This page is part of the FHIR Specification (v0.0.82: DSTU 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions
StructureDefinition for Profile of Encounter for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.
{ "resourceType": "StructureDefinition", "id": "encounter-qicore-qicore-encounter", "text": { "status": "generated", "div": "<div>!-- Snipped for Brevity --></div>" }, "url": "http://hl7.org/fhir/StructureDefinition/encounter-qicore-qicore-encounter", "name": "QICore-Encounter", "publisher": "Health Level Seven, Inc. - CQI WG", "contact": [ { "telecom": [ { "system": "url", "value": "http://hl7.org/special/committees/CQI" } ] } ], "description": "Profile of Encounter for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.", "status": "draft", "date": "2015-02-27", "mapping": [ { "identity": "qdm", "uri": "http://www.healthit.gov/quality-data-model", "name": "Quality Data Model" } ], "type": "constraint", "abstract": false, "base": "http://hl7.org/fhir/StructureDefinition/Encounter", "snapshot": { "element": [ { "path": "Encounter", "name": "QICore-Encounter", "short": "An interaction during which services are provided to the patient", "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.", "alias": [ "Visit" ], "min": 1, "max": "1", "type": [ { "code": "Encounter" } ], "mapping": [ { "identity": "rim", "map": "Encounter[moodCode=EVN]" }, { "identity": "qdm", "map": "Encounter, Active or Performed" } ] }, { "path": "Encounter.id", "short": "Logical id of this artefact", "definition": "The logical id of the resource, as used in the url for the resoure. Once assigned, this value never changes.", "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.", "min": 0, "max": "1", "type": [ { "code": "id" } ] }, { "path": "Encounter.meta", "short": "Metadata about the resource", "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.", "min": 0, "max": "1", "type": [ { "code": "Meta" } ] }, { "path": "Encounter.implicitRules", "short": "A set of rules under which this content was created", "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.", "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.", "min": 0, "max": "1", "type": [ { "code": "uri" } ], "isModifier": true }, { "path": "Encounter.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "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\n\nNot 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).", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "name": "Language", "strength": "required", "description": "A human language", "valueSetUri": "http://tools.ietf.org/html/bcp47" } }, { "path": "Encounter.text", "short": "Text summary of the resource, for human interpretation", "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.", "comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "type": [ { "code": "Narrative" } ], "condition": [ "dom-1" ], "mapping": [ { "identity": "rim", "map": "Act.text?" } ] }, { "path": "Encounter.contained", "short": "Contained, inline Resources", "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.", "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.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "type": [ { "code": "Resource" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.extension", "slicing": { "discriminator": [ "url" ], "ordered": false, "rules": "open" }, "short": "Extension", "definition": "An Extension", "min": 0, "max": "*", "type": [ { "code": "Extension" } ] }, { "path": "Encounter.extension", "name": "Encounter.primaryCondition", "short": "Extension", "definition": "An Extension", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-primaryCondition" } ] }, { "path": "Encounter.extension.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.extension.extension", "short": "Additional Content defined by implementations", "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.", "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.extension.url", "representation": [ "xmlAttr" ], "short": "identifies the meaning of the extension", "definition": "Source of the definition for the extension code - a logical name or a URL.", "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 #.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.extension.valueReference", "name": "Encounter.primaryCondition.valueReference", "short": "Value of extension", "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).", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/condition-qicore-qicore-condition" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.extension", "name": "Encounter.relatedCondition", "short": "Extension", "definition": "An Extension", "min": 0, "max": "*", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-relatedCondition" } ] }, { "path": "Encounter.extension.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.extension.extension", "slicing": { "discriminator": [ "url" ], "ordered": false, "rules": "open" }, "short": "Extension", "definition": "An Extension", "min": 0, "max": "*", "type": [ { "code": "Extension" } ] }, { "path": "Encounter.extension.extension", "name": "Encounter.relatedCondition.condition", "short": "Extension", "definition": "An Extension", "min": 1, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-condition" } ] }, { "path": "Encounter.extension.extension.