Encounter Record
Interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient is store as Encounter (MY Core) record.
Encounter record is mainly used as a main resource that will reference or be referenced by other records for later retrieval/updating purposes.
Click MY Core postman API link to view common API used in HIE.
[base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/" [type] = resource type e.g. "Patient | Encounter | Compostion" @encounterId = unique encounter id defined from source system e.g. "encounter-sample" @encounterIdentifier = encounter registrtion number defined from source system e.g "HTJ-ENC-2211000036" @patientId = unique patient id defined from source system e.g "patient-sample" @patientIdentifier = patient identifier such as mykad number or MRN e.g "HIE-00000003"
| Sample Description | Sample Body | API Method | API |
|---|---|---|---|
| Create/Update encounter record | JSON | PUT | [base]/Encounter/@encounterId |
| Retrieve encounter record by id | - | GET | [base]/Encounter/@encounterId |
| Retrieve encounter record by identifier | - | GET | [base]/Encounter?identifier=@encounterIdentifier |
| Retrieve encounter record with patient id | - | GET | [base]/Encounter?subject=@patientId |
| Retrieve encounter record with patient identifier | - | GET | [base]/Encounter?subject.identifier=@patientIdentifier |
Encounter Classification
Encounter (MY Core) classifies an encounter in 3 level:
- the first level is class
Encounter.class, defines the broadest concept of a encounter- example: Outpatient (Ambulatory), Inpatient, Emergency or a Virtual encounter (based on base FHIR terminology).
- Related ValueSet: ValueSetEncounterClass (MY Core).
- the second level is serviceType
Encounter.serviceType, defines the specific type of service that is be delivered or performed.- example: Outpatient General, Outpatient Specialist (based on SMRP service-type terminology)
- Related ValueSet: ValueSetServiceType (MY Core).
- the third level is services
Encounter.serviceType, defines the main services performed during the encounter.- example: Internal Medicine, General Surgery, Cardiology, Family Medicine, Smoking Cessation, Communicable Disease, Non-communicable Disease (based on multiple combination of service terminology)
- Related ValueSet: ValueSetSpecialty (MY Core).
Below is a diagram related to classification of encounter to further explain the description above
Encounter Diagnosis
Diagnosis captured during an encounter will be referenced by related encounter Encounter.diagnosis.condition.reference. The Diagnosis itself is store as a Condition (MY Core) record. However, the role of the diagnosis (example: main diagnosis, discharge diagnosis, admission diagnosis) is stored in Encounter.diagnosis.use.coding.code.
Related Diagnosis Role ValueSet: ValueSetDiagnosisRole (My Core)