Notice
- Important: This guidance is under active development by NHS England and content may be added or updated on a regular basis.
- This Implementation Guide is currently in Draft and SHOULD NOT be used for development or active implementation without express direction from the NHS England Genomics Unit.
StructureDefinition UKCore-Encounter
The need for a Genomics Encounter is currently under review.
The profile for the UK Core FHIR Encounter is provided below for completeness.
| Profile url | FHIR Module | Normative Status |
|---|---|---|
| https://fhir.hl7.org.uk/StructureDefinition/UKCore-Encounter | UK Core | trial-use |
| UKCoreEncounter (Encounter) | C | Encounter | There are no (further) constraints on this element Element idEncounterShort description An interaction during which services are provided to the patient Alternate namesVisit DefinitionAn interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idEncounter.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idEncounter.metaShort description Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idEncounter.implicitRulesShort description A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. 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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idEncounter.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language. Binding extensions
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | 0..1 | Narrative | There are no (further) constraints on this element Element idEncounter.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can 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. 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 information is added later. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idEncounter.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| dischargeMethod | C | 0..1 | Extension(CodeableConcept) | Element idEncounter.extension:dischargeMethodShort description An extension to support the method of discharge from a hospital. Alternate namesextensions, user content DefinitionThis extension has been developed to demonstrate the representation of the method by which a patient was discharged from hospital. 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. ExtensionUKCoreDischargeMethod ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| emergencyCareDischargeStatus | C | 0..1 | Extension(CodeableConcept) | Element idEncounter.extension:emergencyCareDischargeStatusShort description An extension to support the status of an individual on discharge from an Emergency Care Department. Alternate namesextensions, user content DefinitionThis extension has been developed to demonstrate the representation of the status of a patient on discharge from an Emergency Care Department. 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. ExtensionUKCoreEmergencyCareDischargeStatus ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| legalStatus | C | 0..* | Extension(Complex) | Element idEncounter.extension:legalStatusShort description Information relating to a patient's legal status on admission or discharge. Alternate namesextensions, user content DefinitionInformation relating to a patient's legal status on admission or discharge. 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. Extension(Complex) Extension URLConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| OutcomeOfAttendance | C | 0..1 | Extension(CodeableConcept) | Element idEncounter.extension:OutcomeOfAttendanceShort description An extension to support the outcome of an Outpatient attendance. Alternate namesextensions, user content DefinitionThis extension has been developed to demonstrate the representation of the outcome of an Outpatient attendance. 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. ExtensionUKCoreOutcomeOfAttendance ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | S Σ | 0..* | Identifier | There are no (further) constraints on this element Element idEncounter.identifierShort description Identifier(s) by which this encounter is known DefinitionIdentifier(s) by which this encounter is known. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idEncounter.statusShort description planned | arrived | triaged | in-progress | onleave | finished | cancelled + Definitionplanned | arrived | triaged | in-progress | onleave | finished | cancelled +. Note that internal business rules will determine the appropriate transitions that may occur between statuses (and also classes). Current state of the encounter. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| statusHistory | 0..* | BackboneElement | There are no (further) constraints on this element Element idEncounter.statusHistoryShort description List of past encounter statuses DefinitionThe 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. The current status is always found in the current version of the resource, not the status history. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idEncounter.statusHistory.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.statusHistory.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.statusHistory.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| status | 1..1 | codeBinding | There are no (further) constraints on this element Element idEncounter.statusHistory.statusShort description planned | arrived | triaged | in-progress | onleave | finished | cancelled + Definitionplanned | arrived | triaged | in-progress | onleave | finished | cancelled +. Note that FHIR strings SHALL NOT exceed 1MB in size Current state of the encounter. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| period | C | 1..1 | Period | There are no (further) constraints on this element Element idEncounter.statusHistory.periodShort description The time that the episode was in the specified status DefinitionThe time that the episode was in the specified status. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| class | S Σ | 1..1 | CodingBinding | There are no (further) constraints on this element Element idEncounter.classShort description Classification of patient encounter DefinitionConcepts representing classification of patient encounter such as ambulatory (outpatient), inpatient, emergency, home health or others due to local variations. Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Classification of the encounter. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| classHistory | 0..