HdBe-Encounter
Profile | Description | Status | URL |
---|---|---|---|
HdBe-Encounter | A contact is any interaction, regardless of the situation, between a patient and the healthcare provider, in which the healthcare provider has primary responsibility for diagnosing, evaluating and treating the patient’s condition and informing the patient. These can be visits, appointments or non face-to-face interactions. Contacts can be visits to the general practitioner or other practices, home visits, admissions (in hospitals, nursing homes or care homes, psychiatric institutions or convalescent homes) or other relevant contacts. This includes past and future contacts. | draft | https://fhir.healthdata.be/StructureDefinition/HdBe-Encounter |
Encounter | I | Encounter | Element IdEncounter Encounter Alternate namesVisit, Contact 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.
| |
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdEncounter.identifier Identifier(s) by which this encounter is known DefinitionIdentifier(s) by which this encounter is known.
|
status | Σ ?! | 1..1 | codeBinding | Element IdEncounter.status planned | arrived | triaged | in-progress | onleave | finished | cancelled + Definitionplanned | arrived | triaged | in-progress | onleave | finished | cancelled +. This element is implictly mapped to the concepts StartDateTime and EndDateTime. Unless the status is explicitly recorded, the following guidance applies:
The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Current state of the encounter. EncounterStatus (required)Constraints
|
statusHistory | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.statusHistory 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.
| |
status | 1..1 | codeBinding | There are no (further) constraints on this element Element IdEncounter.statusHistory.status 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. EncounterStatus (required)Constraints
| |
period | I | 1..1 | Period | There are no (further) constraints on this element Element IdEncounter.statusHistory.period 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.
|
class | Σ | 1..1 | CodingBinding | Element IdEncounter.class ContactType Alternate namesContactType DefinitionThe type of contact. 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. Use ConceptMap ContactType-to-ActEncounterCode to translate CBB terminology to profile terminology in ValueSet ActEncounterCode. v3.ActEncounterCode (extensible)Permitted Values ContactType_to_ActEncounterCode Constraints
|
classHistory | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.classHistory 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.
| |
class | 1..1 | CodingBinding | There are no (further) constraints on this element Element IdEncounter.classHistory.class 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. v3.ActEncounterCode (extensible)Constraints
| |
period | I | 1..1 | Period | There are no (further) constraints on this element Element IdEncounter.classHistory.period 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.
|
type | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.type 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..*. The type of encounter. EncounterType (example)Constraints
|
serviceType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.serviceType 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. Broad categorization of the service that is to be provided. ServiceType (example)Constraints
|
priority | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.priority 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. v3.ActPriority (example)Constraints
| |
subject | Σ I | 0..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element IdEncounter.subject 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).
|
episodeOfCare | Σ I | 0..* | Reference(EpisodeOfCare) | There are no (further) constraints on this element Element IdEncounter.episodeOfCare 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.
|
basedOn | I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdEncounter.basedOn 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.
|
participant | Σ | 0..* | BackboneElement | Element IdEncounter.participant List of participants involved in the encounter DefinitionThe list of people responsible for providing the service. Unordered, Open, by individual.resolve()(Profile) Constraints
|
(All Slices) | There are no (further) constraints on this element | |||
type | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.participant.type 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. ParticipantType (extensible)Constraints
|
period | I | 0..1 | Period | There are no (further) constraints on this element Element IdEncounter.participant.period 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.
|
individual | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element IdEncounter.participant.individual 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) Constraints
|
healthProfessional | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.participant:healthProfessional List of participants involved in the encounter DefinitionThe list of people responsible for providing the service.
|
type | Σ | 0..1 | CodeableConceptBinding | Element IdEncounter.participant:healthProfessional.type HealthProfessionalRole Alternate namesZorgverlenerRol DefinitionThe role the health professional fulfils in the healthcare process. For health professionals, this could be for example attender, referrer or performer. 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. ParticipantType (extensible)Constraints
|
period | I | 0..1 | Period | There are no (further) constraints on this element Element IdEncounter.participant:healthProfessional.period 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.
|
individual | Σ I | 0..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | RelatedPerson | HdBe HealthProfessional PractitionerRole) | Element IdEncounter.participant:healthProfessional.individual ContactWith Alternate namesContactMet DefinitionThe health professional with whom the contact took or will take place. The specialty and role of the health professional can be entered in the HealthProfessional information model. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | RelatedPerson | HdBe HealthProfessional PractitionerRole) Constraints
|
appointment | Σ I | 0..* | Reference(Appointment) | There are no (further) constraints on this element Element IdEncounter.appointment 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.
