5.27 Resource Appointment - Content

5.27.1 Scope and Usage

Appointment resources are used to provide information about a planned meeting that may be in the future or past. The resource only describes a single meeting, a series of repeating visits would require multiple appointment resources be created for each instance. Examples include a scheduled surgery, a follow-up for a clinical visit, a scheduled conference call between clinicians to discuss a case, the reservation of a piece of diagnostic equipment for a particular use, etc. The visit scheduled by an appointment may be in person or remote (by phone, video conference, etc.) All that matters is that the time and usage of one or more individuals, locations and/or pieces of equipment is being fully or partially reserved for a designated period of time.

This definition takes the concepts of appointments in a clinical setting and also extends them to be relevant in the community healthcare space, and also ease exposure to other appointment / calendar standards widely used outside of healthcare.

5.27.1.1 The basic workflow to create an appointment

• Discovery/Addressing

  Before an appointment can be made the address/endpoint details of the resource that we want to schedule an appointment with must be determined. This is often based on the healthcare Service Type, any formatting information which indicates how to make the request. This is typically handled via the Schedule resource.

• Checking Availability on the Schedule(optional)

  This optional step permits the checking of any existing available times (slot resources associated with a selected schedule) that can be booked against. Just because a time is indicated it is available doesn't guarantee that an appointment can be made. The booking system that is going to process the request may make other qualifying decisions to determine if the appointment can be made, such as permissions, assessments, availability of other resources etc.

  This step is optional as the creation of the appointment is never a guaranteed action. But by performing this availability check, you can increase the chances of making a successful booking.

• Making the Appointment Request

  When an appointment is required, a requester creates new Appointment resource with the Appointment.status="proposed".
  All included participants (optional or mandatory) should have the status="needs-action" to allow filtering and displaying appointments to user-participants for accepting or rejecting new and updated requests. Based on internal system business rules, certain statuses may be automatically updated, for example: "reject because the requested participant is on vacation" or "this type of user is not allowed to request those specific appointments".

• Replying to the request

  The reply process is simply performed by the person/system handing the requests updating the participant statuses as needed. If there are multiple systems involved, then these will create AppointmentResponse entries with the desired statuses.

  Once all participants have their participation status created/updated (and the main system marking the appointment participant records with the AppointmentResponse statuses) then the overall status of the appointment is updated.

• Checking the overall status (Requester)

  The requester (organizer) of the appointment checks for the overall status of the appointment (and appointment responses, where applicable) using FHIR pub-sub techniques.

  Where the participant statuses indicate that a re-scheduling is required, then the process may start again, with other systems replying to a new set of times.

5.27.1.2 There are 2 typical workflows that occur with appointments

• Outlook Style - Community

  These types of requests are typically handled by selecting a specific time from a list of available slots. Then making the request for that timeslot.

• Hospital Scheduling - Clinical

  Clinical scheduling is often far more complex in its requirements and processing. Often this involves checking multiple availabilities across multiple systems and timing with other internal systems, not just those exposed by the Slot resources.

  Consideration should be given to situations where scheduling needs to be handled in more of a queue-like process.

  Note: This type of clinical appointment scheduling has not been specifically covered with this definition of the appointment (and the related resources), however if you would like to contribute to the modification of this resource to cover these use cases, please contact the HL7 Patient Administration work-group.

5.27.2 Boundaries and Relationships

5.27.2.1 Appointment Request/Response Pattern

When using a request response style of appointment this is done using Appointment and AppointmentResponse resources.
The request is made in the form of an Appointment with a proposed or pending status, and the list of actors with a participation status of "needs-action".

Participants in the appointment respond their acceptance (or not) to the appointment by creating AppointmentResponse resources.
Once all the participants have replied, then the appointment resource is able to be updated with an overall status which collates the results of all the participants and presents the approved details of the appointment.

The participant type property can be used to represent a specific role that a practitioner is required to perform for the appointment. This could be specified without an actor when the actual practitioner is not known, and will be filled in closer to the scheduled time.
This property must be the same between the Appointment-participant and the AppointmentResponse so that the appropriate values can be allocated. If you need multiple actors of a specific type, then multiple participants with that type value are included on the appointment.

5.27.2.2 Appointment Statuses and Encounters

Appointments can be considered as Administrative only, and the Encounter is expected to have Clinical implications.

In general it is expected that appointments will result in the creation of an Encounter. The encounter is typically created when the service starts, not when the patient arrives. When the patient arrives, an appointment can be marked with a status of Arrived.

In an Emergency Room context, this appointment resource is probably not appropriate to be used. In these cases an encounter should be created.

The Appointment request pattern used is different to the order-response pattern used elsewhere in FHIR.
This is due to the close relationship to the iCAL standard. Many non-clinical systems use generic non health appointment systems which implement this standard, and the desire to integrate with the consumer who has no access to health based software is highly desirable.
The mappings to the iCAL standard have been provided to guide implementation of gateways between FHIR servers and iCAL systems.

