QI-Core Implementation Guide
6.0.0 - STU6
QI-Core Implementation Guide
6.0.0 - STU6
This page is part of the Quality Improvement Core Framework (v6.0.0: STU6 (v6.0.0)) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). 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: 6.0.0 | |||
| 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 | USCoreEncounterProfile | |||
  subject | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) The patient or group present at the encounter | |
  participant | 0..* | BackboneElement | (QI-Core)(USCDI) List of participants involved in the encounter | |
  individual | 0..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore RelatedPerson) | (QI-Core)(USCDI) Persons involved in the encounter other than the patient | |
| reasonReference | Σ | 0..* | Reference(QICore Condition Problems Health Concerns | QICore Condition Encounter Diagnosis | QICore Procedure | QICore Simple Observation | QICore ImmunizationRecommendation) | (QI-Core)(USCDI) Reason the encounter takes place (reference) |
| hospitalization | 0..1 | BackboneElement | (QI-Core)(USCDI) Details about the admission to a healthcare service | |
| origin | 0..1 | Reference(QICore Location) | The location/organization from which the patient came before admission | |
| destination | 0..1 | Reference(QICore Location) | Location/organization to which the patient is discharged | |
| dischargeDisposition | 0..1 | CodeableConcept | (QI-Core)(USCDI) Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) | |
| location | 0..* | BackboneElement | (QI-Core)(USCDI) List of locations where the patient has been | |
| location | 1..1 | Reference(QICore Location) | (QI-Core)(USCDI) Location the encounter takes place | |
| period | 0..1 | Period | (QI-Core) Time period during which the patient was present at the location | |
| serviceProvider | 0..1 | Reference(QICore Organization) | (QI-Core)(USCDI) 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 | URI |
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDispositionhttp://terminology.hl7.org/ValueSet/clinical-discharge-disposition |
| 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 | (USCDI) 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 | (USCDI) The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣ | 1..1 | string | (USCDI) The value that is unique Example General: 123456 |
| status | ?!SΣ | 1..1 | code | (USCDI) planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. |
| class | SΣ | 1..1 | Coding | (USCDI) Classification of patient encounter Binding: ActEncounterCode (extensible): Classification of the encounter. |
| type | SΣ | 1..* | CodeableConcept | (USCDI) Specific type of encounter Binding: US Core Encounter Type (extensible): Valueset to describe the Encounter Type |
| subject | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) The patient or group present at the encounter |
| participant | SΣ | 0..* | BackboneElement | (QI-Core)(USCDI) List of participants involved in the encounter |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | SΣ | 0..* | CodeableConcept | (USCDI) Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. |
| period | S | 0..1 | Period | (USCDI) Period of time during the encounter that the participant participated |
| individual | SΣ | 0..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore RelatedPerson) | (QI-Core)(USCDI) Persons involved in the encounter other than the patient |
| period | S | 0..1 | Period | (USCDI) The start and end time of the encounter |
| reasonCode | SΣ | 0..* | CodeableConcept | (USCDI) 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 Simple Observation | QICore ImmunizationRecommendation) | (QI-Core)(USCDI) Reason the encounter takes place (reference) |
| hospitalization | S | 0..1 | BackboneElement | (QI-Core)(USCDI) 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 | |
| destination | 0..1 | Reference(QICore Location) | Location/organization to which the patient is discharged | |
| dischargeDisposition | S | 0..1 | CodeableConcept | (QI-Core)(USCDI) Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) |
| location | S | 0..* | BackboneElement | (QI-Core)(USCDI) 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) | (QI-Core)(USCDI) Location the encounter takes place |
| period | 0..1 | Period | (QI-Core) Time period during which the patient was present at the location | |
| serviceProvider | S | 0..1 | Reference(QICore Organization) | (QI-Core)(USCDI) 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 | URI |
| Encounter.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | |
| Encounter.status | required | EncounterStatushttp://hl7.org/fhir/ValueSet/encounter-status|4.0.1from the FHIR Standard | |
| Encounter.class | extensible | ActEncounterCodehttp://terminology.hl7.org/ValueSet/v3-ActEncounterCode | |
| Encounter.type | extensible | USCoreEncounterTypehttp://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type | |
| Encounter.participant.type | extensible | ParticipantTypehttp://hl7.org/fhir/ValueSet/encounter-participant-typefrom the FHIR Standard | |
| Encounter.reasonCode | preferred | EncounterReasonCodeshttp://hl7.org/fhir/ValueSet/encounter-reasonfrom the FHIR Standard | |
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDispositionhttp://terminology.hl7.org/ValueSet/clinical-discharge-disposition |