|
period | I | 0..1 | Period | Element IdEncounter.period The start and end time of the encounter DefinitionThe start and end time of the encounter. If only a single point in time is known for the encounter rather than a period, both
|
start | Σ I | 0..1 | dateTime | Element IdEncounter.period.start StartDateTime Alternate namesBeginDatumTijd DefinitionThe date and time at which the contact took or will take place. If the low element is missing, the meaning is that the low boundary is not known.
|
end | Σ I | 0..1 | dateTime | Element IdEncounter.period.end EndDateTime Alternate namesEindDatumTijd DefinitionThe date and time at which the contact ended or will end. If the contact takes place over a period of time, this indicates the end of the period, in the case of an admission, for example. The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
|
length | I | 0..1 | DurationBinding | There are no (further) constraints on this element Element IdEncounter.length 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. Appropriate units for Duration. CommonUCUMCodesForDuration (extensible)Constraints
|
reasonCode | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.reasonCode 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)Constraints
|
reasonReference | Σ I | 0..* | Reference(Condition | Procedure | Observation | ImmunizationRecommendation) | Element IdEncounter.reasonReference 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 | Procedure | Observation | ImmunizationRecommendation) Sliced:Unordered, Open, by resolve()(Profile) Constraints
|
(All Slices) | There are no (further) constraints on this element | |||
extension | I | 0..* | Extension | Element IdEncounter.reasonReference.extension 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) Constraints
|
comment | I | 0..1 | Extension(string) | Element IdEncounter.reasonReference.extension:comment Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.healthdata.be/StructureDefinition/ext-Comment Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdEncounter.reasonReference.extension:comment.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. 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. System.String Fixed Valuehttps://fhir.healthdata.be/StructureDefinition/ext-Comment
| |
value[x] | 0..1 | Element IdEncounter.reasonReference.extension:comment.value[x] CommentContactReason Alternate namesToelichtingRedenContact DefinitionExplanation of the reason for the contact
| ||
valueString | string | There are no (further) constraints on this element Data Type | ||
reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element IdEncounter.reasonReference.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
|
type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element IdEncounter.reasonReference.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). ResourceType (extensible)Constraints
|
identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdEncounter.reasonReference.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdEncounter.reasonReference.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
|
problem | Σ I | 0..* | Reference(HdBe Problem) | Element IdEncounter.reasonReference:problem Problem Alternate namesIndication, Admission diagnosis, Probleem DefinitionThe problem that is the reason for the contact. 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).
|
procedure | Σ I | 0..* | Reference(HdBe Procedure event) | Element IdEncounter.reasonReference:procedure Procedure Alternate namesIndication, Admission diagnosis, Verrichting DefinitionThe procedure carried out or will be carried out during the contact. 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(HdBe Procedure event) Constraints
|
deviatingResult | Σ I | 0..* | Reference(HdBe LaboratoryTestResult) | Element IdEncounter.reasonReference:deviatingResult DeviatingResult Alternate namesIndication, Admission diagnosis, AfwijkendeUitslag DefinitionA deviating result which serves as the reason for the contact. DeviatingResult is captured with a reference to the CBB LaboratoryTestResult instead of a string value as the CBB 2020 incorrectly states. This will be fixed in a future version of the CBB. At time of writing (November 2021), the proposed change can be followed in this BITS ticket: https://bits.nictiz.nl/browse/ZIB-1427. Reference(HdBe LaboratoryTestResult) Constraints
|
diagnosis | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.diagnosis The list of diagnosis relevant to this encounter DefinitionThe list of diagnosis relevant to this encounter.
|
condition | Σ I | 1..1 | Reference(Condition | Procedure) | There are no (further) constraints on this element Element IdEncounter.diagnosis.condition 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) Constraints
|
use | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.diagnosis.use 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. DiagnosisRole (preferred)Constraints
| |
rank | 0..1 | positiveInt | There are no (further) constraints on this element Element IdEncounter.diagnosis.rank 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
| |
account | I | 0..* | Reference(Account) | There are no (further) constraints on this element Element IdEncounter.account 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.
|
hospitalization | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdEncounter.hospitalization 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.
| |
preAdmissionIdentifier | 0..1 | Identifier | There are no (further) constraints on this element Element IdEncounter.hospitalization.preAdmissionIdentifier Pre-admission identifier DefinitionPre-admission identifier.
