QI-Core Implementation Guide
5.0.0 - STU5
QI-Core Implementation Guide
5.0.0 - STU5
This page is part of the Quality Improvement Core Framework (v5.0.0: STU5 (v5.0.0)) based on FHIR R4. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter | Version: 5.0.0 | |||
| Active as of 2018-08-22 | Computable Name: QICoreEncounter | |||
Profile of Encounter for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.
The following example illustrates accessing an inpatient encounter:
define "Ophthalmology Encounter Codes":
[Encounter: class in "Inpatient Encounter Classes"] InpatientEncounter
where InpatientEncounter.type in "Ophthalmology Encounter Codes"
| Inpatient Admission for Appendicitis |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreEncounterProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Encounter | 0..* | USCoreEncounterProfile | An interaction during which services are provided to the patient | |
  priority | S | 0..1 | CodeableConcept | Indicates the urgency of the encounter Binding: ActPriority (preferred) |
 subject | S | 1..1 | Reference(QICore Patient) | The patient or group present at the encounter |
| basedOn | 0..* | Reference(QICore ServiceRequest) | The ServiceRequest that initiated this encounter | |
 participant | S | 0..* | BackboneElement | List of participants involved in the encounter |
  individual | S | 0..1 | Reference(QICore Practitioner S | QICore PractitionerRole | QICore RelatedPerson) | Persons involved in the encounter other than the patient |
| length | S | 0..1 | Duration | Quantity of time the encounter lasted (less time absent) |
| reasonReference | SΣ | 0..* | Reference(QICore Condition Problems Health Concerns S | QICore Condition Encounter Diagnosis S | QICore Procedure S | QICore Observation S | QICore ImmunizationRecommendation S) | Reason the encounter takes place (reference) |
| diagnosis | S | 0..* | BackboneElement | The list of diagnosis relevant to this encounter |
 diagnosisPresentOnAdmission | S | 0..1 | CodeableConcept | onAdmission URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission Binding: QICore Present On Admission Codes (required): Indicator of whether the Encounter diagnosis was present at the time of admission |
| condition | S | 1..1 | Reference(QICore Condition Encounter Diagnosis S | QICore Procedure S) | The diagnosis or procedure relevant to the encounter |
| use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) |
| rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) |
| hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service |
| origin | 0..1 | Reference(QICore Location) | The location/organization from which the patient came before admission | |
| admitSource | S | 0..1 | CodeableConcept | From where patient was admitted (physician referral, transfer) |
| reAdmission | S | 0..1 | CodeableConcept | The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission |
| destination | 0..1 | Reference(QICore Location) | Location/organization to which the patient is discharged | |
| dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) |
| location | S | 0..* | BackboneElement | List of locations where the patient has been |
| location | S | 1..1 | Reference(QICore Location) | Location the encounter takes place |
| period | S | 0..1 | Period | Time period during which the patient was present at the location |
| serviceProvider | S | 0..1 | Reference(QICore Organization) | The organization (facility) responsible for this encounter |
| partOf | 0..1 | Reference(QICore Encounter) | Another Encounter this encounter is part of | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Encounter.priority | preferred | ActPriority |
| Encounter.diagnosis.extension:diagnosisPresentOnAdmission [CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission]] | required | QICorePresentOnAdmission |
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDisposition |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Encounter | 0..* | USCoreEncounterProfile | An interaction during which services are provided to the patient | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
 identifier | SΣ | 0..* | Identifier | Identifier(s) by which this encounter is known |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| system | SΣ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣ | 1..1 | string | The value that is unique Example General: 123456 |
| status | ?!SΣ | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. |
| class | SΣ | 1..1 | Coding | Classification of patient encounter Binding: ActEncounterCode (extensible): Classification of the encounter. |
| type | SΣ | 1..* | CodeableConcept | Specific type of encounter Binding: US Core Encounter Type (extensible): Valueset to describe the Encounter Type |