| 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 | (USCDI) 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 | (USCDI) The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | SΣ | 1..1 | string | (USCDI) 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 | (USCDI) 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 | (USCDI) 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 | (USCDI) 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 | 0..1 | CodeableConcept | Indicates the urgency of the encounter Binding: ActPriority (example): Indicates the urgency of the encounter. | |||||
| subject | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) 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(ServiceRequest) | The ServiceRequest that initiated this encounter | |||||
| participant | SΣ | 0..* | BackboneElement | (QI-Core)(USCDI) 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 | (USCDI) Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. | ||||
| period | S | 0..1 | Period | (USCDI) Period of time during the encounter that the participant participated | ||||
| individual | SΣ | 0..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore RelatedPerson) | (QI-Core)(USCDI) 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 | (USCDI) The start and end time of the encounter | ||||
| length | 0..1 | Duration | Quantity of time the encounter lasted (less time absent) | |||||
| reasonCode | SΣ | 0..* | CodeableConcept | (USCDI) 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 Simple Observation | QICore ImmunizationRecommendation) | (QI-Core)(USCDI) Reason the encounter takes place (reference) | ||||
| diagnosis | Σ | 0..* | BackboneElement | The list of diagnosis relevant to this 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 | ||||
| condition | Σ | 1..1 | Reference(Condition | Procedure) | The diagnosis or procedure relevant to the encounter | ||||
| use | 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 | 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 | (QI-Core)(USCDI) 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 | 0..1 | CodeableConcept | From where patient was admitted (physician referral, transfer) Binding: AdmitSource (preferred): From where the patient was admitted. | |||||
| reAdmission | 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 | (QI-Core)(USCDI) Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) | ||||
| location | S | 0..* | BackboneElement | (QI-Core)(USCDI) 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) | (QI-Core)(USCDI) 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 | 0..1 | Period | (QI-Core) Time period during which the patient was present at the location | |||||
| serviceProvider | S | 0..1 | Reference(QICore Organization) | (QI-Core)(USCDI) 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 | URI | |||
| Encounter.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Encounter.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| Encounter.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | ||||
| Encounter.status | required | EncounterStatushttp://hl7.org/fhir/ValueSet/encounter-status|4.0.1from the FHIR Standard | ||||
| Encounter.statusHistory.status | required | EncounterStatushttp://hl7.org/fhir/ValueSet/encounter-status|4.0.1from the FHIR Standard | ||||
| Encounter.class | extensible | ActEncounterCodehttp://terminology.hl7.org/ValueSet/v3-ActEncounterCode | ||||
| Encounter.classHistory.class | extensible | ActEncounterCodehttp://terminology.hl7.org/ValueSet/v3-ActEncounterCode | ||||
| Encounter.type | extensible | USCoreEncounterTypehttp://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type | ||||
| Encounter.serviceType | example | ServiceTypehttp://hl7.org/fhir/ValueSet/service-typefrom the FHIR Standard | ||||
| Encounter.priority | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | ||||
| Encounter.participant.type | extensible | ParticipantTypehttp://hl7.org/fhir/ValueSet/encounter-participant-typefrom the FHIR Standard | ||||
| Encounter.reasonCode | preferred | EncounterReasonCodeshttp://hl7.org/fhir/ValueSet/encounter-reasonfrom the FHIR Standard | ||||
| Encounter.diagnosis.use | preferred | DiagnosisRolehttp://hl7.org/fhir/ValueSet/diagnosis-rolefrom the FHIR Standard | ||||
| Encounter.hospitalization.admitSource | preferred | AdmitSourcehttp://hl7.org/fhir/ValueSet/encounter-admit-sourcefrom the FHIR Standard | ||||
| Encounter.hospitalization.reAdmission | example | Hl7VSReAdmissionIndicatorhttp://terminology.hl7.org/ValueSet/v2-0092 | ||||
| Encounter.hospitalization.dietPreference | example | Diethttp://hl7.org/fhir/ValueSet/encounter-dietfrom the FHIR Standard | ||||
| Encounter.hospitalization.specialCourtesy | preferred | SpecialCourtesyhttp://hl7.org/fhir/ValueSet/encounter-special-courtesyfrom the FHIR Standard | ||||
| Encounter.hospitalization.specialArrangement | preferred | SpecialArrangementshttp://hl7.org/fhir/ValueSet/encounter-special-arrangementsfrom the FHIR Standard | ||||
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDispositionhttp://terminology.hl7.org/ValueSet/clinical-discharge-disposition | ||||
| Encounter.location.status | required | EncounterLocationStatushttp://hl7.org/fhir/ValueSet/encounter-location-status|4.0.1from the FHIR Standard | ||||
| Encounter.location.physicalType | example | LocationTypehttp://hl7.org/fhir/ValueSet/location-physical-typefrom the FHIR Standard |
| 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() |
This structure is derived from USCoreEncounterProfile
Summary
Structures
This structure refers to these other structures:
Differential View
