{ "resourceType": "StructureDefinition", "base": "http://hl7.org/fhir/StructureDefinition/DomainResource", "id": "spark39", "meta": { "versionId": "spark39", "lastUpdated": "2015-10-02T11:53:22.897+00:00" }, "text": { "status": "generated", "div": "
NameFlagsCard.TypeDescription & Constraints\"doco\"
\".\"\".\"EncounterDomainResourceAn interaction during which services are provided to the patient
\".\"\".\"\".\"identifierΣ0..*IdentifierIdentifier(s) by which this encounter is known
\".\"\".\"\".\"status?! Σ1..1codeplanned | arrived | in-progress | onleave | finished | cancelled\n
EncounterState (\n Required)\n
\".\"\".\"\".\"statusHistory0..*BackboneElementList of past encounter statuses
\".\"\".\"\".\"\".\"status1..1codeplanned | arrived | in-progress | onleave | finished | cancelled\n
EncounterState (\n Required)\n
\".\"\".\"\".\"\".\"period1..1PeriodThe time that the episode was in the specified status
\".\"\".\"\".\"classΣ0..1codeinpatient | outpatient | ambulatory | emergency +\n
EncounterClass (\n Required)\n
\".\"\".\"\".\"typeΣ0..*CodeableConceptSpecific type of encounter\n
EncounterType (\n Example)\n
\".\"\".\"\".\"priority0..1CodeableConceptIndicates the urgency of the encounter\n
Encounter Priority (\n Example)\n
\".\"\".\"\".\"patientΣ0..1Reference(\n Patient)\n The patient present at the encounter
\".\"\".\"\".\"episodeOfCareΣ0..*Reference(\n EpisodeOfCare)\n Episode(s) of care that this encounter should be recorded against
\".\"\".\"\".\"incomingReferral0..*Reference(\n ReferralRequest)\n The ReferralRequest that initiated this encounter
\".\"\".\"\".\"participantΣ0..*BackboneElementList of participants involved in the encounter
\".\"\".\"\".\"\".\"typeΣ0..*CodeableConceptRole of participant in encounter\n
ParticipantType (\n Extensible)\n
\".\"\".\"\".\"\".\"period0..1PeriodPeriod of time during the encounter participant was present
\".\"\".\"\".\"\".\"individualΣ0..1Reference(\n Practitioner | \n RelatedPerson)\n Persons involved in the encounter other than the patient
\".\"\".\"\".\"appointmentΣ0..1Reference(\n Appointment)\n The appointment that scheduled this encounter
\".\"\".\"\".\"period0..1PeriodThe start and end time of the encounter
\".\"\".\"\".\"length0..1DurationQuantity of time the encounter lasted (less time absent)
\".\"\".\"\".\"reasonΣ0..*CodeableConceptReason the encounter takes place (code)\n
Encounter Reason Codes (\n Example)\n
\".\"\".\"\".\"indication0..*Reference(\n Condition | \n Procedure)\n Reason the encounter takes place (resource)
\".\"\".\"\".\"hospitalization0..1BackboneElementDetails about the admission to a healthcare service
\".\"\".\"\".\"\".\"preAdmissionIdentifier0..1IdentifierPre-admission identifier
\".\"\".\"\".\"\".\"origin0..1Reference(\n Location)\n The location from which the patient came before admission
\".\"\".\"\".\"\".\"admitSource0..1CodeableConceptFrom where patient was admitted (physician referral, transfer)\n
AdmitSource (\n Preferred)\n
\".\"\".\"\".\"\".\"admittingDiagnosis0..*Reference(\n Condition)\n The admitting diagnosis as reported by admitting practitioner
\".\"\".\"\".\"\".\"reAdmission0..1CodeableConceptThe type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
\".\"\".\"\".\"\".\"dietPreference0..*CodeableConceptDiet preferences reported by the patient\n
Diet (\n Example)\n
\".\"\".\"\".\"\".\"specialCourtesy0..*CodeableConceptSpecial courtesies (VIP, board member)\n
SpecialCourtesy (\n Preferred)\n
\".\"\".\"\".\"\".\"specialArrangement0..*CodeableConceptWheelchair, translator, stretcher, etc.\n
SpecialArrangements (\n Preferred)\n
\".\"\".\"\".\"\".\"destination0..1Reference(\n Location)\n Location to which the patient is discharged
\".\"\".\"\".\"\".\"dischargeDisposition0..1CodeableConceptCategory or kind of location after discharge\n
DischargeDisposition (\n Preferred)\n
\".\"\".\"\".\"\".\"dischargeDiagnosis0..*Reference(\n Condition)\n The final diagnosis given a patient before release from the hospital after all testing, surgery, and workup are complete
\".\"\".\"\".\"location0..*BackboneElementList of locations where the patient has been
\".\"\".\"\".\"\".\"location1..1Reference(\n Location)\n Location the encounter takes place
\".\"\".\"\".\"\".\"status0..1codeplanned | active | reserved | completed\n
EncounterLocationStatus (\n Required)\n
\".\"\".\"\".\"\".\"period0..1PeriodTime period during which the patient was present at the location
\".\"\".\"\".\"serviceProvider0..1Reference(\n Organization)\n The custodian organization of this Encounter record
\".\"\".\"\".\"partOf0..1Reference(\n Encounter)\n Another Encounter this encounter is part of

\"doco\" Documentation for this format\n