| priority | S | 0..1 | CodeableConcept | Indicates the urgency of the encounter Binding: ActPriority (preferred) |
| subject | SΣ | 1..1 | Reference(QICore Patient) | The patient or group present at the encounter |
| basedOn | 0..* | Reference(QICore ServiceRequest) | The ServiceRequest that initiated this encounter | |
| participant | SΣ | 0..* | BackboneElement | List of participants involved in the encounter |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | SΣ | 0..* | CodeableConcept | Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. |
| period | S | 0..1 | Period | Period of time during the encounter that the participant participated |
| individual | SΣ | 0..1 | Reference(QICore Practitioner) | Persons involved in the encounter other than the patient |
| period | S | 0..1 | Period | The start and end time of the encounter |
| length | S | 0..1 | Duration | Quantity of time the encounter lasted (less time absent) |
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason the encounter takes place Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place. |
| reasonReference | SΣ | 0..* | Reference(QICore Condition Problems Health Concerns | QICore Condition Encounter Diagnosis | QICore Procedure | QICore Observation | QICore ImmunizationRecommendation) | Reason the encounter takes place (reference) |
| diagnosis | SΣ | 0..* | BackboneElement | The list of diagnosis relevant to this encounter |
| diagnosisPresentOnAdmission | S | 0..1 | CodeableConcept | onAdmission URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission Binding: QICore Present On Admission Codes (required): Indicator of whether the Encounter diagnosis was present at the time of admission |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| condition | SΣ | 1..1 | Reference(QICore Condition Encounter Diagnosis | QICore Procedure) | The diagnosis or procedure relevant to the encounter |
| use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents. |
| rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) |
| hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| origin | 0..1 | Reference(QICore Location) | The location/organization from which the patient came before admission | |
| admitSource | S | 0..1 | CodeableConcept | From where patient was admitted (physician referral, transfer) Binding: AdmitSource (preferred): From where the patient was admitted. |
| reAdmission | S | 0..1 | CodeableConcept | The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter. |
| destination | 0..1 | Reference(QICore Location) | Location/organization to which the patient is discharged | |
| dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) |
| location | S | 0..* | BackboneElement | List of locations where the patient has been |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| location | S | 1..1 | Reference(QICore Location) | Location the encounter takes place |
| period | S | 0..1 | Period | Time period during which the patient was present at the location |
| serviceProvider | S | 0..1 | Reference(QICore Organization) | The organization (facility) responsible for this encounter |
| partOf | 0..1 | Reference(QICore Encounter) | Another Encounter this encounter is part of | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Encounter.identifier.use | required | IdentifierUse |
| Encounter.status | required | EncounterStatus |
| Encounter.class | extensible | ActEncounterCode |
| Encounter.type | extensible | USCoreEncounterType |
| Encounter.priority | preferred | ActPriority |
| Encounter.participant.type | extensible | ParticipantType |
| Encounter.reasonCode | preferred | EncounterReasonCodes |
| Encounter.diagnosis.use | preferred | DiagnosisRole |
| Encounter.hospitalization.admitSource | preferred | AdmitSource |
| Encounter.hospitalization.reAdmission | example | Hl7VSReAdmissionIndicator |
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDisposition |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Encounter | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Encounter | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Encounter | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Encounter | 0..* | USCoreEncounterProfile | An interaction during which services are provided to the patient | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 0..* | Identifier | Identifier(s) by which this encounter is known | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| system | SΣ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | SΣ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!SΣ | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. | ||||