This structure is derived from USCoreEncounterProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Encounter | USCoreEncounterProfile | |||
| subject | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) The patient or group present at the encounter | |
| participant | 0..* | BackboneElement | (QI-Core)(USCDI) List of participants involved in the encounter | |
| individual | 0..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore RelatedPerson) | (QI-Core)(USCDI) Persons involved in the encounter other than the patient | |
| reasonReference | Σ | 0..* | Reference(QICore Condition Problems Health Concerns | QICore Condition Encounter Diagnosis | QICore Procedure | QICore Simple Observation | QICore ImmunizationRecommendation) | (QI-Core)(USCDI) Reason the encounter takes place (reference) |
| hospitalization | 0..1 | BackboneElement | (QI-Core)(USCDI) Details about the admission to a healthcare service | |
| origin | 0..1 | Reference(QICore Location) | The location/organization from which the patient came before admission | |
| destination | 0..1 | Reference(QICore Location) | Location/organization to which the patient is discharged | |
| dischargeDisposition | 0..1 | CodeableConcept | (QI-Core)(USCDI) Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) | |
| location | 0..* | BackboneElement | (QI-Core)(USCDI) List of locations where the patient has been | |
| location | 1..1 | Reference(QICore Location) | (QI-Core)(USCDI) Location the encounter takes place | |
| period | 0..1 | Period | (QI-Core) Time period during which the patient was present at the location | |
| serviceProvider | 0..1 | Reference(QICore Organization) | (QI-Core)(USCDI) 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 | URI |
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDispositionhttp://terminology.hl7.org/ValueSet/clinical-discharge-disposition |
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 | (USCDI) 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 | (USCDI) The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣ | 1..1 | string | (USCDI) The value that is unique Example General: 123456 |
| status | ?!SΣ | 1..1 | code | (USCDI) planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. |
| class | SΣ | 1..1 | Coding | (USCDI) Classification of patient encounter Binding: ActEncounterCode (extensible): Classification of the encounter. |
| type | SΣ | 1..* | CodeableConcept | (USCDI) Specific type of encounter Binding: US Core Encounter Type (extensible): Valueset to describe the Encounter Type |
| subject | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) The patient or group present at the encounter |
| participant | SΣ | 0..* | BackboneElement | (QI-Core)(USCDI) List of participants involved in the encounter |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | SΣ | 0..* | CodeableConcept | (USCDI) Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. |
| period | S | 0..1 | Period | (USCDI) Period of time during the encounter that the participant participated |
| individual | SΣ | 0..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore RelatedPerson) | (QI-Core)(USCDI) Persons involved in the encounter other than the patient |
| period | S | 0..1 | Period | (USCDI) The start and end time of the encounter |
| reasonCode | SΣ | 0..* | CodeableConcept | (USCDI) 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 Simple Observation | QICore ImmunizationRecommendation) | (QI-Core)(USCDI) Reason the encounter takes place (reference) |
| hospitalization | S | 0..1 | BackboneElement | (QI-Core)(USCDI) 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 | |
| destination | 0..1 | Reference(QICore Location) | Location/organization to which the patient is discharged | |
| dischargeDisposition | S | 0..1 | CodeableConcept | (QI-Core)(USCDI) Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) |
| location | S | 0..* | BackboneElement | (QI-Core)(USCDI) 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) | (QI-Core)(USCDI) Location the encounter takes place |
| period | 0..1 | Period | (QI-Core) Time period during which the patient was present at the location | |
| serviceProvider | S | 0..1 | Reference(QICore Organization) | (QI-Core)(USCDI) 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 | URI |
| Encounter.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | |
| Encounter.status | required | EncounterStatushttp://hl7.org/fhir/ValueSet/encounter-status|4.0.1from the FHIR Standard | |
| Encounter.class | extensible | ActEncounterCodehttp://terminology.hl7.org/ValueSet/v3-ActEncounterCode | |
| Encounter.type | extensible | USCoreEncounterTypehttp://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type | |
| Encounter.participant.type | extensible | ParticipantTypehttp://hl7.org/fhir/ValueSet/encounter-participant-typefrom the FHIR Standard | |
| Encounter.reasonCode | preferred | EncounterReasonCodeshttp://hl7.org/fhir/ValueSet/encounter-reasonfrom the FHIR Standard | |
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDispositionhttp://terminology.hl7.org/ValueSet/clinical-discharge-disposition |
| 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 | (USCDI) 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 | (USCDI) The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | SΣ | 1..1 | string | (USCDI) 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 | (USCDI) 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 | (USCDI) 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 | (USCDI) 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 | 0..1 | CodeableConcept | Indicates the urgency of the encounter Binding: ActPriority (example): Indicates the urgency of the encounter. | |||||