" }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm", "valueInteger": 0 } ], "url": "http://hl7.org/fhir/StructureDefinition/Encounter", "name": "Encounter", "status": "draft", "date": "2015-09-22T03:47:23+00:00", "publisher": "Health Level Seven International (Patient Administration)", "contact": [ { "telecom": [ { "system": "other", "value": "http://hl7.org/fhir" } ] }, { "telecom": [ { "system": "other", "value": "http://www.hl7.org/Special/committees/pafm/index.cfm" } ] } ], "description": "Base StructureDefinition for Encounter Resource", "fhirVersion": "1.0.1", "mapping": [ { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM" }, { "identity": "w5", "uri": "http://hl7.org/fhir/w5", "name": "W5 Mapping" }, { "identity": "v2", "uri": "http://hl7.org/v2", "name": "HL7 v2" } ], "kind": "resource", "abstract": false, "snapshot": { "element": [ { "path": "Encounter", "short": "An interaction during which services are provided to the patient", "definition": "An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.", "alias": [ "Visit" ], "min": 0, "max": "*", "type": [ { "code": "DomainResource" } ], "mapping": [ { "identity": "rim", "map": "Encounter[moodCode=EVN]" }, { "identity": "w5", "map": "workflow.encounter" } ] }, { "comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.", "path": "Encounter.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "min": 0, "max": "1", "type": [ { "code": "id" } ], "isSummary": true }, { "path": "Encounter.meta", "short": "Metadata about the resource", "definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.", "min": 0, "max": "1", "type": [ { "code": "Meta" } ], "isSummary": true }, { "comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.", "path": "Encounter.implicitRules", "short": "A set of rules under which this content was created", "definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.", "min": 0, "max": "1", "type": [ { "code": "uri" } ], "isModifier": true, "isSummary": true }, { "comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).", "path": "Encounter.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "A human language.", "valueSetUri": "http://tools.ietf.org/html/bcp47" } }, { "comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.", "path": "Encounter.text", "short": "Text summary of the resource, for human interpretation", "definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "type": [ { "code": "Narrative" } ], "condition": [ "dom-1" ], "mapping": [ { "identity": "rim", "map": "Act.text?" } ] }, { "comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.", "path": "Encounter.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "type": [ { "code": "Resource" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "path": "Encounter.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "path": "Encounter.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.identifier", "short": "Identifier(s) by which this encounter is known", "definition": "Identifier(s) by which this encounter is known.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PV1-19" }, { "identity": "rim", "map": ".id" }, { "identity": "w5", "map": "id" } ] }, { "path": "Encounter.status", "short": "planned | arrived | in-progress | onleave | finished | cancelled", "definition": "planned | arrived | in-progress | onleave | finished | cancelled.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "strength": "required", "description": "Current state of the encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-state" } }, "mapping": [ { "identity": "v2", "map": "No clear equivalent in HL7 v2; active/finished could be inferred from PV1-44, PV1-45, PV2-24; inactive could be inferred from PV2-16" }, { "identity": "rim", "map": ".statusCode" }, { "identity": "w5", "map": "status" } ] }, { "comments": "The current status is always found in the current version of the resource, not the status history.", "path": "Encounter.statusHistory", "short": "List of past encounter statuses", "definition": "The status history permits the encounter resource to contain the status history without needing to read through the historical versions of the resource, or even have the server store them.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ] }, { "path": "Encounter.statusHistory.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "path": "Encounter.statusHistory.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "path": "Encounter.statusHistory.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.statusHistory.status", "short": "planned | arrived | in-progress | onleave | finished | cancelled", "definition": "planned | arrived | in-progress | onleave | finished | cancelled.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "Current state of the encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-state" } } }, { "path": "Encounter.statusHistory.period", "short": "The time that the episode was in the specified status", "definition": "The time that the episode was in the specified status.", "min": 1, "max": "1", "type": [ { "code": "Period" } ] }, { "path": "Encounter.class", "short": "inpatient | outpatient | ambulatory | emergency +", "definition": "inpatient | outpatient | ambulatory | emergency +.