| statusHistory | 0..* | BackboneElement | List of past encounter statuses | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| status | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. | |||||
| period | 1..1 | Period | The time that the episode was in the specified status | |||||
| class | SΣ | 1..1 | Coding | Classification of patient encounter Binding: ActEncounterCode (extensible): Classification of the encounter. | ||||
| classHistory | 0..* | BackboneElement | List of past encounter classes | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| class | 1..1 | Coding | inpatient | outpatient | ambulatory | emergency + Binding: ActEncounterCode (extensible): Classification of the encounter. | |||||
| period | 1..1 | Period | The time that the episode was in the specified class | |||||
| type | SΣ | 1..* | CodeableConcept | Specific type of encounter Binding: US Core Encounter Type (extensible): Valueset to describe the Encounter Type | ||||
| serviceType | Σ | 0..1 | CodeableConcept | Specific type of service Binding: ServiceType (example): Broad categorization of the service that is to be provided. | ||||
| priority | S | 0..1 | CodeableConcept | Indicates the urgency of the encounter Binding: ActPriority (preferred) | ||||
| subject | SΣ | 1..1 | Reference(QICore Patient) | The patient or group present at the encounter | ||||
| episodeOfCare | Σ | 0..* | Reference(EpisodeOfCare) | Episode(s) of care that this encounter should be recorded against | ||||
| basedOn | 0..* | Reference(QICore ServiceRequest) | The ServiceRequest that initiated this encounter | |||||
| participant | SΣ | 0..* | BackboneElement | List of participants involved in the encounter | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | SΣ | 0..* | CodeableConcept | Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. | ||||
| period | S | 0..1 | Period | Period of time during the encounter that the participant participated | ||||
| individual | SΣ | 0..1 | Reference(QICore Practitioner S | QICore PractitionerRole | QICore RelatedPerson) | Persons involved in the encounter other than the patient | ||||
| appointment | Σ | 0..* | Reference(Appointment) | The appointment that scheduled this encounter | ||||
| period | S | 0..1 | Period | The start and end time of the encounter | ||||
| length | S | 0..1 | Duration | Quantity of time the encounter lasted (less time absent) | ||||
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason the encounter takes place Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place. | ||||
| reasonReference | SΣ | 0..* | Reference(QICore Condition Problems Health Concerns S | QICore Condition Encounter Diagnosis S | QICore Procedure S | QICore Observation S | QICore ImmunizationRecommendation S) | Reason the encounter takes place (reference) | ||||
| diagnosis | SΣ | 0..* | BackboneElement | The list of diagnosis relevant to this encounter | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| diagnosisPresentOnAdmission | S | 0..1 | CodeableConcept | onAdmission URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission Binding: QICore Present On Admission Codes (required): Indicator of whether the Encounter diagnosis was present at the time of admission | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| condition | SΣ | 1..1 | Reference(QICore Condition Encounter Diagnosis S | QICore Procedure S) | The diagnosis or procedure relevant to the encounter | ||||
| use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents. | ||||
| rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) | ||||
| account | 0..* | Reference(Account) | The set of accounts that may be used for billing for this Encounter | |||||
| hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| preAdmissionIdentifier | 0..1 | Identifier | Pre-admission identifier | |||||
| origin | 0..1 | Reference(QICore Location) | The location/organization from which the patient came before admission | |||||
| admitSource | S | 0..1 | CodeableConcept | From where patient was admitted (physician referral, transfer) Binding: AdmitSource (preferred): From where the patient was admitted. | ||||
| reAdmission | S | 0..1 | CodeableConcept | The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter. | ||||
| dietPreference | 0..* | CodeableConcept | Diet preferences reported by the patient Binding: Diet (example): Medical, cultural or ethical food preferences to help with catering requirements. | |||||
| specialCourtesy | 0..* | CodeableConcept | Special courtesies (VIP, board member) Binding: SpecialCourtesy (preferred): Special courtesies. | |||||
| specialArrangement | 0..* | CodeableConcept | Wheelchair, translator, stretcher, etc. Binding: SpecialArrangements (preferred): Special arrangements. | |||||