| |
origin | I | 0..1 | Reference(Location | Organization) | There are no (further) constraints on this element Element IdEncounter.hospitalization.origin 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) Constraints
|
admitSource | 0..1 | CodeableConceptBinding | Element IdEncounter.hospitalization.admitSource Origin Alternate namesHerkomst DefinitionLocation from which the patient comes before the encounter. In most cases this will only be used when the patient is admitted. 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. From where the patient was admitted. Origin (extensible)Constraints
| |
reAdmission | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.hospitalization.reAdmission 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. v2.0092 (example)Constraints
| |
dietPreference | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.hospitalization.dietPreference 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. Diet (example)Constraints
| |
specialCourtesy | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.hospitalization.specialCourtesy 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. SpecialCourtesy (preferred)Constraints
| |
specialArrangement | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.hospitalization.specialArrangement 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)Constraints
| |
destination | I | 0..1 | Reference(Location | Organization) | There are no (further) constraints on this element Element IdEncounter.hospitalization.destination 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) Constraints
|
dischargeDisposition | 0..1 | CodeableConceptBinding | Element IdEncounter.hospitalization.dischargeDisposition Destination Alternate namesBestemming DefinitionLocation to which the patient will go after the encounter. In most cases this will only be used when the patient is discharged. 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. Discharge Disposition. Destination (extensible)Constraints
| |
location | 0..* | BackboneElement | Element IdEncounter.location List of locations where the patient has been DefinitionList of locations where the patient has been during this encounter. The CBB has a restricted cardinality of 0..1 for the Location concept. However, this cardianlity is propably too restricted (see https://bits.nictiz.nl/browse/ZIB-1632 for discussion) and would prevent some practical use cases. Therefore, the cardinality has been left on 0..* in this profile.
| |
location | I | 1..1 | Reference(Location | HdBe HealthcareOrganization) | Element IdEncounter.location.location Location Alternate namesLocatie DefinitionThe physical location at which the contact took or will take 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. Reference(Location | HdBe HealthcareOrganization) Constraints
|
status | 0..1 | codeBinding | There are no (further) constraints on this element Element IdEncounter.location.status 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)Constraints
| |
physicalType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.location.physicalType 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. Physical form of the location. LocationType (example)Constraints
| |
period | I | 0..1 | Period | There are no (further) constraints on this element Element IdEncounter.location.period 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.
|
serviceProvider | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element IdEncounter.serviceProvider 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.
|
partOf | I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdEncounter.partOf 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.
|
Encounter | I | Encounter | Element IdEncounter Encounter Alternate namesVisit, Contact 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.
| |
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdEncounter.identifier Identifier(s) by which this encounter is known DefinitionIdentifier(s) by which this encounter is known.
|
status | Σ ?! | 1..1 | codeBinding | Element IdEncounter.status planned | arrived | triaged | in-progress | onleave | finished | cancelled + Definitionplanned | arrived | triaged | in-progress | onleave | finished | cancelled +. This element is implictly mapped to the concepts StartDateTime and EndDateTime. Unless the status is explicitly recorded, the following guidance applies:
The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Current state of the encounter. EncounterStatus (required)Constraints
|
statusHistory | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.statusHistory 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.
| |
status | 1..1 | codeBinding | There are no (further) constraints on this element Element IdEncounter.statusHistory.status 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. EncounterStatus (required)Constraints
| |
period | I | 1..1 | Period | There are no (further) constraints on this element Element IdEncounter.statusHistory.period 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.
|
class | Σ | 1..1 | CodingBinding | Element IdEncounter.class ContactType Alternate namesContactType DefinitionThe type of contact. 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. Use ConceptMap ContactType-to-ActEncounterCode to translate CBB terminology to profile terminology in ValueSet ActEncounterCode. v3.ActEncounterCode (extensible)Permitted Values ContactType_to_ActEncounterCode Constraints
|
classHistory | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.classHistory 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.
| |
class | 1..1 | CodingBinding | There are no (further) constraints on this element Element IdEncounter.classHistory.class 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. v3.ActEncounterCode (extensible)Constraints
| |
period | I | 1..1 | Period | There are no (further) constraints on this element Element IdEncounter.classHistory.period 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.
|
type | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.type 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..*. The type of encounter. EncounterType (example)Constraints
|
serviceType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.serviceType 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. Broad categorization of the service that is to be provided. ServiceType (example)Constraints
|
priority | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.priority 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. v3.ActPriority (example)Constraints
| |
subject | Σ I | 0..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element IdEncounter.subject 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).