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "isSummary": true, "binding": { "strength": "required", "description": "Classification of the encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-class" } }, "mapping": [ { "identity": "v2", "map": "PV1-2" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=SUBJ].source[classCode=LIST].code" }, { "identity": "w5", "map": "class" } ] }, { "comments": "Since there are many ways to further classify encounters, this element is 0..*.", "path": "Encounter.type", "short": "Specific type of encounter", "definition": "Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation).", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "example", "description": "The type of encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-type" } }, "mapping": [ { "identity": "v2", "map": "PV1-4 / PV1-18" }, { "identity": "rim", "map": ".code" }, { "identity": "w5", "map": "class" } ] }, { "path": "Encounter.priority", "short": "Indicates the urgency of the encounter", "definition": "Indicates the urgency of the encounter.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "Indicates the urgency of the encounter.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-priority" } }, "mapping": [ { "identity": "v2", "map": "PV2-25" }, { "identity": "rim", "map": ".priorityCode" }, { "identity": "w5", "map": "grade" } ] }, { "comments": "While the encounter is always about the patient, the patient may not actually be known in all contexts of use.", "path": "Encounter.patient", "short": "The patient present at the encounter", "definition": "The patient present at the encounter.", "alias": [ "patient" ], "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Patient" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PID-3" }, { "identity": "rim", "map": ".participation[typeCode=SBJ]/role[classCode=PAT]" }, { "identity": "w5", "map": "who.focus" } ] }, { "path": "Encounter.episodeOfCare", "short": "Episode(s) of care that this encounter should be recorded against", "definition": "Where a specific encounter should be classified as a part of a specific episode(s) of care this field should be used. This association can facilitate grouping of related encounters together for a specific purpose, such as government reporting, issue tracking, association via a common problem. The association is recorded on the encounter as these are typically created after the episode of care, and grouped on entry rather than editing the episode of care to append another encounter to it (the episode of care could span years).", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PV1-54, PV1-53" }, { "identity": "w5", "map": "context" } ] }, { "path": "Encounter.incomingReferral", "short": "The ReferralRequest that initiated this encounter", "definition": "The referral request this encounter satisfies (incoming referral).", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest" } ] }, { "path": "Encounter.participant", "short": "List of participants involved in the encounter", "definition": "The list of people responsible for providing the service.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "ROL" }, { "identity": "rim", "map": ".participation[typeCode=PFM]" } ] }, { "path": "Encounter.participant.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "path": "Encounter.participant.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "path": "Encounter.participant.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "comments": "The participant type indicates how an individual partitipates in an encounter. It includes non-practitioner participants, and for practitioners this is to describe the action type in the context of this encounter (e.g. Admitting Dr, Attending Dr, Translator, Consulting Dr). This is different to the practitioner roles which are functional roles, derived from terms of employment, education, licensing, etc.", "path": "Encounter.participant.type", "short": "Role of participant in encounter", "definition": "Role of participant in encounter.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "extensible", "description": "Role of participant in encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-participant-type" } }, "mapping": [ { "identity": "v2", "map": "ROL-3 (or maybe PRT-4)" }, { "identity": "rim", "map": ".functionCode" } ] }, { "path": "Encounter.participant.period", "short": "Period of time during the encounter participant was present", "definition": "The period of time that the specified participant was present during the encounter. These can overlap or be sub-sets of the overall encounters period.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mapping": [ { "identity": "v2", "map": "ROL-5, ROL-6 (or maybe PRT-5)" } ] }, { "path": "Encounter.participant.individual", "short": "Persons involved in the encounter other than the patient", "definition": "Persons involved in the encounter other than the patient.