| destination | 0..1 | Reference(QICore Location) | Location/organization to which the patient is discharged | |||||
| dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) | ||||
| location | S | 0..* | BackboneElement | List of locations where the patient has been | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| location | S | 1..1 | Reference(QICore Location) | Location the encounter takes place | ||||
| status | 0..1 | code | planned | active | reserved | completed Binding: EncounterLocationStatus (required): The status of the location. | |||||
| physicalType | 0..1 | CodeableConcept | The physical type of the location (usually the level in the location hierachy - bed room ward etc.) Binding: LocationType (example): Physical form of the location. | |||||
| period | S | 0..1 | Period | Time period during which the patient was present at the location | ||||
| serviceProvider | S | 0..1 | Reference(QICore Organization) | The organization (facility) responsible for this encounter | ||||
| partOf | 0..1 | Reference(QICore Encounter) | Another Encounter this encounter is part of | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| Encounter.language | preferred | CommonLanguages
| ||||
| Encounter.identifier.use | required | IdentifierUse | ||||
| Encounter.identifier.type | extensible | Identifier Type Codes | ||||
| Encounter.status | required | EncounterStatus | ||||
| Encounter.statusHistory.status | required | EncounterStatus | ||||
| Encounter.class | extensible | ActEncounterCode | ||||
| Encounter.classHistory.class | extensible | ActEncounterCode | ||||
| Encounter.type | extensible | USCoreEncounterType | ||||
| Encounter.serviceType | example | ServiceType | ||||
| Encounter.priority | preferred | ActPriority | ||||
| Encounter.participant.type | extensible | ParticipantType | ||||
| Encounter.reasonCode | preferred | EncounterReasonCodes | ||||
| Encounter.diagnosis.use | preferred | DiagnosisRole | ||||
| Encounter.hospitalization.admitSource | preferred | AdmitSource | ||||
| Encounter.hospitalization.reAdmission | example | Hl7VSReAdmissionIndicator | ||||
| Encounter.hospitalization.dietPreference | example | Diet | ||||
| Encounter.hospitalization.specialCourtesy | preferred | SpecialCourtesy | ||||
| Encounter.hospitalization.specialArrangement | preferred | SpecialArrangements | ||||
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDisposition | ||||
| Encounter.location.status | required | EncounterLocationStatus | ||||
| Encounter.location.physicalType | example | LocationType |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USCoreEncounterProfile
Summary
Must-Support: 19 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from USCoreEncounterProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Encounter | 0..* | USCoreEncounterProfile | An interaction during which services are provided to the patient | |
| priority | S | 0..1 | CodeableConcept | Indicates the urgency of the encounter Binding: ActPriority (preferred) |
| subject | S | 1..1 | Reference(QICore Patient) | The patient or group present at the encounter |
| basedOn | 0..* | Reference(QICore ServiceRequest) | The ServiceRequest that initiated this encounter | |
| participant | S | 0..* | BackboneElement | List of participants involved in the encounter |
| individual | S | 0..1 | Reference(QICore Practitioner S | QICore PractitionerRole | QICore RelatedPerson) | Persons involved in the encounter other than the patient |
| length | S | 0..1 | Duration | Quantity of time the encounter lasted (less time absent) |
| reasonReference | SΣ | 0..* | Reference(QICore Condition Problems Health Concerns S | QICore Condition Encounter Diagnosis S | QICore Procedure S | QICore Observation S | QICore ImmunizationRecommendation S) | Reason the encounter takes place (reference) |
| diagnosis | S | 0..* | BackboneElement | The list of diagnosis relevant to this encounter |
| diagnosisPresentOnAdmission | S | 0..1 | CodeableConcept | onAdmission URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission Binding: QICore Present On Admission Codes (required): Indicator of whether the Encounter diagnosis was present at the time of admission |
| condition | S | 1..1 | Reference(QICore Condition Encounter Diagnosis S | QICore Procedure S) | The diagnosis or procedure relevant to the encounter |
| use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) |
| rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) |
| hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service |
| origin | 0..1 | Reference(QICore Location) | The location/organization from which the patient came before admission | |
| admitSource | S | 0..1 | CodeableConcept | From where patient was admitted (physician referral, transfer) |