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.extension.extension.extension", "short": "Additional Content defined by implementations", "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.", "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.extension.extension.url", "representation": [ "xmlAttr" ], "short": "identifies the meaning of the extension", "definition": "Source of the definition for the extension code - a logical name or a URL.", "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 #.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.extension.extension.valueReference", "name": "Encounter.relatedCondition.condition.valueReference", "short": "Value of extension", "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).", "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/condition-qicore-qicore-condition" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.extension.extension", "name": "Encounter.relatedCondition.conditionRole", "short": "Extension", "definition": "An Extension", "min": 1, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-conditionRole" } ] }, { "path": "Encounter.extension.url", "representation": [ "xmlAttr" ], "short": "identifies the meaning of the extension", "definition": "Source of the definition for the extension code - a logical name or a URL.", "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 #.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.extension.value[x]", "short": "Value of extension", "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).", "min": 0, "max": "1", "type": [ { "code": "*" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.extension", "name": "Encounter.reasonCancelled", "short": "Extension", "definition": "An Extension", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-reasonCancelled" } ], "mapping": [ { "identity": "qdm", "map": "negation rationale" } ] }, { "path": "Encounter.modifierExtension", "short": "Extensions that cannot be ignored", "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.", "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.identifier", "short": "Identifier(s) by which this encounter is known", "definition": "Identifier(s) by which this encounter is known.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PV1-19-visit number" }, { "identity": "rim", "map": ".id" } ] }, { "path": "Encounter.status", "short": "planned | arrived | in-progress | onleave | finished | cancelled", "definition": "planned | arrived | in-progress | onleave | finished | cancelled.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "isModifier": true, "isSummary": true, "binding": { "name": "EncounterState", "strength": "required", "description": "Current state of the encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-state" } }, "mapping": [ { "identity": "v2", "map": "No clear equivalent in V2.x; active/finished could be inferred from PV1-44, PV1-45, PV2-24; inactive could be inferred from PV2-16" }, { "identity": "rim", "map": ".statusCode" } ] }, { "path": "Encounter.statusHistory", "short": "List of Encounter statuses", "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.", "min": 0, "max": "*" }, { "path": "Encounter.statusHistory.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.statusHistory.extension", "short": "Additional Content defined by implementations", "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.", "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.statusHistory.modifierExtension", "short": "Extensions that cannot be ignored", "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.", "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.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.statusHistory.status", "short": "planned | arrived | in-progress | onleave | finished | cancelled", "definition": "planned | arrived | in-progress | onleave | finished | cancelled.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "name": "EncounterState", "strength": "required", "description": "Current state of the encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-state" } } }, { "path": "Encounter.statusHistory.period", "short": "The time that the episode was in the specified status", "definition": "The time that the episode was in the specified status.", "min": 1, "max": "1", "type": [ { "code": "Period" } ] }, { "path": "Encounter.class", "short": "inpatient | outpatient | ambulatory | emergency +", "definition": "inpatient | outpatient | ambulatory | emergency +.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "isSummary": true, "binding": { "name": "EncounterClass", "strength": "required", "description": "Classification of the encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-class" } }, "mapping": [ { "identity": "v2", "map": "PV1-2-patient class" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=SUBJ].source[classCode=LIST].code" } ] }, { "path": "Encounter.type", "short": "Specific type of encounter", "definition": "Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation).", "comments": "Since there are many ways to further classify encounters, this element is 0..*.