HL7 FHIR Profile: Skin and Wound Assessment, Release 1 (For Comment)

EncounterProfile

Definitions for cimi-encounter-Encounter.

Encounter
Definition

A description of 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.

Control0..*
Alternate NamesVisit
InvariantsDefined on this element
dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative (: contained.text.empty())
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource (: contained.where(('#'+id in %resource.descendants().reference).not()).empty())
dom-4: 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())
Encounter.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Encounter.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
Encounter.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

Encounter.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language.
The codes SHALL be taken from Common Languages; other codes may be used where these codes are not suitable
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Encounter.text
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.

Encounter.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

Encounter.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-core-Recorded-extension]])
Definition

The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Encounter.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-core-Signed-extension]])
Definition

Provenance information specific to the signing of the clinical statement.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Encounter.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-core-AdditionalText-extension]])
Definition

A text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: string)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Encounter.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-encounter-EncounterClass-extension]])
Definition

Concepts representing classification of patient encounter such as ambulatory (outpatient), inpatient, emergency, home health or others due to local variations.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Encounter.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-element-PartOf-extension]])
Definition

The larger entity that this is a portion of. For example, an organization might be part of a larger organization, or an encounter with a hospitalist might be part of a larger hospitalization encounter.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Encounter.extension.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Encounter.extension.extension
Definition

An Extension

Control1..*
TypeExtension
Encounter.extension.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-core-Independent-extension]])
Definition

Base class for classes in CIMI that stand alone. Analogous to FHIR's DomainResource.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Encounter.extension.extension.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Encounter.extension.extension.extension
Definition

An Extension

Control0..*
TypeExtension
Encounter.extension.extension.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Fixed Valuehttp://hl7.org/fhir/us/sw/StructureDefinition/cimi-core-Independent-extension
Encounter.extension.extension.value[x]
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control0..0
TypeChoice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta
[x] NoteSee Choice of Data Types for further information about how to use [x]
Encounter.extension.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Fixed Valuehttp://hl7.org/fhir/us/sw/StructureDefinition/cimi-element-PartOf-extension
Encounter.extension.value[x]
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control0..0
TypeChoice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta
[x] NoteSee Choice of Data Types for further information about how to use [x]
Encounter.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-encounter-Diagnosis-extension]])
Definition

A diagnosis, which is a disease or injury determined to be present through evaluation of patient history, examination, and/or review of laboratory data.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Encounter.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-statement-ClinicalNote-extension]])
Definition

An entry concerning a patient where the result is a narrative text.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(ClinicalNoteProfile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Encounter.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.identifier
Definition

Identifier(s) by which this encounter is known.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Encounter.status
Definition

planned | arrived | triaged | in-progress | onleave | finished | cancelled +.

Control1..1
BindingCurrent state of the encounter
The codes SHALL be taken from EncounterStatus
Typecode
Is Modifiertrue
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.

Control0..*
TypeBackboneElement
Comments

The current status is always found in the current version of the resource, not the status history.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Encounter.statusHistory.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Encounter.statusHistory.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.statusHistory.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.statusHistory.status
Definition

planned | arrived | triaged | in-progress | onleave | finished | cancelled +.

Control1..1
BindingCurrent state of the encounter
The codes SHALL be taken from EncounterStatus
Typecode
Encounter.statusHistory.period
Definition

The time that the episode was in the specified status.

Control1..1
TypePeriod
Encounter.class
Definition

inpatient | outpatient | ambulatory | emergency +.

Control0..1
BindingClassification of the encounter
The codes SHALL be taken from ActEncounterCode; other codes may be used where these codes are not suitable
TypeCoding
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.

Control0..*
TypeBackboneElement
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Encounter.classHistory.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Encounter.classHistory.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.classHistory.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.classHistory.class
Definition

inpatient | outpatient | ambulatory | emergency +.

Control1..1
BindingClassification of the encounter
The codes SHALL be taken from ActEncounterCode; other codes may be used where these codes are not suitable
TypeCoding
Encounter.classHistory.period
Definition

The time that the episode was in the specified class.

Control1..1
TypePeriod
Encounter.type
Definition

Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation).

Control0..*
BindingThe codes SHALL be taken from ActEncounterCode; other codes may be used where these codes are not suitable
TypeCodeableConcept
Comments

Since there are many ways to further classify encounters, this element is 0..*.

Encounter.priority
Definition

Indicates the urgency of the encounter.

Control0..1
BindingIndicates the urgency of the encounter.
For example codes, see v3 Code System ActPriority
TypeCodeableConcept
Encounter.subject
Definition

The patient ro group present at the encounter.