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "ROL-4" }, { "identity": "rim", "map": ".role" }, { "identity": "w5", "map": "who" } ] }, { "path": "Encounter.appointment", "short": "The appointment that scheduled this encounter", "definition": "The appointment that scheduled this encounter.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Appointment" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "SCH-1 / SCH-2" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=FLFS].target[classCode=ENC, moodCode=APT]" } ] }, { "comments": "If not (yet) known, the end of the Period may be omitted.", "path": "Encounter.period", "short": "The start and end time of the encounter", "definition": "The start and end time of the encounter.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mapping": [ { "identity": "v2", "map": "PV1-44, PV1-45" }, { "identity": "rim", "map": ".effectiveTime (low & high)" }, { "identity": "w5", "map": "when.done" } ] }, { "comments": "May differ from the time the Encounter.period lasted because of leave of absence.", "path": "Encounter.length", "short": "Quantity of time the encounter lasted (less time absent)", "definition": "Quantity of time the encounter lasted. This excludes the time during leaves of absence.", "min": 0, "max": "1", "type": [ { "code": "Quantity", "profile": "http://hl7.org/fhir/StructureDefinition/Duration" } ], "mapping": [ { "identity": "v2", "map": "(PV1-45 less PV1-44) iff ( (PV1-44 not empty) and (PV1-45 not empty) ); units in minutes" }, { "identity": "rim", "map": ".lengthOfStayQuantity" } ] }, { "comments": "For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).", "path": "Encounter.reason", "short": "Reason the encounter takes place (code)", "definition": "Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis.", "alias": [ "Indication", "Admission diagnosis" ], "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "example", "description": "Reason why the encounter takes place.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-reason" } }, "mapping": [ { "identity": "v2", "map": "EVN-4 / PV2-3 (note: PV2-3 is nominally constrained to inpatient admissions; HL7 v2 makes no vocabulary suggestions for PV2-3; would not expect PV2 segment or PV2-3 to be in use in all implementations )" }, { "identity": "rim", "map": ".reasonCode" }, { "identity": "w5", "map": "why" } ] }, { "comments": "For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).", "path": "Encounter.indication", "short": "Reason the encounter takes place (resource)", "definition": "Reason the encounter takes place, as specified using information from another resource. For admissions, this is the admission diagnosis. The indication will typically be a Condition (with other resources referenced in the evidence.detail), or a Procedure.", "alias": [ "Admission diagnosis" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Condition" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Procedure" } ], "mapping": [ { "identity": "v2", "map": "Resources that would commonly referenced at Encounter.indication would be Condition and/or Procedure. These most closely align with DG1/PRB and PR1 respectively." }, { "identity": "rim", "map": ".outboundRelationship[typeCode=RSON].target" }, { "identity": "w5", "map": "why" } ] }, { "comments": "An Encounter may cover more than just the inpatient stay. Contexts such as outpatients, community clinics, and aged care facilities are also included. The duration recorded in the period of this encounter covers the entire scope of this hospitalization record.", "path": "Encounter.hospitalization", "short": "Details about the admission to a healthcare service", "definition": "Details about the admission to a healthcare service.", "min": 0, "max": "1", "type": [ { "code": "BackboneElement" } ], "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=COMP].target[classCode=ENC, moodCode=EVN]" } ] }, { "path": "Encounter.hospitalization.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "path": "Encounter.hospitalization.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "path": "Encounter.hospitalization.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.hospitalization.preAdmissionIdentifier", "short": "Pre-admission identifier", "definition": "Pre-admission identifier.", "min": 0, "max": "1", "type": [ { "code": "Identifier" } ], "mapping": [ { "identity": "v2", "map": "PV1-5" }, { "identity": "rim", "map": ".id" } ] }, { "path": "Encounter.hospitalization.origin", "short": "The location from which the patient came before admission", "definition": "The location from which the patient came before admission.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Location" } ], "mapping": [ { "identity": "rim", "map": ".participation[typeCode=ORG].role" } ] }, { "path": "Encounter.hospitalization.admitSource", "short": "From where patient was admitted (physician referral, transfer)", "definition": "From where patient was admitted (physician referral, transfer).", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "preferred", "description": "From where the patient was admitted.