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "isSummary": true, "binding": { "name": "DAFEncounterType", "strength": "extensible", "description": "Encounter type Value set to describe the type of encounter.", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/daf-encounter-type" } }, "mapping": [ { "identity": "v2", "map": "PV1-4-admission type" }, { "identity": "rim", "map": ".code" }, { "identity": "qdm", "map": "primary code" } ] }, { "path": "Encounter.patient", "short": "The patient present at the encounter", "definition": "The patient present at the encounter.", "comments": "While the encounter is always about the patient, the patient may not actually be known in all contexts of use.", "alias": [ "patient" ], "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/patient-qicore-qicore-patient" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "v2", "map": "PID-3-patient ID list" }, { "identity": "rim", "map": ".participation[typeCode=SBJ]/role[classCode=PAT]" } ] }, { "path": "Encounter.episodeOfCare", "short": "An episode of care that this encounter should be recorded against", "definition": "Where a specific encounter should be classified as a part of a specific episode of care this field should be used. This association can facilitate grouping of related encounters together for a specific purpose, such as govt reporting, or issue tracking.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PV1-54, PV1-53" } ] }, { "path": "Encounter.incomingReferralRequest", "short": "Incoming Referral Request", "definition": "The referral request that this encounter is satisfies (incoming referral).", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/referralrequest-qicore-qicore-referralrequest" } ] }, { "path": "Encounter.participant", "short": "List of participants involved in the encounter", "definition": "The main practitioner responsible for providing the service.", "min": 0, "max": "*", "isSummary": true, "mapping": [ { "identity": "v2", "map": "ROL" }, { "identity": "rim", "map": ".participation[typeCode=PFM]" } ] }, { "path": "Encounter.participant.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.participant.extension", "short": "Additional Content defined by implementations", "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.", "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.participant.modifierExtension", "short": "Extensions that cannot be ignored", "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.", "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.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.participant.type", "short": "Role of participant in encounter", "definition": "Role of participant in encounter.", "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.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "name": "ParticipantType", "strength": "required", "description": "Role of participant in encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-participant-type" } }, "mapping": [ { "identity": "v2", "map": "ROL-3" }, { "identity": "rim", "map": ".functionCode" } ] }, { "path": "Encounter.participant.period", "short": "Period of time during the encounter participant was present", "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.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mapping": [ { "identity": "v2", "map": "ROL-5, ROL-6" } ] }, { "path": "Encounter.participant.individual", "short": "Persons involved in the encounter other than the patient", "definition": "Persons involved in the encounter other than the patient.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/practitioner-qicore-qicore-practitioner" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/relatedperson-qicore-qicore-relatedperson" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "ROL-4" }, { "identity": "rim", "map": ".role" } ] }, { "path": "Encounter.fulfills", "short": "The appointment that scheduled this encounter", "definition": "The appointment that scheduled this encounter.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Appointment" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "SCH-1-placer appointment ID / SCH-2-filler appointment ID" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=FLFS].target[classCode=ENC, moodCode=APT]" } ] }, { "path": "Encounter.period", "short": "The start and end time of the encounter", "definition": "The start and end time of the encounter.", "comments": "If not (yet) known, the end of the Period may be omitted.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "PV1-44, PV1-45" }, { "identity": "rim", "map": ".effectiveTime\n(low & high)" } ] }, { "path": "Encounter.length", "short": "Quantity of time the encounter lasted (less time absent)", "definition": "Quantity of time the encounter lasted. This excludes the time during leaves of absence.", "comments": "May differ from the time the Encounter.period lasted because of leave of absence.", "min": 0, "max": "1", "type": [ { "code": "Duration" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "(PV1-45 less PV1-44) iff ( (PV1-44 not empty) and (PV1-45 not empty) ); units in minutes" }, { "identity": "rim", "map": ".lengthOfStayQuantity" }, { "identity": "qdm", "map": "length of stay" } ] }, { "path": "Encounter.reason", "short": "Reason the encounter takes place (code)", "definition": "Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "isSummary": true, "binding": { "name": "DAFEncounterReasonValueset", "strength": "extensible", "description": "Encounter Diagnoses Value set to describe the specific encounter code.", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/daf-encounter-reason" } }, "mapping": [ { "identity": "v2", "map": "EVN-4-event reason code / PV2-3-admit reason (note: PV2-3 is nominally constrained to inpatient admissions; V2.x makes no vocabulary suggestions for PV2-3; would not expect PV2 segment or PV2-3 to be in use in all implementations\n)" }, { "identity": "rim", "map": ".reasonCode" }, { "identity": "qdm", "map": "reason" } ] }, { "path": "Encounter.indication", "short": "Reason the encounter takes place (resource)", "definition": "Reason the encounter takes place, as specified using information from another resource. For admissions, this is the admission diagnosis.