|
episodeOfCare | Σ I | 0..* | Reference(EpisodeOfCare) | There are no (further) constraints on this element Element IdEncounter.episodeOfCare 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.
|
basedOn | I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdEncounter.basedOn 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.
|
participant | Σ | 0..* | BackboneElement | Element IdEncounter.participant List of participants involved in the encounter DefinitionThe list of people responsible for providing the service. Unordered, Open, by individual.resolve()(Profile) Constraints
|
(All Slices) | There are no (further) constraints on this element | |||
type | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.participant.type 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. ParticipantType (extensible)Constraints
|
period | I | 0..1 | Period | There are no (further) constraints on this element Element IdEncounter.participant.period 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.
|
individual | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element IdEncounter.participant.individual 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) Constraints
|
healthProfessional | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.participant:healthProfessional List of participants involved in the encounter DefinitionThe list of people responsible for providing the service.
|
type | Σ | 0..1 | CodeableConceptBinding | Element IdEncounter.participant:healthProfessional.type HealthProfessionalRole Alternate namesZorgverlenerRol DefinitionThe role the health professional fulfils in the healthcare process. For health professionals, this could be for example attender, referrer or performer. 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. ParticipantType (extensible)Constraints
|
period | I | 0..1 | Period | There are no (further) constraints on this element Element IdEncounter.participant:healthProfessional.period 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.
|
individual | Σ I | 0..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | RelatedPerson | HdBe HealthProfessional PractitionerRole) | Element IdEncounter.participant:healthProfessional.individual ContactWith Alternate namesContactMet DefinitionThe health professional with whom the contact took or will take place. The specialty and role of the health professional can be entered in the HealthProfessional information model. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | RelatedPerson | HdBe HealthProfessional PractitionerRole) Constraints
|
appointment | Σ I | 0..* | Reference(Appointment) | There are no (further) constraints on this element Element IdEncounter.appointment 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.
|
period | I | 0..1 | Period | Element IdEncounter.period The start and end time of the encounter DefinitionThe start and end time of the encounter. If only a single point in time is known for the encounter rather than a period, both
|
start | Σ I | 0..1 | dateTime | Element IdEncounter.period.start StartDateTime Alternate namesBeginDatumTijd DefinitionThe date and time at which the contact took or will take place. If the low element is missing, the meaning is that the low boundary is not known.
|
end | Σ I | 0..1 | dateTime | Element IdEncounter.period.end EndDateTime Alternate namesEindDatumTijd DefinitionThe date and time at which the contact ended or will end. If the contact takes place over a period of time, this indicates the end of the period, in the case of an admission, for example. The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
|
length | I | 0..1 | DurationBinding | There are no (further) constraints on this element Element IdEncounter.length 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. Appropriate units for Duration. CommonUCUMCodesForDuration (extensible)Constraints
|
reasonCode | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.reasonCode 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)Constraints
|
reasonReference | Σ I | 0..* | Reference(Condition | Procedure | Observation | ImmunizationRecommendation) | Element IdEncounter.reasonReference 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 | Procedure | Observation | ImmunizationRecommendation) Sliced:Unordered, Open, by resolve()(Profile) Constraints
|
(All Slices) | There are no (further) constraints on this element | |||
extension | I | 0..* | Extension | Element IdEncounter.reasonReference.extension 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) Constraints
|
comment | I | 0..1 | Extension(string) | Element IdEncounter.reasonReference.extension:comment Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.healthdata.be/StructureDefinition/ext-Comment Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdEncounter.reasonReference.extension:comment.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. 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. System.String Fixed Valuehttps://fhir.healthdata.be/StructureDefinition/ext-Comment
| |
value[x] | 0..1 | Element IdEncounter.reasonReference.extension:comment.value[x] CommentContactReason Alternate namesToelichtingRedenContact DefinitionExplanation of the reason for the contact
| ||
valueString | string | There are no (further) constraints on this element Data Type | ||
reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element IdEncounter.reasonReference.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
|
type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element IdEncounter.reasonReference.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). ResourceType (extensible)Constraints
|
identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdEncounter.reasonReference.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdEncounter.reasonReference.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
|
problem | Σ I | 0..* | Reference(HdBe Problem) | Element IdEncounter.reasonReference:problem Problem Alternate namesIndication, Admission diagnosis, Probleem DefinitionThe problem that is the reason for the contact. 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).
