binding: ParticipantType (extensible)
.... period S0..1PeriodPeriod of time during the encounter that the participant participated
.... individual SΣ0..1Reference(US Core Practitioner Profile)Persons involved in the encounter other than the patient
... appointment Σ0..*Reference(Appointment)The appointment that scheduled this encounter
... period S0..1PeriodThe start and end time of the encounter
... length 0..1DurationQuantity of time the encounter lasted (less time absent)
... reasonCode SΣ0..*CodeableConceptCoded reason the encounter takes place
Binding: EncounterReasonCodes (preferred)
... reasonReference Σ0..*Reference(Condition | Procedure | Observation | ImmunizationRecommendation)Reason the encounter takes place (reference)
... diagnosis SΣI0..*BackboneElementThe list of diagnosis relevant to this encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... condition SΣ1..1Reference(US Core Condition Profile | US Core Procedure Profile)The diagnosis or procedure relevant to the encounter
.... use 0..1CodeableConceptRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred)
.... rank S0..1positiveIntRanking of the diagnosis (for each role type)
... account 0..*Reference(Account)The set of accounts that may be used for billing for this Encounter
... hospitalization SI0..1BackboneElementDetails about the admission to a healthcare service
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... preAdmissionIdentifier 0..1IdentifierPre-admission identifier
.... origin 0..1Reference(Location | Organization)The location/organization from which the patient came before admission
.... admitSource 0..1CodeableConceptFrom where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred)
.... reAdmission 0..1CodeableConceptThe type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
Binding: v2 RE-ADMISSION INDICATOR (example)
.... dietPreference 0..*CodeableConceptDiet preferences reported by the patient
Binding: Diet (example)
.... specialCourtesy 0..*CodeableConceptSpecial courtesies (VIP, board member)
Binding: SpecialCourtesy (preferred)
.... specialArrangement 0..*CodeableConceptWheelchair, translator, stretcher, etc.
Binding: SpecialArrangements (preferred)
.... destination 0..1Reference(Location | Organization)Location/organization to which the patient is discharged
.... dischargeDisposition S0..1CodeableConceptCategory or kind of location after discharge
Binding: DischargeDisposition (example)
... location SI0..*BackboneElementList of locations where the patient has been
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... location S1..1Reference(US Core Location Profile)Location the encounter takes place
.... status 0..1codeplanned | active | reserved | completed
Binding: EncounterLocationStatus (required)
.... physicalType 0..1CodeableConceptThe physical type of the location (usually the level in the location heirachy - bed room ward etc)
Binding: LocationType (example)
.... period 0..1PeriodTime period during which the patient was present at the location
... serviceProvider 0..1Reference(Organization)The organization (facility) responsible for this encounter
... partOf 0..1Reference(Encounter)Another Encounter this encounter is part of

doco Documentation for this format

​Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron


Quick Start

Below is an overview of the required set of RESTful FHIR interactions - for example, search and read operations - for this profile. See the Conformance requirements for a complete list of supported RESTful interactions for this IG.

GET /Encounter/[id]

Example: GET [base]/Encounter/12354

Support: Mandatory.

Implementation Notes: Fetches a single Encounter.

GET /Encounter?patient=[id]

Example: GET [base]/Encounter?patient=1137192

Support: Mandatory to support search by patient.

Implementation Notes: Search for all Encounters for a patient. Fetches a bundle of all Encounter resources for the specified patient (how to search by reference).

GET [base]/Encounter?patient=[id]&period=[date]

Example: GET [base]/Encounter?patient=2169591&period=ge2016-01-01

Support: Mandatory to support search by date range.

Implementation Notes: Fetches a bundle of all Encounter resources for the specified patient for a given time period. (how to search by reference), and (how to search by date).