\nThe indication will typically be a Condition (with other resources referenced in the evidence.detail), or a Procedure.", "alias": [ "Admission diagnosis" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Resource" } ], "mapping": [ { "identity": "v2", "map": "Resources that would commonly referenced at Encounter.indication would be Condition and/or Procedure. These most closely align with DG1/PRB and PR1 respectively." }, { "identity": "rim", "map": ".outboundRelationship[typeCode=RSON].target" } ] }, { "path": "Encounter.priority", "short": "Indicates the urgency of the encounter", "definition": "Indicates the urgency of the encounter.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "name": "Priority", "strength": "example", "description": "Indicates the urgency of the encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-priority" } }, "mapping": [ { "identity": "v2", "map": "PV2-25-visit priority code" }, { "identity": "rim", "map": ".priorityCode" } ] }, { "path": "Encounter.hospitalization", "short": "Details about an admission to a clinic", "definition": "Details about an admission to a clinic.", "min": 0, "max": "1", "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=COMP].target[classCode=ENC, moodCode=EVN]" } ] }, { "path": "Encounter.hospitalization.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.hospitalization.extension", "slicing": { "discriminator": [ "url" ], "ordered": false, "rules": "open" }, "short": "Extension", "definition": "An Extension", "min": 0, "max": "*", "type": [ { "code": "Extension" } ] }, { "path": "Encounter.hospitalization.extension", "name": "Encounter.hospitalization.admission", "short": "Extension", "definition": "An Extension", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-admission" } ], "mapping": [ { "identity": "qdm", "map": "admission datetime" } ] }, { "path": "Encounter.hospitalization.extension", "name": "Encounter.hospitalization.discharge", "short": "Extension", "definition": "An Extension", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-discharge" } ], "mapping": [ { "identity": "qdm", "map": "discharge datetime" } ] }, { "path": "Encounter.hospitalization.modifierExtension", "short": "Extensions that cannot be ignored", "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.", "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.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.hospitalization.preAdmissionIdentifier", "short": "Pre-admission identifier", "definition": "Pre-admission identifier.", "min": 0, "max": "1", "type": [ { "code": "Identifier" } ], "mapping": [ { "identity": "v2", "map": "PV1-5-preadmit number" }, { "identity": "rim", "map": ".id" } ] }, { "path": "Encounter.hospitalization.origin", "short": "The location from which the patient came before admission", "definition": "The location from which the patient came before admission.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/location-qicore-qicore-location" } ], "mapping": [ { "identity": "rim", "map": ".participation[typeCode=ORG].role" } ] }, { "path": "Encounter.hospitalization.admitSource", "short": "From where patient was admitted (physician referral, transfer)", "definition": "From where patient was admitted (physician referral, transfer).", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "binding": { "name": "AdmitSource", "strength": "required", "description": "From where the patient was admitted", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-admit-source" } }, "mapping": [ { "identity": "v2", "map": "PV1-14-admit source" }, { "identity": "rim", "map": ".admissionReferralSourceCode" } ] }, { "path": "Encounter.hospitalization.diet", "short": "Dietary restrictions for the patient", "definition": "Dietary restrictions for the patient.", "requirements": "Track patients reported dietary restrictions to help with catering requirements.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "name": "PatientDiet", "strength": "example", "description": "Medical, cultural or ethical food preferences to help with catering requirements", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-diet" } }, "mapping": [ { "identity": "v2", "map": "PV1-38-diet type" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=COMP].target[classCode=SBADM, moodCode=EVN, code=\"diet\"]" } ] }, { "path": "Encounter.hospitalization.specialCourtesy", "short": "Special courtesies (VIP, board member)", "definition": "Special courtesies (VIP, board member).", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "binding": { "name": "Courtesies", "strength": "required", "description": "Special courtesies", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-special-courtesy" } }, "mapping": [ { "identity": "v2", "map": "PV1-16-VIP indicator" }, { "identity": "rim", "map": ".specialCourtesiesCode" } ] }, { "path": "Encounter.hospitalization.specialArrangement", "short": "Wheelchair, translator, stretcher, etc", "definition": "Wheelchair, translator, stretcher, etc.