Control0..1
TypeReference(US Core Patient Profile)
Alternate Namespatient
Comments

While the encounter is always about the patient, the patient may 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).

Control0..*
TypeReference(EpisodeOfCare)
Encounter.incomingReferral
Definition

The referral request this encounter satisfies (incoming referral).

Control0..*
TypeReference(ReferralRequest)
Encounter.participant
Definition

The list of people responsible for providing the service.

Control0..*
TypeBackboneElement
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Encounter.participant.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Encounter.participant.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.participant.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.participant.type
Definition

Role of participant in encounter.

Control0..*
BindingRole of participant in encounter
The codes SHALL be taken from ParticipantType; other codes may be used where these codes are not suitable
TypeCodeableConcept
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.

Control0..1
TypePeriod
Encounter.participant.individual
Definition

Persons involved in the encounter other than the patient.

Control0..1
TypeReference(Practitioner | RelatedPerson)
Encounter.appointment
Definition

The appointment that scheduled this encounter.

Control0..1
TypeReference(Appointment)
Encounter.period
Definition

The start and end time of the encounter.

Control0..1
TypePeriod
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.

Control0..1
TypeDuration
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.

Control0..*
BindingReason why the encounter takes place.
The codes SHOULD be taken from Encounter Reason Codes
TypeCodeableConcept
Alternate NamesIndication, Admission diagnosis
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.

Control0..*
TypeBackboneElement
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Encounter.diagnosis.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Encounter.diagnosis.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.diagnosis.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

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.

Control1..1
TypeReference(Condition | Procedure)
Alternate NamesAdmission diagnosis, discharge diagnosis, indication
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 …).

Control0..1
BindingThe type of diagnosis this condition represents
The codes SHOULD be taken from DiagnosisRole
TypeCodeableConcept
Encounter.diagnosis.rank
Definition

Ranking of the diagnosis (for each role type).

Control0..1
TypepositiveInt
Encounter.account
Definition

The set of accounts that may be used for billing for this Encounter.

Control0..*
TypeReference(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.

Control0..1
TypeBackboneElement
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.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Encounter.hospitalization.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Encounter.hospitalization.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.hospitalization.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.hospitalization.preAdmissionIdentifier
Definition

Pre-admission identifier.

Control0..1
TypeIdentifier
Encounter.hospitalization.origin
Definition

The location from which the patient came before admission.

Control0..1
TypeReference(Location)
Encounter.hospitalization.admitSource
Definition

From where patient was admitted (physician referral, transfer).

Control0..1
BindingFrom where the patient was admitted.
The codes SHOULD be taken from AdmitSource
TypeCodeableConcept
Encounter.hospitalization.reAdmission
Definition

Whether this hospitalization is a readmission and why if known.

Control0..1
BindingThe reason for re-admission of this hospitalization encounter.
For example codes, see v2 Re-Admission Indicator
TypeCodeableConcept
Encounter.hospitalization.dietPreference
Definition

Diet preferences reported by the patient.

Control0..*
BindingMedical, cultural or ethical food preferences to help with catering requirements.
For example codes, see Diet
TypeCodeableConcept
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).

Control0..*
BindingSpecial courtesies
The codes SHOULD be taken from SpecialCourtesy
TypeCodeableConcept
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.

Control0..*
BindingSpecial arrangements
The codes SHOULD be taken from SpecialArrangements
TypeCodeableConcept
Encounter.hospitalization.destination
Definition

Location to which the patient is discharged.

Control0..1
TypeReference(Location)
Encounter.hospitalization.dischargeDisposition
Definition

Category or kind of location after discharge.

Control0..1
BindingDischarge Disposition
For example codes, see DischargeDisposition
TypeCodeableConcept
Encounter.location
Definition

List of locations where the patient has been during this encounter.

Control0..*
TypeBackboneElement
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".

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Encounter.location.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Encounter.location.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.location.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Encounter.location.location
Definition

The location where the encounter takes place.

Control1..1
TypeReference(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.

Control0..1
BindingThe status of the location.
The codes SHALL be taken from EncounterLocationStatus
Typecode
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.

Control0..1
TypePeriod
Encounter.serviceProvider
Definition

An organization that is in charge of maintaining the information of this Encounter (e.g. who maintains the report or the master service catalog item, etc.). This MAY be the same as the organization on the Patient record, however it could be different. This MAY not be not the Service Delivery Location's Organization.

Control0..1
TypeReference(Organization)
Encounter.partOf
Definition

Another Encounter of which this encounter is a part of (administratively or in time).

Control0..1
TypeReference(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.