5.27.2.3 Appointment Locations and Participation

The Location of the appointment is to be defined by using a participant that references a location or HealthcareService.
This permits the location to also have its availability checked via a schedule and any conflicts more easily managed.

• Structure
• UML
• XML
• JSON
• All

Structure

Name	Flags	Card.	Type	Description & Constraints
Appointment	I		DomainResource	A booking of a healthcare event among patient(s), practitioner(s), related person(s) and/or device(s) for a specific date/time. This may result in one or more Encounter(s) Only proposed or cancelled appointments can be missing start/end dates Either start and end are specified, or neither
identifier	Σ	0..*	Identifier	External Ids for this item
status	?! Σ	1..1	code	proposed | pending | booked | arrived | fulfilled | cancelled | noshow AppointmentStatus (Required)
type	Σ	0..1	CodeableConcept	The type of appointment that is being booked Practice Setting Code Value Set (Preferred)
reason	Σ	0..1	CodeableConcept	Reason this appointment is scheduled Encounter Reason Codes (Required)
priority		0..1	unsignedInt	Used to make informed decisions if needing to re-prioritize
description		0..1	string	Shown on a subject line in a meeting request, or appointment list
start	Σ	0..1	instant	When appointment is to take place
end	Σ	0..1	instant	When appointment is to conclude
minutesDuration		0..1	positiveInt	Can be less than start/end (e.g. estimate)
slot		0..*	Reference(Slot)	If provided, then no schedule and start/end values MUST match slot
comment		0..1	string	Additional comments
participant	I	1..*	BackboneElement	Participants involved in appointment Either the type or actor on the participant MUST be specified
type	Σ	0..*	CodeableConcept	Role of participant in the appointment ParticipantType (Required)
actor	Σ	0..1	Reference(Patient | Practitioner | RelatedPerson | Device | HealthcareService | Location)	Person, Location/HealthcareService or Device
required	Σ	0..1	code	required | optional | information-only ParticipantRequired (Required)
status		1..1	code	accepted | declined | tentative | needs-action ParticipationStatus (Required)
Documentation for this format

<Appointment xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this item --></identifier>
 <status value="[code]"/><!-- 1..1 proposed | pending | booked | arrived | fulfilled | cancelled | noshow -->
 <type><!-- 0..1 CodeableConcept The type of appointment that is being booked --></type>
 <reason><!-- 0..1 CodeableConcept Reason this appointment is scheduled --></reason>
 <priority value="[unsignedInt]"/><!-- 0..1 Used to make informed decisions if needing to re-prioritize -->
 <description value="[string]"/><!-- 0..1 Shown on a subject line in a meeting request, or appointment list -->
 <start value="[instant]"/><!-- 0..1 When appointment is to take place -->
 <end value="[instant]"/><!-- 0..1 When appointment is to conclude -->
 <minutesDuration value="[positiveInt]"/><!-- 0..1 Can be less than start/end (e.g. estimate) -->
 <slot><!-- 0..* Reference(Slot) If provided, then no schedule and start/end values MUST match slot --></slot>
 <comment value="[string]"/><!-- 0..1 Additional comments -->
 <participant>  <!-- 1..* Participants involved in appointment -->
  <type><!-- 0..* CodeableConcept Role of participant in the appointment --></type>
  <actor><!-- 0..1 Reference(Patient|Practitioner|RelatedPerson|Device|
    HealthcareService|Location) Person, Location/HealthcareService or Device --></actor>
  <required value="[code]"/><!-- 0..1 required | optional | information-only -->
  <status value="[code]"/><!-- 1..1 accepted | declined | tentative | needs-action -->
 </participant>
</Appointment>

{
  "resourceType" : "Appointment",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this item
  "status" : "<code>", // R!  proposed | pending | booked | arrived | fulfilled | cancelled | noshow
  "type" : { CodeableConcept }, // The type of appointment that is being booked
  "reason" : { CodeableConcept }, // Reason this appointment is scheduled
  "priority" : "<unsignedInt>", // Used to make informed decisions if needing to re-prioritize
  "description" : "<string>", // Shown on a subject line in a meeting request, or appointment list
  "start" : "<instant>", // When appointment is to take place
  "end" : "<instant>", // When appointment is to conclude
  "minutesDuration" : "<positiveInt>", // Can be less than start/end (e.g. estimate)
  "slot" : [{ Reference(Slot) }], // If provided, then no schedule and start/end values MUST match slot
  "comment" : "<string>", // Additional comments
  "participant" : [{ // R!  Participants involved in appointment
    "type" : [{ CodeableConcept }], // Role of participant in the appointment
    "actor" : { Reference(Patient|Practitioner|RelatedPerson|Device|
    HealthcareService|Location) }, // Person, Location/HealthcareService or Device
    "required" : "<code>", // required | optional | information-only
    "status" : "<code>" // R!  accepted | declined | tentative | needs-action
  }]
}