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "binding": { "name": "Arrangements", "strength": "required", "description": "Special arrangements", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-special-arrangements" } }, "mapping": [ { "identity": "v2", "map": "PV1-15-ambulatory status / OBR-30-transportation mode / OBR-43-planned patient transport comment" }, { "identity": "rim", "map": ".specialArrangementCode" } ] }, { "path": "Encounter.hospitalization.destination", "short": "Location to which the patient is discharged", "definition": "Location to which the patient is discharged.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/location-qicore-qicore-location" } ], "mapping": [ { "identity": "v2", "map": "PV1-37" }, { "identity": "rim", "map": ".participation[typeCode=DST]" } ] }, { "path": "Encounter.hospitalization.dischargeDisposition", "short": "Category or kind of location after discharge", "definition": "Category or kind of location after discharge.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "binding": { "name": "DischargeDisp", "strength": "required", "description": "Discharge Disposition", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-discharge-disposition" } }, "mapping": [ { "identity": "v2", "map": "PV1-36-discharge disposition" }, { "identity": "rim", "map": ".dischargeDispositionCode" }, { "identity": "qdm", "map": "discharge status" } ] }, { "path": "Encounter.hospitalization.dischargeDiagnosis", "short": "The final diagnosis given a patient before release from the hospital after all testing, surgery, and workup are complete", "definition": "The final diagnosis given a patient before release from the hospital after all testing, surgery, and workup are complete.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Resource" } ], "mustSupport": true, "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=OUT].target[classCode=OBS, moodCode=EVN, code=ASSERTION].value" } ] }, { "path": "Encounter.hospitalization.reAdmission", "short": "Is this hospitalization a readmission?", "definition": "Whether this hospitalization is a readmission.", "min": 0, "max": "1", "type": [ { "code": "boolean" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "PV1-13-re-admission indicator" }, { "identity": "rim", "map": "Propose at harmonization" } ] }, { "path": "Encounter.location", "short": "List of locations the patient has been at", "definition": "List of locations at which the patient has been.", "min": 0, "max": "*", "mapping": [ { "identity": "rim", "map": ".participation[typeCode=LOC]" } ] }, { "path": "Encounter.location.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.location.extension", "short": "Additional Content defined by implementations", "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.", "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Encounter.location.modifierExtension", "short": "Extensions that cannot be ignored", "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.", "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.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.location.location", "short": "Location the encounter takes place", "definition": "The location where the encounter takes place.", "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/location-qicore-qicore-location" } ], "mapping": [ { "identity": "v2", "map": "PV1-3-assigned patient location / PV1-6-prior patient location / PV1-11-temporary location / PV1-42-pending location / PV1-43-prior temporary location" }, { "identity": "rim", "map": ".role" } ] }, { "path": "Encounter.location.status", "short": "planned | present | reserved", "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.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "name": "EncounterLocationStatus", "strength": "required", "description": "The status of the location", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/encounter-location-status" } } }, { "path": "Encounter.location.period", "short": "Time period during which the patient was present at the location", "definition": "Time period during which the patient was present at the location.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mapping": [ { "identity": "rim", "map": ".time" }, { "identity": "qdm", "map": "start datetime, stop datetime" } ] }, { "path": "Encounter.serviceProvider", "short": "The custodian organization of this Encounter record", "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.