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-admit-source" } }, "mapping": [ { "identity": "v2", "map": "PV1-14" }, { "identity": "rim", "map": ".admissionReferralSourceCode" } ] }, { "path": "Encounter.hospitalization.admittingDiagnosis", "short": "The admitting diagnosis as reported by admitting practitioner", "definition": "The admitting diagnosis field is used to record the diagnosis codes as reported by admitting practitioner. This could be different or in addition to the conditions reported as reason-condition(s) for the encounter.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Condition" } ] }, { "path": "Encounter.hospitalization.reAdmission", "short": "The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission", "definition": "Whether this hospitalization is a readmission and why if known.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "The reason for re-admission of this hospitalization encounter." }, "mapping": [ { "identity": "v2", "map": "PV1-13" }, { "identity": "rim", "map": "Propose at harmonization" } ] }, { "comments": "For example a patient may request both a dairy-free and nut-free diet preference (not mutually exclusive).", "path": "Encounter.hospitalization.dietPreference", "short": "Diet preferences reported by the patient", "definition": "Diet preferences reported by the patient.", "requirements": "Used to track patient's diet restrictions and/or preference. For a complete description of the nutrition needs of a patient during their stay, one should use the nutritionOrder resource which links to Encounter.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "Medical, cultural or ethical food preferences to help with catering requirements.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-diet" } }, "mapping": [ { "identity": "v2", "map": "PV1-38" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=COMP].target[classCode=SBADM, moodCode=EVN, code=\"diet\"]" } ] }, { "path": "Encounter.hospitalization.specialCourtesy", "short": "Special courtesies (VIP, board member)", "definition": "Special courtesies (VIP, board member).", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "preferred", "description": "Special courtesies", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-special-courtesy" } }, "mapping": [ { "identity": "v2", "map": "PV1-16" }, { "identity": "rim", "map": ".specialCourtesiesCode" } ] }, { "path": "Encounter.hospitalization.specialArrangement", "short": "Wheelchair, translator, stretcher, etc.", "definition": "Wheelchair, translator, stretcher, etc.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "preferred", "description": "Special arrangements", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-special-arrangements" } }, "mapping": [ { "identity": "v2", "map": "PV1-15 / OBR-30 / OBR-43" }, { "identity": "rim", "map": ".specialArrangementCode" } ] }, { "path": "Encounter.hospitalization.destination", "short": "Location to which the patient is discharged", "definition": "Location to which the patient is discharged.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Location" } ], "mapping": [ { "identity": "v2", "map": "PV1-37" }, { "identity": "rim", "map": ".participation[typeCode=DST]" } ] }, { "path": "Encounter.hospitalization.dischargeDisposition", "short": "Category or kind of location after discharge", "definition": "Category or kind of location after discharge.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "preferred", "description": "Discharge Disposition", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-discharge-disposition" } }, "mapping": [ { "identity": "v2", "map": "PV1-36" }, { "identity": "rim", "map": ".dischargeDispositionCode" } ] }, { "path": "Encounter.hospitalization.dischargeDiagnosis", "short": "The final diagnosis given a patient before release from the hospital after all testing, surgery, and workup are complete", "definition": "The final diagnosis given a patient before release from the hospital after all testing, surgery, and workup are complete.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Condition" } ], "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=OUT].target[classCode=OBS, moodCode=EVN, code=ASSERTION].value" } ] }, { "comments": "Virtual encounters can be recorded in the Encounter by specifying a location reference to a location of type \"kind\" such as \"client's home\" and an encounter.class = \"virtual\".", "path": "Encounter.location", "short": "List of locations where the patient has been", "definition": "List of locations where the patient has been during this encounter.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "mapping": [ { "identity": "rim", "map": ".participation[typeCode=LOC]" } ] }, { "path": "Encounter.location.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "path": "Encounter.location.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "path": "Encounter.location.