|
procedure | Σ I | 0..* | Reference(HdBe Procedure event) | Element IdEncounter.reasonReference:procedure Procedure Alternate namesIndication, Admission diagnosis, Verrichting DefinitionThe procedure carried out or will be carried out during the contact. 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(HdBe Procedure event) Constraints
|
deviatingResult | Σ I | 0..* | Reference(HdBe LaboratoryTestResult) | Element IdEncounter.reasonReference:deviatingResult DeviatingResult Alternate namesIndication, Admission diagnosis, AfwijkendeUitslag DefinitionA deviating result which serves as the reason for the contact. DeviatingResult is captured with a reference to the CBB LaboratoryTestResult instead of a string value as the CBB 2020 incorrectly states. This will be fixed in a future version of the CBB. At time of writing (November 2021), the proposed change can be followed in this BITS ticket: https://bits.nictiz.nl/browse/ZIB-1427. Reference(HdBe LaboratoryTestResult) Constraints
|
diagnosis | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.diagnosis The list of diagnosis relevant to this encounter DefinitionThe list of diagnosis relevant to this encounter.
|
condition | Σ I | 1..1 | Reference(Condition | Procedure) | There are no (further) constraints on this element Element IdEncounter.diagnosis.condition 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) Constraints
|
use | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.diagnosis.use 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. DiagnosisRole (preferred)Constraints
| |
rank | 0..1 | positiveInt | There are no (further) constraints on this element Element IdEncounter.diagnosis.rank 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
| |
account | I | 0..* | Reference(Account) | There are no (further) constraints on this element Element IdEncounter.account 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.
|
hospitalization | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdEncounter.hospitalization 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.
| |
preAdmissionIdentifier | 0..1 | Identifier | There are no (further) constraints on this element Element IdEncounter.hospitalization.preAdmissionIdentifier Pre-admission identifier DefinitionPre-admission identifier.
| |
origin | I | 0..1 | Reference(Location | Organization) | There are no (further) constraints on this element Element IdEncounter.hospitalization.origin 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) Constraints
|
admitSource | 0..1 | CodeableConceptBinding | Element IdEncounter.hospitalization.admitSource Origin Alternate namesHerkomst DefinitionLocation from which the patient comes before the encounter. In most cases this will only be used when the patient is admitted. 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. From where the patient was admitted. Origin (extensible)Constraints
| |
reAdmission | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.hospitalization.reAdmission 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. v2.0092 (example)Constraints
| |
dietPreference | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.hospitalization.dietPreference 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. Diet (example)Constraints
| |
specialCourtesy | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.hospitalization.specialCourtesy 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. SpecialCourtesy (preferred)Constraints
| |
specialArrangement | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.hospitalization.specialArrangement 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)Constraints
| |
destination | I | 0..1 | Reference(Location | Organization) | There are no (further) constraints on this element Element IdEncounter.hospitalization.destination 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) Constraints
|
dischargeDisposition | 0..1 | CodeableConceptBinding | Element IdEncounter.hospitalization.dischargeDisposition Destination Alternate namesBestemming DefinitionLocation to which the patient will go after the encounter. In most cases this will only be used when the patient is discharged. 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. Discharge Disposition. Destination (extensible)Constraints
| |
location | 0..* | BackboneElement | Element IdEncounter.location List of locations where the patient has been DefinitionList of locations where the patient has been during this encounter. The CBB has a restricted cardinality of 0..1 for the Location concept. However, this cardianlity is propably too restricted (see https://bits.nictiz.nl/browse/ZIB-1632 for discussion) and would prevent some practical use cases. Therefore, the cardinality has been left on 0..* in this profile.
| |
location | I | 1..1 | Reference(Location | HdBe HealthcareOrganization) | Element IdEncounter.location.location Location Alternate namesLocatie DefinitionThe physical location at which the contact took or will take 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. Reference(Location | HdBe HealthcareOrganization) Constraints
|
status | 0..1 | codeBinding | There are no (further) constraints on this element Element IdEncounter.location.status 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)Constraints
| |
physicalType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.location.physicalType 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. Physical form of the location. LocationType (example)Constraints
| |
period | I | 0..1 | Period | There are no (further) constraints on this element Element IdEncounter.location.period 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.
|
serviceProvider | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element IdEncounter.serviceProvider 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.
|
partOf | I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdEncounter.partOf 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.
|
Encounter | I | Encounter | Element IdEncounter Encounter Alternate namesVisit, Contact 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.
| |
identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdEncounter.identifier Identifier(s) by which this encounter is known DefinitionIdentifier(s) by which this encounter is known.
