This page is part of the FHIR Specification (v1.4.0: STU 3 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
Definitions for the qicore-encounter Profile.
Encounter(QICore-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. |
Control | 0..* |
Type | Encounter |
Alternate Names | Visit |
Encounter.id | |
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. |
Control | 0..1 |
Type | id |
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. |
Control | 0..1 |
Type | Meta |
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. |
Control | 0..1 |
Type | uri |
Is Modifier | true |
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. |
Control | 0..1 |
Binding | A human language. The codes SHALL be taken from http://tools.ietf.org/html/bcp47 |
Type | code |
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. |
Control | 0..1 This element is affected by the following invariants: dom-1 |
Type | Narrative |
Alternate Names | narrative, 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. |
Control | 0..* |
Type | Resource |
Alternate Names | inline 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 | An Extension |
Control | 0..* |
Type | Extension |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Encounter.extension (http://hl7.org/fhir/StructureDefinition/encounter-relatedCondition) | |
Definition | The conditions considered and cared for within this encounter. This includes items such as reason for visit, admission diagnosis, discharge diagnosis, chief complaint. Do not use reason or indication in the Action class to specify encounter-related diagnoses. |
Control | 0..* |
Type | Extension (Extension Type: Reference(Condition)) |
Encounter.extension.id | |
Definition | unique id for the element within a resource (for internal references). |
Control | 0..1 |
Type | id |
Encounter.extension.extension | |
Definition | An Extension |
Control | 0..* |
Type | Extension |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Encounter.extension.extension(condition) | |
Definition | The reference to conditions related to this encounter, aside from the primary condition. |
Control | 0..1 |
Type | Extension |
Encounter.extension.extension | |
Definition | An Extension |
Control | 0..* |
Type | Extension |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Encounter.extension.extension | |
Definition | An Extension |
Control | 0..* |
Type | Extension |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Encounter.extension.extension | |
Definition | An Extension |
Control | 0..* |
Type | Extension |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Encounter.extension.extension | |
Definition | An Extension |
Control | 0..* |
Type | Extension |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Encounter.extension.extension(role) | |
Definition | The role of the condition within this encounter, e.g. chief complaint, admission diagnosis, discharge diagnosis, comorbidity. |
Control | 0..1 |
Type | Extension |
Encounter.extension.extension | |
Definition | An Extension |
Control | 0..* |
Type | Extension |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Encounter.extension.extension | |
Definition | An Extension |
Control | 0..* |
Type | Extension |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Encounter.extension.extension | |
Definition | An Extension |
Control | 0..* |
Type | Extension |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Encounter.extension.extension | |
Definition | An Extension |
Control | 0..* |
Type | Extension |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Encounter.extension.extension (http://hl7.org/fhir/StructureDefinition/encounter-relatedCondition#condition) | |
Definition | The conditions considered and cared for within this encounter. This includes items such as reason for visit, admission diagnosis, discharge diagnosis, chief complaint. Do not use reason or indication in the Action class to specify encounter-related diagnoses. |
Control | 0..* |
Type | Extension (Extension Type: Reference(Condition)) |
Encounter.extension.extension (http://hl7.org/fhir/StructureDefinition/encounter-relatedCondition#role) | |
Definition | The conditions considered and cared for within this encounter. This includes items such as reason for visit, admission diagnosis, discharge diagnosis, chief complaint. Do not use reason or indication in the Action class to specify encounter-related diagnoses. |
Control | 0..* |
Type | Extension (Extension Type: Reference(Condition)) |
Encounter.extension.url | |
Definition | Source of the definition for the extension code - a logical name or a URL. |
Control | 1..1 |
Type | uri |
Comments | The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition should be version specific. This will ideally be the URI for the Resource Profile defining the extension, with the code for the extension after a #. |
Fixed Value | http://hl7.org/fhir/StructureDefinition/encounter-relatedCondition |
Encounter.extension.valueReference | |
Definition | Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list). |
Control | 0..1 |
Type | Reference(Condition) |
Encounter.extension (http://hl7.org/fhir/StructureDefinition/encounter-reasonCancelled) | |
Definition | If the encountered was cancelled after it was planned, why? Applies only if the status is cancelled. |
Control | 0..1 |
Type | Extension (Extension Type: CodeableConcept) |
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. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, 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. |
Control | 0..* |
Type | Identifier |
Encounter.status | |
Definition | planned | arrived | in-progress | onleave | finished | cancelled. |
Control | 1..1 |
Binding | Current state of the encounter The codes SHALL be taken from EncounterState |
Type | code |
Is Modifier | true |
Must Support | true |
Encounter.statusHistory | |
Definition | The status history permits the encounter resource to contain the status history without needing to read through the historical versions of the resource, or even have the server store them. |
Control | 0..* |
Type | BackboneElement |
Comments | The current status is always found in the current version of the resource, not the status history. |
Encounter.statusHistory.id | |
Definition | unique id for the element within a resource (for internal references). |
Control | 0..1 |
Type | id |
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. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, 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. |
Control | 1..1 |
Binding | Current state of the encounter The codes SHALL be taken from EncounterState |
Type | code |
Encounter.statusHistory.period | |
Definition | The time that the episode was in the specified status. |
Control | 1..1 |
Type | Period |
Encounter.class | |
Definition | inpatient | outpatient | ambulatory | emergency +. |
Control | 0..1 |
Binding | Classification of the encounter The codes SHALL be taken from EncounterClass |
Type | code |
Must Support | true |
Encounter.type | |