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Encounter.location.location", "short": "Location the encounter takes place", "definition": "The location where the encounter takes place.", "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Location" } ], "mapping": [ { "identity": "v2", "map": "PV1-3 / PV1-6 / PV1-11 / PV1-42 / PV1-43" }, { "identity": "rim", "map": ".role" }, { "identity": "w5", "map": "where" } ] }, { "comments": "When the patient is no longer active at a location, then the period end date is entered, and the status may be changed to completed.", "path": "Encounter.location.status", "short": "planned | active | reserved | completed", "definition": "The status of the participants' presence at the specified location during the period specified. If the participant is is no longer at the location, then the period will have an end date/time.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "The status of the location.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-location-status" } } }, { "path": "Encounter.location.period", "short": "Time period during which the patient was present at the location", "definition": "Time period during which the patient was present at the location.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mapping": [ { "identity": "rim", "map": ".time" } ] }, { "path": "Encounter.serviceProvider", "short": "The custodian organization of this Encounter record", "definition": "An organization that is in charge of maintaining the information of this Encounter (e.g. who maintains the report or the master service catalog item, etc.). This MAY be the same as the organization on the Patient record, however it could be different. This MAY not be not the Service Delivery Location's Organization.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "mapping": [ { "identity": "v2", "map": "PV1-10 / PL.6 & PL.1 (note: HL7 v2 definition is \"the treatment or type of surgery that the patient is scheduled to receive\"; seems slightly out of alignment with the concept name 'hospital service'. Would not trust that implementations apply this semantic by default)" }, { "identity": "rim", "map": ".particiaption[typeCode=PFM].role" } ] }, { "path": "Encounter.partOf", "short": "Another Encounter this encounter is part of", "definition": "Another Encounter of which this encounter is a part of (administratively or in time).", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Encounter" } ], "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[classCode=COMP, moodCode=EVN]" } ] } ] }, "differential": { "element": [ { "path": "Encounter", "short": "An interaction during which services are provided to the patient", "definition": "An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.", "alias": [ "Visit" ], "min": 0, "max": "*", "type": [ { "code": "DomainResource" } ], "mapping": [ { "identity": "rim", "map": "Encounter[moodCode=EVN]" }, { "identity": "w5", "map": "workflow.encounter" } ] }, { "path": "Encounter.identifier", "short": "Identifier(s) by which this encounter is known", "definition": "Identifier(s) by which this encounter is known.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PV1-19" }, { "identity": "rim", "map": ".id" }, { "identity": "w5", "map": "id" } ] }, { "path": "Encounter.status", "short": "planned | arrived | in-progress | onleave | finished | cancelled", "definition": "planned | arrived | in-progress | onleave | finished | cancelled.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "strength": "required", "description": "Current state of the encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-state" } }, "mapping": [ { "identity": "v2", "map": "No clear equivalent in HL7 v2; active/finished could be inferred from PV1-44, PV1-45, PV2-24; inactive could be inferred from PV2-16" }, { "identity": "rim", "map": ".statusCode" }, { "identity": "w5", "map": "status" } ] }, { "comments": "The current status is always found in the current version of the resource, not the status history.", "path": "Encounter.statusHistory", "short": "List of past encounter statuses", "definition": "The status history permits the encounter resource to contain the status history without needing to read through the historical versions of the resource, or even have the server store them.", "min": 0, "max": "*" }, { "path": "Encounter.statusHistory.status", "short": "planned | arrived | in-progress | onleave | finished | cancelled", "definition": "planned | arrived | in-progress | onleave | finished | cancelled.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "Current state of the encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-state" } } }, { "path": "Encounter.statusHistory.period", "short": "The time that the episode was in the specified status", "definition": "The time that the episode was in the specified status.", "min": 1, "max": "1", "type": [ { "code": "Period" } ] }, { "path": "Encounter.class", "short": "inpatient | outpatient | ambulatory | emergency +", "definition": "inpatient | outpatient | ambulatory | emergency +.