| reAdmission | S | 0..1 | CodeableConcept | The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission |
| destination | 0..1 | Reference(QICore Location) | Location/organization to which the patient is discharged | |
| dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) |
| location | S | 0..* | BackboneElement | List of locations where the patient has been |
| location | S | 1..1 | Reference(QICore Location) | Location the encounter takes place |
| period | S | 0..1 | Period | Time period during which the patient was present at the location |
| serviceProvider | S | 0..1 | Reference(QICore Organization) | The organization (facility) responsible for this encounter |
| partOf | 0..1 | Reference(QICore Encounter) | Another Encounter this encounter is part of | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Encounter.priority | preferred | ActPriority |
| Encounter.diagnosis.extension:diagnosisPresentOnAdmission [CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission]] | required | QICorePresentOnAdmission |
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDisposition |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Encounter | 0..* | USCoreEncounterProfile | An interaction during which services are provided to the patient | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 0..* | Identifier | Identifier(s) by which this encounter is known |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| system | SΣ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣ | 1..1 | string | The value that is unique Example General: 123456 |
| status | ?!SΣ | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. |
| class | SΣ | 1..1 | Coding | Classification of patient encounter Binding: ActEncounterCode (extensible): Classification of the encounter. |
| type | SΣ | 1..* | CodeableConcept | Specific type of encounter Binding: US Core Encounter Type (extensible): Valueset to describe the Encounter Type |
| priority | S | 0..1 | CodeableConcept | Indicates the urgency of the encounter Binding: ActPriority (preferred) |
| subject | SΣ | 1..1 | Reference(QICore Patient) | The patient or group present at the encounter |
| basedOn | 0..* | Reference(QICore ServiceRequest) | The ServiceRequest that initiated this encounter | |
| participant | SΣ | 0..* | BackboneElement | List of participants involved in the encounter |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | SΣ | 0..* | CodeableConcept | Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. |
| period | S | 0..1 | Period | Period of time during the encounter that the participant participated |
| individual | SΣ | 0..1 | Reference(QICore Practitioner) | Persons involved in the encounter other than the patient |
| period | S | 0..1 | Period | The start and end time of the encounter |
| length | S | 0..1 | Duration | Quantity of time the encounter lasted (less time absent) |
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason the encounter takes place Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place. |
| reasonReference | SΣ | 0..* | Reference(QICore Condition Problems Health Concerns | QICore Condition Encounter Diagnosis | QICore Procedure | QICore Observation | QICore ImmunizationRecommendation) | Reason the encounter takes place (reference) |
| diagnosis | SΣ | 0..* | BackboneElement | The list of diagnosis relevant to this encounter |
| diagnosisPresentOnAdmission | S | 0..1 | CodeableConcept | onAdmission URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission Binding: QICore Present On Admission Codes (required): Indicator of whether the Encounter diagnosis was present at the time of admission |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| condition | SΣ | 1..1 | Reference(QICore Condition Encounter Diagnosis | QICore Procedure) | The diagnosis or procedure relevant to the encounter |
| use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents. |
| rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) |
| hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| origin | 0..1 | Reference(QICore Location) | The location/organization from which the patient came before admission | |
| admitSource | S | 0..1 | CodeableConcept | From where patient was admitted (physician referral, transfer) Binding: AdmitSource (preferred): From where the patient was admitted. |
| reAdmission | S | 0..1 | CodeableConcept | The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter. |
| destination | 0..1 | Reference(QICore Location) | Location/organization to which the patient is discharged | |
| dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) |
| location | S | 0..* | BackboneElement | List of locations where the patient has been |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| location | S | 1..1 | Reference(QICore Location) | Location the encounter takes place |