|
status | Σ ?! | 1..1 | codeBinding | Element IdEncounter.status planned | arrived | triaged | in-progress | onleave | finished | cancelled + Definitionplanned | arrived | triaged | in-progress | onleave | finished | cancelled +. This element is implictly mapped to the concepts StartDateTime and EndDateTime. Unless the status is explicitly recorded, the following guidance applies:
The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Current state of the encounter. EncounterStatus (required)Constraints
|
statusHistory | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.statusHistory 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.
| |
status | 1..1 | codeBinding | There are no (further) constraints on this element Element IdEncounter.statusHistory.status 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. EncounterStatus (required)Constraints
| |
period | I | 1..1 | Period | There are no (further) constraints on this element Element IdEncounter.statusHistory.period 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.
|
class | Σ | 1..1 | CodingBinding | Element IdEncounter.class ContactType Alternate namesContactType DefinitionThe type of contact. 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. Use ConceptMap ContactType-to-ActEncounterCode to translate CBB terminology to profile terminology in ValueSet ActEncounterCode. v3.ActEncounterCode (extensible)Permitted Values ContactType_to_ActEncounterCode Constraints
|
classHistory | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.classHistory 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.
| |
class | 1..1 | CodingBinding | There are no (further) constraints on this element Element IdEncounter.classHistory.class 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. v3.ActEncounterCode (extensible)Constraints
| |
period | I | 1..1 | Period | There are no (further) constraints on this element Element IdEncounter.classHistory.period 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.
|
type | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.type 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..*. The type of encounter. EncounterType (example)Constraints
|
serviceType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.serviceType 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. Broad categorization of the service that is to be provided. ServiceType (example)Constraints
|
priority | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.priority 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. v3.ActPriority (example)Constraints
| |
subject | Σ I | 0..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element IdEncounter.subject 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).
|
episodeOfCare | Σ I | 0..* | Reference(EpisodeOfCare) | There are no (further) constraints on this element Element IdEncounter.episodeOfCare 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.
|
basedOn | I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdEncounter.basedOn 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.
|
participant | Σ | 0..* | BackboneElement | Element IdEncounter.participant List of participants involved in the encounter DefinitionThe list of people responsible for providing the service. Unordered, Open, by individual.resolve()(Profile) Constraints
|
(All Slices) | There are no (further) constraints on this element | |||
type | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.participant.type 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. ParticipantType (extensible)Constraints
|
period | I | 0..1 | Period | There are no (further) constraints on this element Element IdEncounter.participant.period 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.
|
individual | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element IdEncounter.participant.individual 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) Constraints
|
healthProfessional | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.participant:healthProfessional List of participants involved in the encounter DefinitionThe list of people responsible for providing the service.
|
type | Σ | 0..1 | CodeableConceptBinding | Element IdEncounter.participant:healthProfessional.type HealthProfessionalRole Alternate namesZorgverlenerRol DefinitionThe role the health professional fulfils in the healthcare process. For health professionals, this could be for example attender, referrer or performer. 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. ParticipantType (extensible)Constraints
|
period | I | 0..1 | Period | There are no (further) constraints on this element Element IdEncounter.participant:healthProfessional.period 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.
|
individual | Σ I | 0..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | RelatedPerson | HdBe HealthProfessional PractitionerRole) | Element IdEncounter.participant:healthProfessional.individual ContactWith Alternate namesContactMet DefinitionThe health professional with whom the contact took or will take place. The specialty and role of the health professional can be entered in the HealthProfessional information model. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | RelatedPerson | HdBe HealthProfessional PractitionerRole) Constraints
|
appointment | Σ I | 0..* | Reference(Appointment) | There are no (further) constraints on this element Element IdEncounter.appointment 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.
|
period | I | 0..1 | Period | Element IdEncounter.period The start and end time of the encounter DefinitionThe start and end time of the encounter. If only a single point in time is known for the encounter rather than a period, both
|
start | Σ I | 0..1 | dateTime | Element IdEncounter.period.start StartDateTime Alternate namesBeginDatumTijd DefinitionThe date and time at which the contact took or will take place. If the low element is missing, the meaning is that the low boundary is not known.