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/organization-qicore-qicore-organization" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "PV1-10-hospital service / PL.6 Person Location Type & PL.1 Point of Care (note: V2.x definition is \"the treatment or type of surgery that the patient is scheduled to receive\"; seems slightly out of alignment with the concept name 'hospital service'. Would not trust that implementations apply this semantic by default)" }, { "identity": "rim", "map": ".particiaption[typeCode=PFM].role" } ] }, { "path": "Encounter.partOf", "short": "Another Encounter this encounter is part of", "definition": "Another Encounter of which this encounter is a part of (administratively or in time).", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-qicore-qicore-encounter" } ], "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[classCode=COMP, moodCode=EVN]" } ] } ] }, "differential": { "element": [ { "path": "Encounter", "name": "QICore-Encounter", "min": 1, "max": "1", "type": [ { "code": "Encounter" } ], "mapping": [ { "identity": "qdm", "map": "Encounter, Active or Performed" } ] }, { "path": "Encounter.extension", "slicing": { "discriminator": [ "url" ], "ordered": false, "rules": "open" } }, { "path": "Encounter.extension", "name": "Encounter.primaryCondition", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-primaryCondition" } ] }, { "path": "Encounter.extension.valueReference", "name": "Encounter.primaryCondition.valueReference", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/condition-qicore-qicore-condition" } ] }, { "path": "Encounter.extension", "name": "Encounter.relatedCondition", "min": 0, "max": "*", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-relatedCondition" } ] }, { "path": "Encounter.extension.extension", "slicing": { "discriminator": [ "url" ], "ordered": false, "rules": "open" } }, { "path": "Encounter.extension.extension", "name": "Encounter.relatedCondition.condition", "min": 1, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-condition" } ] }, { "path": "Encounter.extension.extension.valueReference", "name": "Encounter.relatedCondition.condition.valueReference", "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/condition-qicore-qicore-condition" } ] }, { "path": "Encounter.extension.extension", "name": "Encounter.relatedCondition.conditionRole", "min": 1, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-conditionRole" } ] }, { "path": "Encounter.extension", "name": "Encounter.reasonCancelled", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-reasonCancelled" } ], "mapping": [ { "identity": "qdm", "map": "negation rationale" } ] }, { "path": "Encounter.status", "mustSupport": true }, { "path": "Encounter.class", "mustSupport": true }, { "path": "Encounter.type", "mustSupport": true, "binding": { "name": "DAFEncounterType", "strength": "extensible", "description": "Encounter type Value set to describe the type of encounter.", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/daf-encounter-type" } }, "mapping": [ { "identity": "qdm", "map": "primary code" } ] }, { "path": "Encounter.patient", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/patient-qicore-qicore-patient" } ], "mustSupport": true }, { "path": "Encounter.incomingReferralRequest", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/referralrequest-qicore-qicore-referralrequest" } ] }, { "path": "Encounter.participant" }, { "path": "Encounter.participant.individual", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/practitioner-qicore-qicore-practitioner" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/relatedperson-qicore-qicore-relatedperson" } ] }, { "path": "Encounter.fulfills" }, { "path": "Encounter.period", "mustSupport": true }, { "path": "Encounter.length", "mustSupport": true, "mapping": [ { "identity": "qdm", "map": "length of stay" } ] }, { "path": "Encounter.reason", "mustSupport": true, "binding": { "name": "DAFEncounterReasonValueset", "strength": "extensible", "description": "Encounter Diagnoses Value set to describe the specific encounter code.", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/daf-encounter-reason" } }, "mapping": [ { "identity": "qdm", "map": "reason" } ] }, { "path": "Encounter.hospitalization", "min": 0, "max": "1" }, { "path": "Encounter.hospitalization.extension", "slicing": { "discriminator": [ "url" ], "ordered": false, "rules": "open" } }, { "path": "Encounter.hospitalization.extension", "name": "Encounter.hospitalization.admission", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-admission" } ], "mapping": [ { "identity": "qdm", "map": "admission datetime" } ] }, { "path": "Encounter.hospitalization.extension", "name": "Encounter.hospitalization.discharge", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-discharge" } ], "mapping": [ { "identity": "qdm", "map": "discharge datetime" } ] }, { "path": "Encounter.hospitalization.origin", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/location-qicore-qicore-location" } ] }, { "path": "Encounter.hospitalization.admitSource", "mustSupport": true }, { "path": "Encounter.hospitalization.destination", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/location-qicore-qicore-location" } ] }, { "path": "Encounter.hospitalization.dischargeDisposition", "mustSupport": true, "mapping": [ { "identity": "qdm", "map": "discharge status" } ] }, { "path": "Encounter.hospitalization.dischargeDiagnosis", "mustSupport": true }, { "path": "Encounter.hospitalization.reAdmission", "mustSupport": true }, { "path": "Encounter.location" }, { "path": "Encounter.location.location", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/location-qicore-qicore-location" } ] }, { "path": "Encounter.location.period", "mapping": [ { "identity": "qdm", "map": "start datetime, stop datetime" } ] }, { "path": "Encounter.serviceProvider", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/organization-qicore-qicore-organization" } ], "mustSupport": true }, { "path": "Encounter.partOf", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/encounter-qicore-qicore-encounter" } ] } ] } }