This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2
Patient Administration Work Group | Maturity Level: 2 | Trial Use | Compartments: Encounter, Patient, Practitioner, RelatedPerson |
Detailed Descriptions for the elements in the Encounter resource.
Encounter | |
Definition | An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient. |
Control | 1..1 |
Alternate Names | Visit |
Encounter.identifier | |
Definition | Identifier(s) by which this encounter is known. |
Note | This is a business identifer, not a resource identifier (see discussion) |
Control | 0..* |
Type | Identifier |
Summary | true |
Encounter.status | |
Definition | planned | arrived | triaged | in-progress | onleave | finished | cancelled +. |
Control | 1..1 |
Terminology Binding | EncounterStatus (Required) |
Type | code |
Is Modifier | true |
Summary | true |
Comments | Note that internal business rules will detemine the appropraite transitions that may occur between statuses (and also classes). This element is labeled as a modifier because the status contains codes that mark the encounter as not currently valid. |
Encounter.statusHistory | |
Definition | The status history permits the encounter resource to contain the status history without needing to read through the historical versions of the resource, or even have the server store them. |
Control | 0..* |
Comments | The current status is always found in the current version of the resource, not the status history. |
Encounter.statusHistory.status | |
Definition | planned | arrived | triaged | in-progress | onleave | finished | cancelled +. |
Control | 1..1 |
Terminology Binding | EncounterStatus (Required) |
Type | code |
Encounter.statusHistory.period | |
Definition | The time that the episode was in the specified status. |
Control | 1..1 |
Type | Period |
Encounter.class | |
Definition | inpatient | outpatient | ambulatory | emergency +. |
Control | 0..1 |
Terminology Binding | ActEncounterCode (Extensible) |
Type | Coding |
Summary | true |
Encounter.classHistory | |
Definition | The class history permits the tracking of the encounters transitions without needing to go through the resource history. This would be used for a case where an admission starts of as an emergency encounter, then transisions into an inpatient scenario. Doing this and not restarting a new encounter ensures that any lab/diagnostic results can more easily follow the patient and not require re-processing and not get lost or cancelled during a kindof discharge from emergency to inpatient. |
Control | 0..* |
Encounter.classHistory.class | |
Definition | inpatient | outpatient | ambulatory | emergency +. |
Control | 1..1 |
Terminology Binding | ActEncounterCode (Extensible) |
Type | Coding |
Encounter.classHistory.period | |
Definition | The time that the episode was in the specified class. |
Control | 1..1 |
Type | Period |
Encounter.type | |
Definition | Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation). |
Control | 0..* |
Terminology Binding | EncounterType (Example) |
Type | CodeableConcept |
Summary | true |
Comments | Since there are many ways to further classify encounters, this element is 0..*. |
Encounter.serviceType | |
Definition | Broad categorization of the service that is to be provided (e.g. cardiology). |
Control | 0..1 |
Terminology Binding | Broad categorization of the service that is to be provided. |
Type | CodeableConcept |
Summary | true |
Encounter.priority | |
Definition | Indicates the urgency of the encounter. |
Control | 0..1 |
Terminology Binding | v3 Code System ActPriority (Example) |
Type | CodeableConcept |
Encounter.subject | |
Definition | The patient or group present at the encounter. |
Control | 0..1 |
Type | Reference(Patient | Group) |
Alternate Names | patient |
Summary | true |
Comments | While the encounter is always about the patient, the patient might not actually be known in all contexts of use, and there may be a group of patients that could be anonymous (such as in a group therapy for Alcoholics Anonymous - where the recording of the encounter could be used for billing on the number of people/staff and not important to the context of the specific patients) or alternately in veterinary care a herd of sheep receiving treatment (where the animals are not individually tracked). |
Encounter.episodeOfCare | |
Definition | Where a specific encounter should be classified as a part of a specific episode(s) of care this field should be used. This association can facilitate grouping of related encounters together for a specific purpose, such as government reporting, issue tracking, association via a common problem. The association is recorded on the encounter as these are typically created after the episode of care, and grouped on entry rather than editing the episode of care to append another encounter to it (the episode of care could span years). |
Control | 0..* |
Type | Reference(EpisodeOfCare) |
Summary | true |
Encounter.incomingReferral | |
Definition | The referral request this encounter satisfies (incoming referral). |
Control | 0..* |
Type | Reference(ServiceRequest) |
Encounter.participant | |
Definition | The list of people responsible for providing the service. |
Control | 0..* |
Summary | true |
Encounter.participant.type | |
Definition | Role of participant in encounter. |
Control | 0..* |
Terminology Binding | ParticipantType (Extensible) |
Type | CodeableConcept |
Summary | true |
Comments | The participant type indicates how an individual partitipates in an encounter. It includes non-practitioner participants, and for practitioners this is to describe the action type in the context of this encounter (e.g. Admitting Dr, Attending Dr, Translator, Consulting Dr). This is different to the practitioner roles which are functional roles, derived from terms of employment, education, licensing, etc. |
Encounter.participant.period | |
Definition | The period of time that the specified participant participated in the encounter. These can overlap or be sub-sets of the overall encounter's period. |
Control | 0..1 |
Type | Period |
Encounter.participant.individual | |
Definition | Persons involved in the encounter other than the patient. |
Control | 0..1 |
Type | Reference(Practitioner | RelatedPerson) |
Summary | true |
Encounter.appointment | |
Definition | The appointment that scheduled this encounter. |
Control | 0..1 |
Type | Reference(Appointment) |
Summary | true |