* | BackboneElement | There are no (further) constraints on this element Element idEncounter.classHistoryShort description List of past encounter classes DefinitionThe 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 transitions 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 kind of discharge from emergency to inpatient. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idEncounter.classHistory.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.classHistory.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.classHistory.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| class | 1..1 | CodingBinding | There are no (further) constraints on this element Element idEncounter.classHistory.classShort description inpatient | outpatient | ambulatory | emergency + Definitioninpatient | outpatient | ambulatory | emergency +. Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Classification of the encounter. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| period | C | 1..1 | Period | There are no (further) constraints on this element Element idEncounter.classHistory.periodShort description The time that the episode was in the specified class DefinitionThe time that the episode was in the specified class. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | Σ | 0..* | CodeableConceptBinding | Element idEncounter.typeShort description Specific type of encounter DefinitionSpecific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation). Since there are many ways to further classify encounters, this element is 0..*. A code from the SNOMED Clinical Terminology UK coding system that describes an encounter between a care professional and the patient (or patient's record). UKCoreEncounterType (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| serviceType | Σ | 0..1 | CodeableConceptBinding | Element idEncounter.serviceTypeShort description Specific type of service DefinitionBroad categorization of the service that is to be provided (e.g. cardiology). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Any code from the SNOMED CT UK Refset with fully specified name 'Services simple reference set (foundation metadata concept)' with Refset Id 1127531000000102. UKCoreCareSettingType (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| priority | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idEncounter.priorityShort description Indicates the urgency of the encounter DefinitionIndicates the urgency of the encounter. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Indicates the urgency of the encounter. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| subject | S Σ C | 0..1 | Reference(Group | Patient) | There are no (further) constraints on this element Element idEncounter.subjectShort description The patient or group present at the encounter Alternate namespatient DefinitionThe patient or group present at the encounter. 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). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| episodeOfCare | Σ C | 0..* | Reference(EpisodeOfCare) | There are no (further) constraints on this element Element idEncounter.episodeOfCareShort description Episode(s) of care that this encounter should be recorded against DefinitionWhere 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). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| basedOn | C | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element idEncounter.basedOnShort description The ServiceRequest that initiated this encounter Alternate namesincomingReferral DefinitionThe request this encounter satisfies (e.g. incoming referral or procedure request). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| participant | S Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idEncounter.participantShort description List of participants involved in the encounter DefinitionThe list of people responsible for providing the service. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idEncounter.participant.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.participant.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.participant.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idEncounter.participant.typeShort description Role of participant in encounter DefinitionRole of participant in encounter. The participant type indicates how an individual participates 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. Role of participant in encounter. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| period | C | 0..1 | Period | There are no (further) constraints on this element Element idEncounter.participant.periodShort description Period of time during the encounter that the participant participated DefinitionThe period of time that the specified participant participated in the encounter. These can overlap or be sub-sets of the overall encounter's period. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| individual | Σ C | 0..1 | Reference(Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idEncounter.participant.individualShort description Persons involved in the encounter other than the patient DefinitionPersons involved in the encounter other than the patient. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | RelatedPerson) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| appointment | Σ C | 0..* | Reference(Appointment) | There are no (further) constraints on this element Element idEncounter.appointmentShort description The appointment that scheduled this encounter DefinitionThe appointment that scheduled this encounter. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| period | C | 0..1 | Period | There are no (further) constraints on this element Element idEncounter.periodShort description The start and end time of the encounter DefinitionThe start and end time of the encounter. If not (yet) known, the end of the Period may be omitted. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| length | C | 0..1 | Duration | There are no (further) constraints on this element Element idEncounter.lengthShort description Quantity of time the encounter lasted (less time absent) DefinitionQuantity of time the encounter lasted. This excludes the time during leaves of absence. May differ from the time the Encounter.period lasted because of leave of absence. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reasonCode | S Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idEncounter.reasonCodeShort description Coded reason the encounter takes place Alternate namesIndication, Admission diagnosis DefinitionReason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis. 