Definition | Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation). |
Control | 0..* |
Binding | Encounter Type Value set to describe the type of encounter The codes SHOULD be taken from DAF Encounter Type |
Type | CodeableConcept |
Must Support | true |
Comments | Since there are many ways to further classify encounters, this element is 0..*. |
Encounter.priority | |
Definition | Indicates the urgency of the encounter. |
Control | 0..1 |
Binding | The priority of the encounter (e.g., Urgent, Normal, etc.) The codes SHOULD be taken from SNOMED CT Priorities Codes |
Type | CodeableConcept |
Encounter.patient | |
Definition | The patient present at the encounter. |
Control | 0..1 |
Type | Reference(QICore-Patient) |
Must Support | true |
Alternate Names | patient |
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 government 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). |
Control | 0..* |
Type | Reference(EpisodeOfCare) |
Encounter.incomingReferral | |
Definition | The referral request this encounter satisfies (incoming referral). |
Control | 0..* |
Type | Reference(QICore-ReferralRequest) |
Encounter.participant | |
Definition | The list of people responsible for providing the service. |
Control | 0..* |
Type | BackboneElement |
Encounter.participant.id | |
Definition | unique id for the element within a resource (for internal references). |
Control | 0..1 |
Type | id |
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. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, 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. |
Control | 0..* |
Binding | Role of participant in encounter The codes SHALL be taken from ParticipantType; other codes may be used where these codes are not suitable |
Type | CodeableConcept |
Comments | The participant type indicates how an individual partitipates 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. |
Control | 0..1 |
Type | Period |
Encounter.participant.individual | |
Definition | Persons involved in the encounter other than the patient. |
Control | 0..1 |
Type | Choice of: Reference(QICore-Practitioner), Reference(QICore-RelatedPerson) |
Encounter.appointment | |
Definition | The appointment that scheduled this encounter. |
Control | 0..1 |
Type | Reference(Appointment) |
Encounter.period | |
Definition | The start and end time of the encounter. |
Control | 0..1 |
Type | Period |
Must Support | true |
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. |
Control | 0..1 |
Type | Quantity(Duration) |
Must Support | true |
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. |
Control | 0..* |
Binding | Encounter Reason Value Set to describe reason for encounter The codes SHOULD be taken from DAF Encounter Diagnoses |
Type | CodeableConcept |
Must Support | true |
Alternate Names | Indication, 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. |
Control | 0..* |
Type | Choice of: Reference(Condition), Reference(Procedure) |
Alternate Names | 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.hospitalization | |
Definition | Details about the admission to a healthcare service. |
Control | 0..1 |
Type | BackboneElement |
Comments | An Encounter may cover more than just the inpatient stay. Contexts such as outpatients, community clinics, and aged care facilities are also included. The duration 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). |
Control | 0..1 |
Type | id |
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. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, 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. |
Control | 0..1 |
Type | Identifier |
Encounter.hospitalization.origin | |
Definition | The location from which the patient came before admission. |
Control | 0..1 |
Type | Reference(QICore-Location) |
Encounter.hospitalization.admitSource | |
Definition | From where patient was admitted (physician referral, transfer). |
Control | 0..1 |
Binding | From where the patient was admitted. The codes SHOULD be taken from AdmitSource |
Type | CodeableConcept |
Must Support | true |
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. |
Control | 0..* |
Type | Reference(Condition) |
Encounter.hospitalization.reAdmission | |
Definition | Whether this hospitalization is a readmission and why if known. |
Control | 0..1 |
Binding | The reason for re-admission of this hospitalization encounter. |
Type | CodeableConcept |
Must Support | true |
Encounter.hospitalization.dietPreference | |
Definition | Diet preferences reported by the patient. |
Control | 0..* |
Binding | Medical, cultural or ethical food preferences to help with catering requirements. For example codes, see Diet |
Type | CodeableConcept |
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). |
Control | 0..* |
Binding | Special courtesies The codes SHOULD be taken from SpecialCourtesy |
Type | CodeableConcept |
Encounter.hospitalization.specialArrangement | |
Definition | Wheelchair, translator, stretcher, etc. |
Control | 0..* |
Binding | Special arrangements The codes SHOULD be taken from SpecialArrangements |
Type | CodeableConcept |
Encounter.hospitalization.destination | |
Definition | Location to which the patient is discharged. |
Control | 0..1 |
Type | Reference(QICore-Location) |
Encounter.hospitalization.dischargeDisposition | |
Definition | Category or kind of location after discharge. |
Control | 0..1 |
Binding | Discharge Disposition The codes SHOULD be taken from DischargeDisposition |
Type | CodeableConcept |
Must Support | true |
Encounter.hospitalization.dischargeDiagnosis | |
Definition | The final diagnosis given a patient before release from the hospital after all testing, surgery, and workup are complete. |
Control | 0..* |
Type | Reference(Condition) |
Must Support | true |
Encounter.location | |
Definition | List of locations where the patient has been during this encounter. |
Control | 0..* |
Type | BackboneElement |
Comments | Virtual encounters can be recorded in the Encounter by specifying a location reference to a location of type "kind" such as "client's home" and an encounter.class = "virtual". |
Encounter.location.id | |
Definition | unique id for the element within a resource (for internal references). |
Control | 0..1 |
Type | id |
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. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, 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. |
Control | 1..1 |
Type | Reference(QICore-Location) |
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. |
Control | 0..1 |
Binding | The status of the location. The codes SHALL be taken from EncounterLocationStatus |
Type | code |
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. |
Control | 0..1 |
Type | Period |
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. |
Control | 0..1 |
Type | Reference(QICore-Organization) |
Must Support | true |
Encounter.partOf | |
Definition | Another Encounter of which this encounter is a part of (administratively or in time). |
Control | 0..1 |
Type | Reference(QICore-Encounter) |