Encounter.period | |
Definition | The start and end time of the encounter. |
Control | 0..1 |
Type | Period |
Comments | If not (yet) known, the end of the Period may be omitted. |
Encounter.length | |
Definition | Quantity of time the encounter lasted. This excludes the time during leaves of absence. |
Control | 0..1 |
Type | Duration |
Comments | May differ from the time the Encounter.period lasted because of leave of absence. |
Encounter.reason | |
Definition | Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis. |
Control | 0..* |
Terminology Binding | Encounter Reason Codes (Preferred) |
Type | CodeableConcept |
Alternate Names | Indication; Admission diagnosis |
Summary | true |
Comments | For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis). |
Encounter.diagnosis | |
Definition | The list of diagnosis relevant to this encounter. |
Control | 0..* |
Summary | true |
Encounter.diagnosis.condition | |
Definition | Reason the encounter takes place, as specified using information from another resource. For admissions, this is the admission diagnosis. The indication will typically be a Condition (with other resources referenced in the evidence.detail), or a Procedure. |
Control | 1..1 |
Type | Reference(Condition | Procedure) |
Alternate Names | Admission diagnosis; discharge diagnosis; indication |
Summary | true |
Comments | For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis). |
Encounter.diagnosis.role | |
Definition | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …). |
Control | 0..1 |
Terminology Binding | DiagnosisRole (Preferred) |
Type | CodeableConcept |
Encounter.diagnosis.rank | |
Definition | Ranking of the diagnosis (for each role type). |
Control | 0..1 |
Type | positiveInt |
Encounter.account | |
Definition | The set of accounts that may be used for billing for this Encounter. |
Control | 0..* |
Type | Reference(Account) |
Comments | The billing system may choose to allocate billable items associated with the Encounter to different referenced Accounts based on internal business rules. |
Encounter.hospitalization | |
Definition | Details about the admission to a healthcare service. |
Control | 0..1 |
Comments | An Encounter may cover more than just the inpatient stay. Contexts such as outpatients, community clinics, and aged care facilities are also included. The duration recorded in the period of this encounter covers the entire scope of this hospitalization record. |
Encounter.hospitalization.preAdmissionIdentifier | |
Definition | Pre-admission identifier. |
Control | 0..1 |
Type | Identifier |
Encounter.hospitalization.origin | |
Definition | The location from which the patient came before admission. |
Control | 0..1 |
Type | Reference(Location) |
Encounter.hospitalization.admitSource | |
Definition | From where patient was admitted (physician referral, transfer). |
Control | 0..1 |
Terminology Binding | AdmitSource (Preferred) |
Type | CodeableConcept |
Encounter.hospitalization.reAdmission | |
Definition | Whether this hospitalization is a readmission and why if known. |
Control | 0..1 |
Terminology Binding | v2 Re-Admission Indicator (Example) |
Type | CodeableConcept |
Encounter.hospitalization.dietPreference | |
Definition | Diet preferences reported by the patient. |
Control | 0..* |
Terminology Binding | Diet (Example) |
Type | CodeableConcept |
Requirements | Used to track patient's diet restrictions and/or preference. For a complete description of the nutrition needs of a patient during their stay, one should use the nutritionOrder resource which links to Encounter. |
Comments | For example a patient may request both a dairy-free and nut-free diet preference (not mutually exclusive). |
Encounter.hospitalization.specialCourtesy | |
Definition | Special courtesies (VIP, board member). |
Control | 0..* |
Terminology Binding | SpecialCourtesy (Preferred) |
Type | CodeableConcept |
Encounter.hospitalization.specialArrangement | |
Definition | Any special requests that have been made for this hospitalization encounter, such as the provision of specific equipment or other things. |
Control | 0..* |
Terminology Binding | SpecialArrangements (Preferred) |
Type | CodeableConcept |
Encounter.hospitalization.destination | |
Definition | Location to which the patient is discharged. |
Control | 0..1 |
Type | Reference(Location) |
Encounter.hospitalization.dischargeDisposition | |
Definition | Category or kind of location after discharge. |
Control | 0..1 |
Terminology Binding | DischargeDisposition (Example) |
Type | CodeableConcept |
Encounter.location | |
Definition | List of locations where the patient has been during this encounter. |
Control | 0..* |
Comments | Virtual encounters can be recorded in the Encounter by specifying a location reference to a location of type "kind" such as "client's home" and an encounter.class = "virtual". |
Encounter.location.location | |
Definition | The location where the encounter takes place. |
Control | 1..1 |
Type | Reference(Location) |
Encounter.location.status | |
Definition | The status of the participants' presence at the specified location during the period specified. If the participant is is no longer at the location, then the period will have an end date/time. |
Control | 0..1 |
Terminology Binding | EncounterLocationStatus (Required) |
Type | code |
Comments | When the patient is no longer active at a location, then the period end date is entered, and the status may be changed to completed. |
Encounter.location.period | |
Definition | Time period during which the patient was present at the location. |
Control | 0..1 |
Type | Period |
Encounter.serviceProvider | |
Definition | The organization that is primarily responsible for this Encounter's services. This MAY be the same as the organization on the Patient record, however it could be different, such as if the actor performing the services was from an external organization (which may be billed seperately) for an external consultation. Refer to the example bundle showing an abbreviated set of Encounters for a colonoscopy. |
Control | 0..1 |
Type | Reference(Organization) |
Encounter.partOf | |
Definition | Another Encounter of which this encounter is a part of (administratively or in time). |
Control | 0..1 |
Type | Reference(Encounter) |
Comments | This is also used for associating a child's encounter back to the mother's encounter. Refer to the Notes section in the Patient resource for further details. |