DSTU2 QA Preview

This page is part of the FHIR Specification (v1.0.0: DSTU 2 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

D.7.1.4 StructureDefinition: DAF-Encounter - Detailed Descriptions

Definitions for the daf-encounter Profile.

Encounter(DAF-Encounter)
Definition

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.

Control0..*
TypeEncounter
Alternate NamesVisit
Encounter.id
Definition

The logical id of the resource, as used in the url for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.

Encounter.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
Encounter.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.

Encounter.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language
The codes SHALL be taken from http://tools.ietf.org/html/bcp47
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Encounter.text
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

Encounter.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

Encounter.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.identifier
Definition

Identifier(s) by which this encounter is known.

Control1..*
TypeIdentifier
Must Supporttrue
Encounter.status
Definition

planned | in-progress | onleave | finished | cancelled.

Control1..1
BindingCurrent state of the encounter
The codes SHALL be taken from EncounterState
Typecode
Is Modifiertrue
Must Supporttrue
Encounter.statusHistory
Definition

The current status is always found in the current version of the resource. This status history permits the encounter resource to contain the status history without the needing to read through the historical versions of the resource, or even have the server store them.

Control0..*
TypeBackboneElement
Encounter.statusHistory.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Encounter.statusHistory.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.statusHistory.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.statusHistory.status
Definition

planned | arrived | in-progress | onleave | finished | cancelled.

Control1..1
BindingCurrent state of the encounter
The codes SHALL be taken from EncounterState
Typecode
Encounter.statusHistory.period
Definition

The time that the episode was in the specified status.

Control1..1
TypePeriod
Encounter.class
Definition

inpatient | outpatient | ambulatory | emergency +.

Control1..1
BindingClassification of the encounter
The codes SHALL be taken from EncounterClass
Typecode
Must Supporttrue
Encounter.type
Definition

Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation).

Control0..1
BindingEncounter type Value set to describe the type of encounter.
The codes SHOULD be taken from DAF Encounter Type
TypeCodeableConcept
Must Supporttrue
Comments

Since there are many ways to further classify encounters, this element is 0..*.

Encounter.priority
Definition

Indicates the urgency of the encounter.

Control0..1
BindingIndicates the urgency of the encounter
For example codes, see Encounter Priority
TypeCodeableConcept
Encounter.patient
Definition

Patient present at encounter.

Control1..1
TypeReference(U.S. Data Access Framework (DAF) Patient Profile)
Must Supporttrue
Alternate Namespatient
Comments

While the encounter is always about the patient, the patient may not actually be known in all contexts of use.

Encounter.episodeOfCare
Definition

Where a specific encounter should be classified as a part of a specific episode(s) of care this field should be used. This association can facilitate grouping of related encounters together for a specific purpose, such as govt reporting, issue tracking, association via a common problem. The association is recorded on the encounter as these are typically created after the episode of care, and grouped on entry rather than editing the episode of care to append another encounter to it (the episode of care could span years).

Control0..*
TypeReference(EpisodeOfCare)
Encounter.incomingReferral
Definition

The referral request that this encounter satisfies (incoming referral).

Control0..*
TypeReference(ReferralRequest)
Encounter.participant
Definition

The list of people responsible for providing the service.

Control0..*
TypeBackboneElement
Must Supporttrue
Encounter.participant.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Encounter.participant.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.participant.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.participant.type
Definition

Role of participant in encounter.

Control0..*
BindingRole of participant in encounter
The codes SHALL be taken from ParticipantType; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Comments

The Participant Type indicates how an individual parcitipates in an encounter. It includes non practitioner participants, and for practitioners this is to describe the action type in the context of this encounter (e.g. Admitting Dr, Attending Dr, Translator, Consulting Dr). This is different to the Practitioner Roles which are functional roles, derived from terms of employment, education, licensing, etc.

Encounter.participant.period
Definition

The period of time that the specified participant was present during the encounter. These can overlap or be sub-sets of the overall encounters period.

Control0..1
TypePeriod
Encounter.participant.individual
Definition

Persons involved in the encounter other than the patient.

Control0..1
TypeChoice of: Reference(U.S. Data Access Framework (DAF) Practitioner Profile), Reference(U.S. DAF Related Person Profile)
Must Supporttrue
Encounter.appointment
Definition

The appointment that scheduled this encounter.

Control0..1
TypeReference(Appointment)
Encounter.period
Definition

The start and end time of the encounter.

Control0..1
TypePeriod
Must Supporttrue
Comments

If not (yet) known, the end of the Period may be omitted.

Encounter.length
Definition

Quantity of time the encounter lasted. This excludes the time during leaves of absence.

Control0..1
TypeQuantity(Duration)
Comments

May differ from the time the Encounter.period lasted because of leave of absence.

Encounter.reason
Definition

Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis.