| period | S | 0..1 | Period | Time period during which the patient was present at the location |
| serviceProvider | S | 0..1 | Reference(QICore Organization) | The organization (facility) responsible for this encounter |
| partOf | 0..1 | Reference(QICore Encounter) | Another Encounter this encounter is part of | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Encounter.identifier.use | required | IdentifierUse |
| Encounter.status | required | EncounterStatus |
| Encounter.class | extensible | ActEncounterCode |
| Encounter.type | extensible | USCoreEncounterType |
| Encounter.priority | preferred | ActPriority |
| Encounter.participant.type | extensible | ParticipantType |
| Encounter.reasonCode | preferred | EncounterReasonCodes |
| Encounter.diagnosis.use | preferred | DiagnosisRole |
| Encounter.hospitalization.admitSource | preferred | AdmitSource |
| Encounter.hospitalization.reAdmission | example | Hl7VSReAdmissionIndicator |
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDisposition |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Encounter | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Encounter | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Encounter | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Encounter | 0..* | USCoreEncounterProfile | An interaction during which services are provided to the patient | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 0..* | Identifier | Identifier(s) by which this encounter is known | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| system | SΣ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | SΣ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!SΣ | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. | ||||
| statusHistory | 0..* | BackboneElement | List of past encounter statuses | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| status | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. | |||||
| period | 1..1 | Period | The time that the episode was in the specified status | |||||
| class | SΣ | 1..1 | Coding | Classification of patient encounter Binding: ActEncounterCode (extensible): Classification of the encounter. | ||||
| classHistory | 0..* | BackboneElement | List of past encounter classes | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| class | 1..1 | Coding | inpatient | outpatient | ambulatory | emergency + Binding: ActEncounterCode (extensible): Classification of the encounter. | |||||
| period | 1..1 | Period | The time that the episode was in the specified class | |||||
| type | SΣ | 1..* | CodeableConcept | Specific type of encounter Binding: US Core Encounter Type (extensible): Valueset to describe the Encounter Type | ||||
| serviceType | Σ | 0..1 | CodeableConcept | Specific type of service Binding: ServiceType (example): Broad categorization of the service that is to be provided. | ||||
| priority | S | 0..1 | CodeableConcept | Indicates the urgency of the encounter Binding: ActPriority (preferred) | ||||
| subject | SΣ | 1..1 | Reference(QICore Patient) | The patient or group present at the encounter | ||||
| episodeOfCare | Σ | 0..* | Reference(EpisodeOfCare) | Episode(s) of care that this encounter should be recorded against | ||||
| basedOn | 0..* | Reference(QICore ServiceRequest) | The ServiceRequest that initiated this encounter | |||||
| participant | SΣ | 0..* | BackboneElement | List of participants involved in the encounter | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | SΣ | 0..* | CodeableConcept | Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. | ||||
| period | S | 0..1 | Period | Period of time during the encounter that the participant participated | ||||
| individual | SΣ | 0..1 | Reference(QICore Practitioner S | QICore PractitionerRole | QICore RelatedPerson) | Persons involved in the encounter other than the patient | ||||
| appointment | Σ | 0..* | Reference(Appointment) | The appointment that scheduled this encounter | ||||
| period | S | 0..1 | Period | The start and end time of the encounter | ||||
| length | S | 0..1 | Duration | Quantity of time the encounter lasted (less time absent) | ||||
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason the encounter takes place Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place. | ||||
| reasonReference | SΣ | 0..* | Reference(QICore Condition Problems Health Concerns S | QICore Condition Encounter Diagnosis S | QICore Procedure S | QICore Observation S | QICore ImmunizationRecommendation S) | Reason the encounter takes place (reference) | ||||