|
end | Σ I | 0..1 | dateTime | Element IdEncounter.period.end EndDateTime Alternate namesEindDatumTijd DefinitionThe date and time at which the contact ended or will end. If the contact takes place over a period of time, this indicates the end of the period, in the case of an admission, for example. The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
|
length | I | 0..1 | DurationBinding | There are no (further) constraints on this element Element IdEncounter.length 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. Appropriate units for Duration. CommonUCUMCodesForDuration (extensible)Constraints
|
reasonCode | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.reasonCode 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)Constraints
|
reasonReference | Σ I | 0..* | Reference(Condition | Procedure | Observation | ImmunizationRecommendation) | Element IdEncounter.reasonReference 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 | Procedure | Observation | ImmunizationRecommendation) Sliced:Unordered, Open, by resolve()(Profile) Constraints
|
(All Slices) | There are no (further) constraints on this element | |||
extension | I | 0..* | Extension | Element IdEncounter.reasonReference.extension 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) Constraints
|
comment | I | 0..1 | Extension(string) | Element IdEncounter.reasonReference.extension:comment Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.healthdata.be/StructureDefinition/ext-Comment Constraints
|
url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdEncounter.reasonReference.extension:comment.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. 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. System.String Fixed Valuehttps://fhir.healthdata.be/StructureDefinition/ext-Comment
| |
value[x] | 0..1 | Element IdEncounter.reasonReference.extension:comment.value[x] CommentContactReason Alternate namesToelichtingRedenContact DefinitionExplanation of the reason for the contact
| ||
valueString | string | There are no (further) constraints on this element Data Type | ||
reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element IdEncounter.reasonReference.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
|
type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element IdEncounter.reasonReference.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). ResourceType (extensible)Constraints
|
identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdEncounter.reasonReference.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
|
display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdEncounter.reasonReference.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
|
problem | Σ I | 0..* | Reference(HdBe Problem) | Element IdEncounter.reasonReference:problem Problem Alternate namesIndication, Admission diagnosis, Probleem DefinitionThe problem that is the reason for the contact. 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).
|
procedure | Σ I | 0..* | Reference(HdBe Procedure event) | Element IdEncounter.reasonReference:procedure Procedure Alternate namesIndication, Admission diagnosis, Verrichting DefinitionThe procedure carried out or will be carried out during the contact. 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(HdBe Procedure event) Constraints
|
deviatingResult | Σ I | 0..* | Reference(HdBe LaboratoryTestResult) | Element IdEncounter.reasonReference:deviatingResult DeviatingResult Alternate namesIndication, Admission diagnosis, AfwijkendeUitslag DefinitionA deviating result which serves as the reason for the contact. DeviatingResult is captured with a reference to the CBB LaboratoryTestResult instead of a string value as the CBB 2020 incorrectly states. This will be fixed in a future version of the CBB. At time of writing (November 2021), the proposed change can be followed in this BITS ticket: https://bits.nictiz.nl/browse/ZIB-1427. Reference(HdBe LaboratoryTestResult) Constraints
|
diagnosis | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdEncounter.diagnosis The list of diagnosis relevant to this encounter DefinitionThe list of diagnosis relevant to this encounter.
|
condition | Σ I | 1..1 | Reference(Condition | Procedure) | There are no (further) constraints on this element Element IdEncounter.diagnosis.condition 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) Constraints
|
use | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.diagnosis.use 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. DiagnosisRole (preferred)Constraints
| |
rank | 0..1 | positiveInt | There are no (further) constraints on this element Element IdEncounter.diagnosis.rank 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
| |
account | I | 0..* | Reference(Account) | There are no (further) constraints on this element Element IdEncounter.account 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.
|
hospitalization | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdEncounter.hospitalization 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.
| |
preAdmissionIdentifier | 0..1 | Identifier | There are no (further) constraints on this element Element IdEncounter.hospitalization.preAdmissionIdentifier Pre-admission identifier DefinitionPre-admission identifier.