Structure

Name	Flags	Card.	Type	Description & Constraints
Appointment	I		DomainResource	A booking of a healthcare event among patient(s), practitioner(s), related person(s) and/or device(s) for a specific date/time. This may result in one or more Encounter(s) Only proposed or cancelled appointments can be missing start/end dates Either start and end are specified, or neither
identifier	Σ	0..*	Identifier	External Ids for this item
status	?! Σ	1..1	code	proposed | pending | booked | arrived | fulfilled | cancelled | noshow AppointmentStatus (Required)
type	Σ	0..1	CodeableConcept	The type of appointment that is being booked Practice Setting Code Value Set (Preferred)
reason	Σ	0..1	CodeableConcept	Reason this appointment is scheduled Encounter Reason Codes (Required)
priority		0..1	unsignedInt	Used to make informed decisions if needing to re-prioritize
description		0..1	string	Shown on a subject line in a meeting request, or appointment list
start	Σ	0..1	instant	When appointment is to take place
end	Σ	0..1	instant	When appointment is to conclude
minutesDuration		0..1	positiveInt	Can be less than start/end (e.g. estimate)
slot		0..*	Reference(Slot)	If provided, then no schedule and start/end values MUST match slot
comment		0..1	string	Additional comments
participant	I	1..*	BackboneElement	Participants involved in appointment Either the type or actor on the participant MUST be specified
type	Σ	0..*	CodeableConcept	Role of participant in the appointment ParticipantType (Required)
actor	Σ	0..1	Reference(Patient | Practitioner | RelatedPerson | Device | HealthcareService | Location)	Person, Location/HealthcareService or Device
required	Σ	0..1	code	required | optional | information-only ParticipantRequired (Required)
status		1..1	code	accepted | declined | tentative | needs-action ParticipationStatus (Required)
Documentation for this format

UML Diagram

XML Template

<Appointment xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this item --></identifier>
 <status value="[code]"/><!-- 1..1 proposed | pending | booked | arrived | fulfilled | cancelled | noshow -->
 <type><!-- 0..1 CodeableConcept The type of appointment that is being booked --></type>
 <reason><!-- 0..1 CodeableConcept Reason this appointment is scheduled --></reason>
 <priority value="[unsignedInt]"/><!-- 0..1 Used to make informed decisions if needing to re-prioritize -->
 <description value="[string]"/><!-- 0..1 Shown on a subject line in a meeting request, or appointment list -->
 <start value="[instant]"/><!-- 0..1 When appointment is to take place -->
 <end value="[instant]"/><!-- 0..1 When appointment is to conclude -->
 <minutesDuration value="[positiveInt]"/><!-- 0..1 Can be less than start/end (e.g. estimate) -->
 <slot><!-- 0..* Reference(Slot) If provided, then no schedule and start/end values MUST match slot --></slot>
 <comment value="[string]"/><!-- 0..1 Additional comments -->
 <participant>  <!-- 1..* Participants involved in appointment -->
  <type><!-- 0..* CodeableConcept Role of participant in the appointment --></type>
  <actor><!-- 0..1 Reference(Patient|Practitioner|RelatedPerson|Device|
    HealthcareService|Location) Person, Location/HealthcareService or Device --></actor>
  <required value="[code]"/><!-- 0..1 required | optional | information-only -->
  <status value="[code]"/><!-- 1..1 accepted | declined | tentative | needs-action -->
 </participant>
</Appointment>

JSON Template

{
  "resourceType" : "Appointment",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this item
  "status" : "<code>", // R!  proposed | pending | booked | arrived | fulfilled | cancelled | noshow
  "type" : { CodeableConcept }, // The type of appointment that is being booked
  "reason" : { CodeableConcept }, // Reason this appointment is scheduled
  "priority" : "<unsignedInt>", // Used to make informed decisions if needing to re-prioritize
  "description" : "<string>", // Shown on a subject line in a meeting request, or appointment list
  "start" : "<instant>", // When appointment is to take place
  "end" : "<instant>", // When appointment is to conclude
  "minutesDuration" : "<positiveInt>", // Can be less than start/end (e.g. estimate)
  "slot" : [{ Reference(Slot) }], // If provided, then no schedule and start/end values MUST match slot
  "comment" : "<string>", // Additional comments
  "participant" : [{ // R!  Participants involved in appointment
    "type" : [{ CodeableConcept }], // Role of participant in the appointment
    "actor" : { Reference(Patient|Practitioner|RelatedPerson|Device|
    HealthcareService|Location) }, // Person, Location/HealthcareService or Device
    "required" : "<code>", // required | optional | information-only
    "status" : "<code>" // R!  accepted | declined | tentative | needs-action
  }]
}