| diagnosis | SΣ | 0..* | BackboneElement | The list of diagnosis relevant to this encounter | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| diagnosisPresentOnAdmission | S | 0..1 | CodeableConcept | onAdmission URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission Binding: QICore Present On Admission Codes (required): Indicator of whether the Encounter diagnosis was present at the time of admission | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| condition | SΣ | 1..1 | Reference(QICore Condition Encounter Diagnosis S | QICore Procedure S) | The diagnosis or procedure relevant to the encounter | ||||
| use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents. | ||||
| rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) | ||||
| account | 0..* | Reference(Account) | The set of accounts that may be used for billing for this Encounter | |||||
| hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| preAdmissionIdentifier | 0..1 | Identifier | Pre-admission identifier | |||||
| origin | 0..1 | Reference(QICore Location) | The location/organization from which the patient came before admission | |||||
| admitSource | S | 0..1 | CodeableConcept | From where patient was admitted (physician referral, transfer) Binding: AdmitSource (preferred): From where the patient was admitted. | ||||
| reAdmission | S | 0..1 | CodeableConcept | The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter. | ||||
| dietPreference | 0..* | CodeableConcept | Diet preferences reported by the patient Binding: Diet (example): Medical, cultural or ethical food preferences to help with catering requirements. | |||||
| specialCourtesy | 0..* | CodeableConcept | Special courtesies (VIP, board member) Binding: SpecialCourtesy (preferred): Special courtesies. | |||||
| specialArrangement | 0..* | CodeableConcept | Wheelchair, translator, stretcher, etc. Binding: SpecialArrangements (preferred): Special arrangements. | |||||
| destination | 0..1 | Reference(QICore Location) | Location/organization to which the patient is discharged | |||||
| dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) | ||||
| location | S | 0..* | BackboneElement | List of locations where the patient has been | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| location | S | 1..1 | Reference(QICore Location) | Location the encounter takes place | ||||
| status | 0..1 | code | planned | active | reserved | completed Binding: EncounterLocationStatus (required): The status of the location. | |||||
| physicalType | 0..1 | CodeableConcept | The physical type of the location (usually the level in the location hierachy - bed room ward etc.) Binding: LocationType (example): Physical form of the location. | |||||
| period | S | 0..1 | Period | Time period during which the patient was present at the location | ||||
| serviceProvider | S | 0..1 | Reference(QICore Organization) | The organization (facility) responsible for this encounter | ||||
| partOf | 0..1 | Reference(QICore Encounter) | Another Encounter this encounter is part of | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| Encounter.language | preferred | CommonLanguages
| ||||
| Encounter.identifier.use | required | IdentifierUse | ||||
| Encounter.identifier.type | extensible | Identifier Type Codes | ||||
| Encounter.status | required | EncounterStatus | ||||
| Encounter.statusHistory.status | required | EncounterStatus | ||||
| Encounter.class | extensible | ActEncounterCode | ||||
| Encounter.classHistory.class | extensible | ActEncounterCode | ||||
| Encounter.type | extensible | USCoreEncounterType | ||||
| Encounter.serviceType | example | ServiceType | ||||
| Encounter.priority | preferred | ActPriority | ||||
| Encounter.participant.type | extensible | ParticipantType | ||||
| Encounter.reasonCode | preferred | EncounterReasonCodes | ||||
| Encounter.diagnosis.use | preferred | DiagnosisRole | ||||
| Encounter.hospitalization.admitSource | preferred | AdmitSource | ||||
| Encounter.hospitalization.reAdmission | example | Hl7VSReAdmissionIndicator | ||||
| Encounter.hospitalization.dietPreference | example | Diet | ||||
| Encounter.hospitalization.specialCourtesy | preferred | SpecialCourtesy | ||||
| Encounter.hospitalization.specialArrangement | preferred | SpecialArrangements | ||||
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDisposition | ||||
| Encounter.location.status | required | EncounterLocationStatus | ||||
| Encounter.location.physicalType | example | LocationType |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USCoreEncounterProfile
Summary
Must-Support: 19 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ http://www.hl7.org/Special/committees/cqi/index.cfm. Package hl7.fhir.us.qicore#5.0.0 based on FHIR 4.0.1. Generated 2023-04-04
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