Control0..1
BindingEncounter Diagnoses Value set to describe the specific encounter code.
The codes SHALL be taken from DAF Encounter Diagnoses; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Alternate NamesIndication, Admission diagnosis
Comments

For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).

Encounter.indication
Definition

Reason the encounter takes place, as specified using information from another resource. For admissions, this is the admission diagnosis. The indication will typically be a Condition (with other resources referenced in the evidence.detail), or a Procedure.

Control0..*
TypeChoice of: Reference(Condition), Reference(Procedure)
Alternate NamesAdmission diagnosis
Comments

For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).

Encounter.hospitalization
Definition

Details about the admission to a healthcare service.

Control0..1
TypeBackboneElement
Must Supporttrue
Comments

This admission does not just include the inpatient context, but also other contexts such as outpatients and community clinics, and potentially aged care facilities.

The duation recorded in the period of this encounter covers the entire scope of this hospitalization record.

Encounter.hospitalization.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Encounter.hospitalization.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.hospitalization.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.hospitalization.preAdmissionIdentifier
Definition

Pre-admission identifier.

Control0..1
TypeIdentifier
Encounter.hospitalization.origin
Definition

The location from which the patient came before admission.

Control0..1
TypeReference(Location)
Encounter.hospitalization.admitSource
Definition

From where patient was admitted (physician referral, transfer).

Control0..1
BindingFrom where the patient was admitted
The codes SHOULD be taken from AdmitSource
TypeCodeableConcept
Encounter.hospitalization.admittingDiagnosis
Definition

The admitting Diagnosis field is used to record the diagnosis codes as reported by admitting practitioner. This could be different or in addition to the conditions reported as reason-condition(s) for the encounter.

Control0..*
TypeReference(Condition)
Encounter.hospitalization.reAdmission
Definition

Whether this hospitalization is a readmission and why if known.

Control0..1
TypeCodeableConcept
Encounter.hospitalization.dietPreference
Definition

Diet preferences reported by the patient.

Control0..*
BindingMedical, cultural or ethical food preferences to help with catering requirements
For example codes, see Diet
TypeCodeableConcept
Requirements

Used to track patient's diet restrictions and/or preference. For a complete description of the nutrition needs of a patient during their stay, one should use the nutritionOrder resource which links to Encounter.

Comments

For example a patient may request both a dairy-free and nut-free diet preference (not mutually exclusive).

Encounter.hospitalization.specialCourtesy
Definition

Special courtesies (VIP, board member).

Control0..*
BindingSpecial courtesies
The codes SHOULD be taken from SpecialCourtesy
TypeCodeableConcept
Encounter.hospitalization.specialArrangement
Definition

Wheelchair, translator, stretcher, etc.

Control0..*
BindingSpecial arrangements
The codes SHOULD be taken from SpecialArrangements
TypeCodeableConcept
Encounter.hospitalization.destination
Definition

Location to which the patient is discharged.

Control0..1
TypeReference(Location)
Encounter.hospitalization.dischargeDisposition
Definition

Category or kind of location after discharge.

Control0..1
BindingValue set to describe kind of location or category of discharge.
The codes SHALL be taken from DAF Encounter Discharge Disposition; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Encounter.hospitalization.dischargeDiagnosis
Definition

The final diagnosis given a patient before release from the hospital after all testing, surgery, and workup are complete.

Control0..*
TypeReference(Condition)
Encounter.location
Definition

List of locations at which the patient has been during this encounter.

Control0..1
TypeBackboneElement
Must Supporttrue
Comments

Virtual encounters can be recorded in the ancounter by specifying a location reference to a location of type "kind" such as "client's home" and an ecnounter.class = "virtual".

Encounter.location.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Encounter.location.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.location.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.location.location
Definition

The location where the encounter takes place.

Control1..1
TypeReference(U.S. Data Access Framework (DAF) Location Profile)
Must Supporttrue
Encounter.location.status
Definition

The status of the participants presence at the specified location during the period specified. If the participant is is no longer at the location, then the period will have an end date/time.

Control0..1
BindingThe status of the location
The codes SHALL be taken from EncounterLocationStatus
Typecode
Comments

When the patient is no longer active at a location, then the period end date is entered, and the status may be changed to completed.

Encounter.location.period
Definition

Time period during which the patient was present at the location.

Control0..1
TypePeriod
Encounter.serviceProvider
Definition

An organization that is in charge of maintaining the information of this Encounter (e.g., who maintains the report or the master service catalog item, etc.). This MAY be the same as the organization on the Patient record, however it could be different. This MAY not be not the Service Delivery Location's Organization.

Control0..1
TypeReference(Organization)
Encounter.partOf
Definition

Another Encounter of which this encounter is a part of (administratively or in time).

Control0..1
TypeReference(Encounter)