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "isSummary": true, "binding": { "strength": "required", "description": "Classification of the encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-class" } }, "mapping": [ { "identity": "v2", "map": "PV1-2" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=SUBJ].source[classCode=LIST].code" }, { "identity": "w5", "map": "class" } ] }, { "comments": "Since there are many ways to further classify encounters, this element is 0..*.", "path": "Encounter.type", "short": "Specific type of encounter", "definition": "Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation).", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "example", "description": "The type of encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-type" } }, "mapping": [ { "identity": "v2", "map": "PV1-4 / PV1-18" }, { "identity": "rim", "map": ".code" }, { "identity": "w5", "map": "class" } ] }, { "path": "Encounter.priority", "short": "Indicates the urgency of the encounter", "definition": "Indicates the urgency of the encounter.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "Indicates the urgency of the encounter.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-priority" } }, "mapping": [ { "identity": "v2", "map": "PV2-25" }, { "identity": "rim", "map": ".priorityCode" }, { "identity": "w5", "map": "grade" } ] }, { "comments": "While the encounter is always about the patient, the patient may not actually be known in all contexts of use.", "path": "Encounter.patient", "short": "The patient present at the encounter", "definition": "The patient present at the encounter.", "alias": [ "patient" ], "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Patient" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PID-3" }, { "identity": "rim", "map": ".participation[typeCode=SBJ]/role[classCode=PAT]" }, { "identity": "w5", "map": "who.focus" } ] }, { "path": "Encounter.episodeOfCare", "short": "Episode(s) of care that this encounter should be recorded against", "definition": "Where a specific encounter should be classified as a part of a specific episode(s) of care this field should be used. This association can facilitate grouping of related encounters together for a specific purpose, such as government reporting, issue tracking, association via a common problem. The association is recorded on the encounter as these are typically created after the episode of care, and grouped on entry rather than editing the episode of care to append another encounter to it (the episode of care could span years).", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PV1-54, PV1-53" }, { "identity": "w5", "map": "context" } ] }, { "path": "Encounter.incomingReferral", "short": "The ReferralRequest that initiated this encounter", "definition": "The referral request this encounter satisfies (incoming referral).", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest" } ] }, { "path": "Encounter.participant", "short": "List of participants involved in the encounter", "definition": "The list of people responsible for providing the service.", "min": 0, "max": "*", "isSummary": true, "mapping": [ { "identity": "v2", "map": "ROL" }, { "identity": "rim", "map": ".participation[typeCode=PFM]" } ] }, { "comments": "The participant type indicates how an individual partitipates in an encounter. It includes non-practitioner participants, and for practitioners this is to describe the action type in the context of this encounter (e.g. Admitting Dr, Attending Dr, Translator, Consulting Dr). This is different to the practitioner roles which are functional roles, derived from terms of employment, education, licensing, etc.", "path": "Encounter.participant.type", "short": "Role of participant in encounter", "definition": "Role of participant in encounter.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "extensible", "description": "Role of participant in encounter", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-participant-type" } }, "mapping": [ { "identity": "v2", "map": "ROL-3 (or maybe PRT-4)" }, { "identity": "rim", "map": ".functionCode" } ] }, { "path": "Encounter.participant.period", "short": "Period of time during the encounter participant was present", "definition": "The period of time that the specified participant was present during the encounter. These can overlap or be sub-sets of the overall encounters period.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mapping": [ { "identity": "v2", "map": "ROL-5, ROL-6 (or maybe PRT-5)" } ] }, { "path": "Encounter.participant.individual", "short": "Persons involved in the encounter other than the patient", "definition": "Persons involved in the encounter other than the patient.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "ROL-4" }, { "identity": "rim", "map": ".role" }, { "identity": "w5", "map": "who" } ] }, { "path": "Encounter.appointment", "short": "The appointment that scheduled this encounter", "definition": "The appointment that scheduled this encounter.