| |
origin | I | 0..1 | Reference(Location | Organization) | There are no (further) constraints on this element Element IdEncounter.hospitalization.origin 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) Constraints
|
admitSource | 0..1 | CodeableConceptBinding | Element IdEncounter.hospitalization.admitSource Origin Alternate namesHerkomst DefinitionLocation from which the patient comes before the encounter. In most cases this will only be used when the patient is admitted. 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. From where the patient was admitted. Origin (extensible)Constraints
| |
reAdmission | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.hospitalization.reAdmission 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. v2.0092 (example)Constraints
| |
dietPreference | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.hospitalization.dietPreference 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. Diet (example)Constraints
| |
specialCourtesy | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.hospitalization.specialCourtesy 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. SpecialCourtesy (preferred)Constraints
| |
specialArrangement | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdEncounter.hospitalization.specialArrangement 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)Constraints
| |
destination | I | 0..1 | Reference(Location | Organization) | There are no (further) constraints on this element Element IdEncounter.hospitalization.destination 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) Constraints
|
dischargeDisposition | 0..1 | CodeableConceptBinding | Element IdEncounter.hospitalization.dischargeDisposition Destination Alternate namesBestemming DefinitionLocation to which the patient will go after the encounter. In most cases this will only be used when the patient is discharged. 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. Discharge Disposition. Destination (extensible)Constraints
| |
location | 0..* | BackboneElement | Element IdEncounter.location List of locations where the patient has been DefinitionList of locations where the patient has been during this encounter. The CBB has a restricted cardinality of 0..1 for the Location concept. However, this cardianlity is propably too restricted (see https://bits.nictiz.nl/browse/ZIB-1632 for discussion) and would prevent some practical use cases. Therefore, the cardinality has been left on 0..* in this profile.
| |
location | I | 1..1 | Reference(Location | HdBe HealthcareOrganization) | Element IdEncounter.location.location Location Alternate namesLocatie DefinitionThe physical location at which the contact took or will take 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. Reference(Location | HdBe HealthcareOrganization) Constraints
|
status | 0..1 | codeBinding | There are no (further) constraints on this element Element IdEncounter.location.status 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)Constraints
| |
physicalType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdEncounter.location.physicalType 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. Physical form of the location. LocationType (example)Constraints
| |
period | I | 0..1 | Period | There are no (further) constraints on this element Element IdEncounter.location.period 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.
|
serviceProvider | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element IdEncounter.serviceProvider 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.
|
partOf | I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdEncounter.partOf 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.
|
Mapping FHIR profile to CBB
Path | map | CBB | comment |
---|---|---|---|
Encounter | Encounter | HdBe-Encounter | |
Encounter.status | Encounter.ContactWith.StartDateTime | HdBe-Encounter | implicit, main mapping is on `Encounter.period` |
Encounter.status | Encounter.ContactWith.EndDateTime | HdBe-Encounter | implicit, main mapping is on `Encounter.period` |
Encounter.class | Encounter.ContactType | HdBe-Encounter | |
Encounter.participant:healthProfessional.individual | Encounter.ContactWith.HealthProfessional | HdBe-Encounter | |
Encounter.period.start | Encounter.ContactWith.StartDateTime | HdBe-Encounter | |
Encounter.period.end | Encounter.ContactWith.EndDateTime | HdBe-Encounter | |
Encounter.reasonReference.extension:comment.value[x] | Encounter.ContactReason.CommentContactReason | HdBe-Encounter | |
Encounter.reasonReference:problem | Encounter.ContactReason.Problem | HdBe-Encounter | |
Encounter.reasonReference:procedure | Encounter.ContactReason.Procedure | HdBe-Encounter | |
Encounter.reasonReference:deviatingResult | Encounter.ContactReason.DeviatingResult | HdBe-Encounter | |
Encounter.hospitalization.admitSource | Encounter.Origin | HdBe-Encounter | |
Encounter.hospitalization.dischargeDisposition | Encounter.Destination | HdBe-Encounter | |
Encounter.location.location | Encounter.Location | HdBe-Encounter | |
Encounter.participant:healthProfessional.type | HealthProfessionalRole | HdBe-HealthProfessional |
zib Encounter difference
Concept | Category | Description |
---|---|---|
class |
terminology | Replaced ValueSet (and ConceptMap) with a ValueSet that contains codes in use by Healthdata.be - Sciensano. |
participant:healthProfessional |
textual | Used CBB wording in the pattern-HealthProfessionalReference profile. Changes are in the mentioned profile. |
hospitalization.dischargeDisposition |
terminology | Added SNOMED codes Unkown and Other to the ValueSet. |
hospitalization.origin |
terminology | Added SNOMED codes Unkown and Other to the ValueSet. |
Terminology Bindings
Path | Name | Strength | URL | ConceptMap |
---|---|---|---|---|
Encounter.class | v3-ActEncounterCode | extensible | http://terminology.hl7.org/ValueSet/v3-ActEncounterCode | https://fhir.healthdata.be/ConceptMap/ContactType-to-ActEncounterCode |
Encounter.hospitalization.admitSource | Origin | extensible | https://fhir.healthdata.be/ValueSet/Origin | No bound ConceptMap |
Encounter.hospitalization.dischargeDisposition | Destination | extensible | https://fhir.healthdata.be/ValueSet/Destination | No bound ConceptMap |