Clinical Document Architecture V2.0.1
2.1.0-draft1 - 1st Draft

This page is part of the CDA: Clinical Document Architecture (v2.1.0-draft1: CDA 2.1 Draft) based on FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Logical Model: Encounter (CDA Class)

Official URL: http://hl7.org/fhir/cda/StructureDefinition/Encounter Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: CDAR2.Encounter

A derivative of the RIM PatientEncounter class, used to represent related encounters, such as follow-up visits or referenced past encounters. NOTE: The EncompassingEncounter class in the CDA Header (see Header Relationships (ยง 4.2.3 )) represents the setting of the clinical encounter during which the documented act occurred. The Encounter class in the CDA Body is used to represent other related encounters.

Usage:

  • This Logical Model Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 1..1BaseXML Namespace: urn:hl7-org:v3
Base for all types and resources
... @classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
... @moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... id 0..*II
... code 0..1CDBinding: ActEncounterCode (extensible)
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... dischargeDispositionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
sdtc:dischargeDispositionCode
XML Namespace: urn:hl7-org:sdtc
... priorityCode 0..1CEBinding: ActPriority (extensible)
... subject 0..1Element
.... @typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... @contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... @typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... @contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... entryRelationship C0..*Elementenc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... @typeCode 1..1code
.... @inversionInd 0..1boolean
.... @contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... @negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... @typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
Encounter.classCoderequiredFixed Value: ENC
Encounter.codeextensibleActEncounterCode
Encounter.statusCoderequiredActStatus
Encounter.priorityCodeextensibleActPriority
Encounter.subject.typeCoderequiredFixed Value: SBJ
Encounter.subject.contextControlCoderequiredFixed Value: OP
Encounter.subject.awarenessCodeextensibleTargetAwareness
Encounter.informant.typeCoderequiredFixed Value: INF
Encounter.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
enc-er-1errorEncounter.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 1..1BaseBase for all types and resources
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
... moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... code 0..1CDBinding: ActEncounterCode (extensible)
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... dischargeDispositionCode 0..1CEsdtc:dischargeDispositionCode
XML Namespace: urn:hl7-org:sdtc
... priorityCode 0..1CEBinding: ActPriority (extensible)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... entryRelationship C0..*Elementenc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Encounter.classCoderequiredFixed Value: ENC
Encounter.codeextensibleActEncounterCode
Encounter.statusCoderequiredActStatus
Encounter.priorityCodeextensibleActPriority
Encounter.subject.typeCoderequiredFixed Value: SBJ
Encounter.subject.contextControlCoderequiredFixed Value: OP
Encounter.subject.awarenessCodeextensibleTargetAwareness
Encounter.informant.typeCoderequiredFixed Value: INF
Encounter.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
enc-er-1errorEncounter.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 1..1BaseBase for all types and resources
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
... moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... code 0..1CDBinding: ActEncounterCode (extensible)
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... dischargeDispositionCode 0..1CEsdtc:dischargeDispositionCode
XML Namespace: urn:hl7-org:sdtc
... priorityCode 0..1CEBinding: ActPriority (extensible)
... subject 0..1Element
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... entryRelationship C0..*Elementenc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Encounter.classCoderequiredFixed Value: ENC
Encounter.codeextensibleActEncounterCode
Encounter.statusCoderequiredActStatus
Encounter.priorityCodeextensibleActPriority
Encounter.subject.typeCoderequiredFixed Value: SBJ
Encounter.subject.contextControlCoderequiredFixed Value: OP
Encounter.subject.awarenessCodeextensibleTargetAwareness
Encounter.informant.typeCoderequiredFixed Value: INF
Encounter.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
enc-er-1errorEncounter.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Base

Summary

Mandatory: 0 element (10 nested mandatory elements)
Fixed Value: 5 elements

Differential View

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 1..1BaseXML Namespace: urn:hl7-org:v3
Base for all types and resources
... @classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
... @moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... id 0..*II
... code 0..1CDBinding: ActEncounterCode (extensible)
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... dischargeDispositionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
sdtc:dischargeDispositionCode
XML Namespace: urn:hl7-org:sdtc
... priorityCode 0..1CEBinding: ActPriority (extensible)
... subject 0..1Element
.... @typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... @contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... @typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... @contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... entryRelationship C0..*Elementenc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... @typeCode 1..1code
.... @inversionInd 0..1boolean
.... @contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... @negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... @typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
Encounter.classCoderequiredFixed Value: ENC
Encounter.codeextensibleActEncounterCode
Encounter.statusCoderequiredActStatus
Encounter.priorityCodeextensibleActPriority
Encounter.subject.typeCoderequiredFixed Value: SBJ
Encounter.subject.contextControlCoderequiredFixed Value: OP
Encounter.subject.awarenessCodeextensibleTargetAwareness
Encounter.informant.typeCoderequiredFixed Value: INF
Encounter.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
enc-er-1errorEncounter.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 1..1BaseBase for all types and resources
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
... moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... code 0..1CDBinding: ActEncounterCode (extensible)
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... dischargeDispositionCode 0..1CEsdtc:dischargeDispositionCode
XML Namespace: urn:hl7-org:sdtc
... priorityCode 0..1CEBinding: ActPriority (extensible)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... entryRelationship C0..*Elementenc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Encounter.classCoderequiredFixed Value: ENC
Encounter.codeextensibleActEncounterCode
Encounter.statusCoderequiredActStatus
Encounter.priorityCodeextensibleActPriority
Encounter.subject.typeCoderequiredFixed Value: SBJ
Encounter.subject.contextControlCoderequiredFixed Value: OP
Encounter.subject.awarenessCodeextensibleTargetAwareness
Encounter.informant.typeCoderequiredFixed Value: INF
Encounter.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
enc-er-1errorEncounter.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 1..1BaseBase for all types and resources
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: ENC
... moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... code 0..1CDBinding: ActEncounterCode (extensible)
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... dischargeDispositionCode 0..1CEsdtc:dischargeDispositionCode
XML Namespace: urn:hl7-org:sdtc
... priorityCode 0..1CEBinding: ActPriority (extensible)
... subject 0..1Element
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... entryRelationship C0..*Elementenc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Encounter.classCoderequiredFixed Value: ENC
Encounter.codeextensibleActEncounterCode
Encounter.statusCoderequiredActStatus
Encounter.priorityCodeextensibleActPriority
Encounter.subject.typeCoderequiredFixed Value: SBJ
Encounter.subject.contextControlCoderequiredFixed Value: OP
Encounter.subject.awarenessCodeextensibleTargetAwareness
Encounter.informant.typeCoderequiredFixed Value: INF
Encounter.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
enc-er-1errorEncounter.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Base

Summary

Mandatory: 0 element (10 nested mandatory elements)
Fixed Value: 5 elements

 

Other representations of profile: CSV, Excel