| subject | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) 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(ServiceRequest) | The ServiceRequest that initiated this encounter | |||||
| participant | SΣ | 0..* | BackboneElement | (QI-Core)(USCDI) 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 | (USCDI) Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. | ||||
| period | S | 0..1 | Period | (USCDI) Period of time during the encounter that the participant participated | ||||
| individual | SΣ | 0..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore RelatedPerson) | (QI-Core)(USCDI) 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 | (USCDI) The start and end time of the encounter | ||||
| length | 0..1 | Duration | Quantity of time the encounter lasted (less time absent) | |||||
| reasonCode | SΣ | 0..* | CodeableConcept | (USCDI) 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 Simple Observation | QICore ImmunizationRecommendation) | (QI-Core)(USCDI) Reason the encounter takes place (reference) | ||||
| diagnosis | Σ | 0..* | BackboneElement | The list of diagnosis relevant to this 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 | ||||
| condition | Σ | 1..1 | Reference(Condition | Procedure) | The diagnosis or procedure relevant to the encounter | ||||
| use | 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 | 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 | (QI-Core)(USCDI) 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 | 0..1 | CodeableConcept | From where patient was admitted (physician referral, transfer) Binding: AdmitSource (preferred): From where the patient was admitted. | |||||
| reAdmission | 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 | (QI-Core)(USCDI) Category or kind of location after discharge Binding: Clinical Discharge Disposition (extensible) | ||||
| location | S | 0..* | BackboneElement | (QI-Core)(USCDI) 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) | (QI-Core)(USCDI) 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 | 0..1 | Period | (QI-Core) Time period during which the patient was present at the location | |||||
| serviceProvider | S | 0..1 | Reference(QICore Organization) | (QI-Core)(USCDI) 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 | URI | |||
| Encounter.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Encounter.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| Encounter.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | ||||
| Encounter.status | required | EncounterStatushttp://hl7.org/fhir/ValueSet/encounter-status|4.0.1from the FHIR Standard | ||||
| Encounter.statusHistory.status | required | EncounterStatushttp://hl7.org/fhir/ValueSet/encounter-status|4.0.1from the FHIR Standard | ||||
| Encounter.class | extensible | ActEncounterCodehttp://terminology.hl7.org/ValueSet/v3-ActEncounterCode | ||||
| Encounter.classHistory.class | extensible | ActEncounterCodehttp://terminology.hl7.org/ValueSet/v3-ActEncounterCode | ||||
| Encounter.type | extensible | USCoreEncounterTypehttp://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type | ||||
| Encounter.serviceType | example | ServiceTypehttp://hl7.org/fhir/ValueSet/service-typefrom the FHIR Standard | ||||
| Encounter.priority | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | ||||
| Encounter.participant.type | extensible | ParticipantTypehttp://hl7.org/fhir/ValueSet/encounter-participant-typefrom the FHIR Standard | ||||
| Encounter.reasonCode | preferred | EncounterReasonCodeshttp://hl7.org/fhir/ValueSet/encounter-reasonfrom the FHIR Standard | ||||
| Encounter.diagnosis.use | preferred | DiagnosisRolehttp://hl7.org/fhir/ValueSet/diagnosis-rolefrom the FHIR Standard | ||||
| Encounter.hospitalization.admitSource | preferred | AdmitSourcehttp://hl7.org/fhir/ValueSet/encounter-admit-sourcefrom the FHIR Standard | ||||
| Encounter.hospitalization.reAdmission | example | Hl7VSReAdmissionIndicatorhttp://terminology.hl7.org/ValueSet/v2-0092 | ||||
| Encounter.hospitalization.dietPreference | example | Diethttp://hl7.org/fhir/ValueSet/encounter-dietfrom the FHIR Standard | ||||
| Encounter.hospitalization.specialCourtesy | preferred | SpecialCourtesyhttp://hl7.org/fhir/ValueSet/encounter-special-courtesyfrom the FHIR Standard | ||||
| Encounter.hospitalization.specialArrangement | preferred | SpecialArrangementshttp://hl7.org/fhir/ValueSet/encounter-special-arrangementsfrom the FHIR Standard | ||||
| Encounter.hospitalization.dischargeDisposition | extensible | ClinicalDischargeDispositionhttp://terminology.hl7.org/ValueSet/clinical-discharge-disposition | ||||
| Encounter.location.status | required | EncounterLocationStatushttp://hl7.org/fhir/ValueSet/encounter-location-status|4.0.1from the FHIR Standard | ||||
| Encounter.location.physicalType | example | LocationTypehttp://hl7.org/fhir/ValueSet/location-physical-typefrom the FHIR Standard |
| 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() |
This structure is derived from USCoreEncounterProfile
Summary
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ HL7 International / Clinical Quality Information. Package hl7.fhir.us.qicore#6.0.0 based on FHIR 4.0.1. Generated 2024-03-01
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