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). Reason why the encounter takes place. EncounterReasonCodes (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reasonReference | S Σ C | 0..* | Reference(Condition | ImmunizationRecommendation | Observation | Procedure) | There are no (further) constraints on this element Element idEncounter.reasonReferenceShort description Reason the encounter takes place (reference) Alternate namesIndication, Admission diagnosis DefinitionReason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis. 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). Reference(Condition | ImmunizationRecommendation | Observation | Procedure) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| diagnosis | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idEncounter.diagnosisShort description The list of diagnosis relevant to this encounter DefinitionThe list of diagnosis relevant to this encounter. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idEncounter.diagnosis.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.diagnosis.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.diagnosis.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| condition | Σ C | 1..1 | Reference(Condition | Procedure) | There are no (further) constraints on this element Element idEncounter.diagnosis.conditionShort description The diagnosis or procedure relevant to the encounter Alternate namesAdmission diagnosis, discharge diagnosis, indication DefinitionReason 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. 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). Reference(Condition | Procedure) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| use | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idEncounter.diagnosis.useShort description Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) DefinitionRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The type of diagnosis this condition represents. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| rank | 0..1 | positiveInt | There are no (further) constraints on this element Element idEncounter.diagnosis.rankShort description Ranking of the diagnosis (for each role type) DefinitionRanking of the diagnosis (for each role type). 32 bit number; for values larger than this, use decimal The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| account | C | 0..* | Reference(Account) | There are no (further) constraints on this element Element idEncounter.accountShort description The set of accounts that may be used for billing for this Encounter DefinitionThe set of accounts that may be used for billing for this Encounter. The billing system may choose to allocate billable items associated with the Encounter to different referenced Accounts based on internal business rules. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| hospitalization | 0..1 | BackboneElement | There are no (further) constraints on this element Element idEncounter.hospitalizationShort description Details about the admission to a healthcare service DefinitionDetails about the admission to a healthcare service. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idEncounter.hospitalization.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.hospitalization.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| admissionMethod | C | 0..1 | Extension(CodeableConcept) | Element idEncounter.hospitalization.extension:admissionMethodShort description An extension to support the method by which an individual was admitted into hospital. Alternate namesextensions, user content DefinitionThis extension has been developed to demonstrate the representation of the method by which a patient was admitted to hospital. 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. ExtensionUKCoreAdmissionMethod ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.hospitalization.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| preAdmissionIdentifier | 0..1 | Identifier | There are no (further) constraints on this element Element idEncounter.hospitalization.preAdmissionIdentifierShort description Pre-admission identifier DefinitionPre-admission identifier. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| origin | C | 0..1 | Reference(Location | Organization) | There are no (further) constraints on this element Element idEncounter.hospitalization.originShort description The location/organization from which the patient came before admission DefinitionThe location/organization from which the patient came before admission. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Location | Organization) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| admitSource | 0..1 | CodeableConceptBinding | Element idEncounter.hospitalization.admitSourceShort description From where patient was admitted (physician referral, transfer) DefinitionFrom where patient was admitted (physician referral, transfer). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The source of admission to a Hospital Provider Spell or a Nursing Episode when the Patient is in a Hospital Site or a Care Home. UKCoreSourceOfAdmission (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reAdmission | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idEncounter.hospitalization.reAdmissionShort description The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission DefinitionWhether this hospitalization is a readmission and why if known. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The reason for re-admission of this hospitalization encounter. Hl7VSReAdmissionIndicator (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| dietPreference | 0..* | CodeableConcept | There are no (further) constraints on this element Element idEncounter.hospitalization.dietPreferenceShort description Diet preferences reported by the patient DefinitionDiet preferences reported by the patient. 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. For example, a patient may request both a dairy-free and nut-free diet preference (not mutually exclusive). Medical, cultural or ethical food preferences to help with catering requirements. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| specialCourtesy | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idEncounter.hospitalization.specialCourtesyShort description Special courtesies (VIP, board member) DefinitionSpecial courtesies (VIP, board member). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Special courtesies. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| specialArrangement | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idEncounter.hospitalization.specialArrangementShort description Wheelchair, translator, stretcher, etc. DefinitionAny special requests that have been made for this hospitalization encounter, such as the provision of specific equipment or other things. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Special arrangements. SpecialArrangements (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| destination | C | 0..1 | Reference(Location | Organization) | There are no (further) constraints on this element Element idEncounter.hospitalization.destinationShort description Location/organization to which the patient is discharged DefinitionLocation/organization to which the patient is discharged. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Location | Organization) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| dischargeDisposition | 0..1 | CodeableConceptBinding | Element idEncounter.hospitalization.dischargeDispositionShort description Category or kind of location after discharge DefinitionCategory or kind of location after discharge. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The destination of a Patient on completion of a Hospital Provider Spell, or a note that the Patient died or was a still birth. UKCoreDischargeDestination (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| location | 0..* | BackboneElement | There are no (further) constraints on this element Element idEncounter.locationShort description List of locations where the patient has been DefinitionList of locations where the patient has been during this encounter. 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". The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idEncounter.location.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.location.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idEncounter.location.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| location | C | 1..1 | Reference(Location) | There are no (further) constraints on this element Element idEncounter.location.locationShort description Location the encounter takes place DefinitionThe location where the encounter takes place. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| status | 0..1 | codeBinding | There are no (further) constraints on this element Element idEncounter.location.statusShort description planned | active | reserved | completed DefinitionThe status of the participants' presence at the specified location during the period specified. If the participant is no longer at the location, then the period will have an end date/time. 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. The status of the location. EncounterLocationStatus (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| physicalType | 0..1 | CodeableConceptBinding | Element idEncounter.location.physicalTypeShort description The physical type of the location (usually the level in the location hierachy - bed room ward etc.) DefinitionThis will be used to specify the required levels (bed/ward/room/etc.) desired to be recorded to simplify either messaging or query. This information is de-normalized from the Location resource to support the easier understanding of the encounter resource and processing in messaging or query. There may be many levels in the hierachy, and this may only pic specific levels that are required for a specific usage scenario. A set of codes that define the physical type of location where an encounter takes place. UKCoreEncounterLocationType (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| period | C | 0..1 | Period | There are no (further) constraints on this element Element idEncounter.location.periodShort description Time period during which the patient was present at the location DefinitionTime period during which the patient was present at the location. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| serviceProvider | C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idEncounter.serviceProviderShort description The organization (facility) responsible for this encounter DefinitionThe 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| partOf | C | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idEncounter.partOfShort description Another Encounter this encounter is part of DefinitionAnother Encounter of which this encounter is a part of (administratively or in time). 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
|
| FHIR | MDS | HL7v2 |
|---|---|---|
| Encounter.identifier | HE-003 | PV1-19 |
| Encounter.class | HE-004 | PV1-2 |
| Encounter.serviceType | HE-001 | PV1-10 |
| Encounter.episodeOfCare.identifier | HE-002 | PV1-50 (PV1-53/54 in other versions of HL7v2) |
| Encounter.serviceProvider | PCI-023, PCI-024, PCI-025, PCI-026 | PV1-42 |
Additional Guidance
identifier
SHOULD use a local identifier for the encounter, using a locally managed system or assigner."identifier": [ "system": "https://fhir.leedssth.nhs.uk/Id/encounterId", "value": "E-12764", "assigner": { "identifier": { "system": "https://fhir.nhs.uk/Id/ods-organization-code", "value": "RR8" } } ],
status
SHALL be provided, SHOULD use `finished` for records of Encounters, or `planned` for recording future planned encounters."status": "finished",
class
SHALL be provided, classifying the encounter as inpatient/ambulatory etc. Core HL7 ActCodes are preferred."class": { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "IMP", "display": "inpatient encounter" },
serviceType
MAY be provided. Specifies the treatment function code the encounter falls under (mapped to Care Setting Types in SNOMED CT)."serviceType": { [ "class": { "system": "http://snomed.info/sct", "code": "700241009", "display": "Dermatology service" } ] }
subject
SHALL be provided. Reference to the associated Patient. This MAY be through a resource reference if the ID on the central service is known (or provided within the transaction bundle) or through NHS number where this is known and has been traced through PDS"subject": { "reference": "Patient/Patient-MeirLieberman-Example", "identifier": { "system": "https://fhir.nhs.uk/Id/nhs-number", "value": "9449307873" } },
episodeOfCare
MAY be provided, for hospital provider spells. Only reference by identifier is supported at this time."episodeOfCare": [ { "identifier": { "system": "https://fhir.leedssth.nhs.uk/Id/episodeOfCareId", "value": "EoC-12764", "assigner": { "identifier": { "system": "https://fhir.nhs.uk/Id/ods-organization-code", "value": "RR8" } } } } ]