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Appointment" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "SCH-1 / SCH-2" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=FLFS].target[classCode=ENC, moodCode=APT]" } ] }, { "comments": "If not (yet) known, the end of the Period may be omitted.", "path": "Encounter.period", "short": "The start and end time of the encounter", "definition": "The start and end time of the encounter.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mapping": [ { "identity": "v2", "map": "PV1-44, PV1-45" }, { "identity": "rim", "map": ".effectiveTime (low & high)" }, { "identity": "w5", "map": "when.done" } ] }, { "comments": "May differ from the time the Encounter.period lasted because of leave of absence.", "path": "Encounter.length", "short": "Quantity of time the encounter lasted (less time absent)", "definition": "Quantity of time the encounter lasted. This excludes the time during leaves of absence.", "min": 0, "max": "1", "type": [ { "code": "Quantity", "profile": "http://hl7.org/fhir/StructureDefinition/Duration" } ], "mapping": [ { "identity": "v2", "map": "(PV1-45 less PV1-44) iff ( (PV1-44 not empty) and (PV1-45 not empty) ); units in minutes" }, { "identity": "rim", "map": ".lengthOfStayQuantity" } ] }, { "comments": "For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).", "path": "Encounter.reason", "short": "Reason the encounter takes place (code)", "definition": "Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis.", "alias": [ "Indication", "Admission diagnosis" ], "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "example", "description": "Reason why the encounter takes place.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-reason" } }, "mapping": [ { "identity": "v2", "map": "EVN-4 / PV2-3 (note: PV2-3 is nominally constrained to inpatient admissions; HL7 v2 makes no vocabulary suggestions for PV2-3; would not expect PV2 segment or PV2-3 to be in use in all implementations )" }, { "identity": "rim", "map": ".reasonCode" }, { "identity": "w5", "map": "why" } ] }, { "comments": "For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).", "path": "Encounter.indication", "short": "Reason the encounter takes place (resource)", "definition": "Reason the encounter takes place, as specified using information from another resource. For admissions, this is the admission diagnosis. The indication will typically be a Condition (with other resources referenced in the evidence.detail), or a Procedure.", "alias": [ "Admission diagnosis" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Condition" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Procedure" } ], "mapping": [ { "identity": "v2", "map": "Resources that would commonly referenced at Encounter.indication would be Condition and/or Procedure. These most closely align with DG1/PRB and PR1 respectively." }, { "identity": "rim", "map": ".outboundRelationship[typeCode=RSON].target" }, { "identity": "w5", "map": "why" } ] }, { "comments": "An Encounter may cover more than just the inpatient stay. Contexts such as outpatients, community clinics, and aged care facilities are also included. The duration recorded in the period of this encounter covers the entire scope of this hospitalization record.", "path": "Encounter.hospitalization", "short": "Details about the admission to a healthcare service", "definition": "Details about the admission to a healthcare service.", "min": 0, "max": "1", "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=COMP].target[classCode=ENC, moodCode=EVN]" } ] }, { "path": "Encounter.hospitalization.preAdmissionIdentifier", "short": "Pre-admission identifier", "definition": "Pre-admission identifier.", "min": 0, "max": "1", "type": [ { "code": "Identifier" } ], "mapping": [ { "identity": "v2", "map": "PV1-5" }, { "identity": "rim", "map": ".id" } ] }, { "path": "Encounter.hospitalization.origin", "short": "The location from which the patient came before admission", "definition": "The location from which the patient came before admission.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Location" } ], "mapping": [ { "identity": "rim", "map": ".participation[typeCode=ORG].role" } ] }, { "path": "Encounter.hospitalization.admitSource", "short": "From where patient was admitted (physician referral, transfer)", "definition": "From where patient was admitted (physician referral, transfer).", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "preferred", "description": "From where the patient was admitted.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-admit-source" } }, "mapping": [ { "identity": "v2", "map": "PV1-14" }, { "identity": "rim", "map": ".admissionReferralSourceCode" } ] }, { "path": "Encounter.hospitalization.admittingDiagnosis", "short": "The admitting diagnosis as reported by admitting practitioner", "definition": "The admitting diagnosis field is used to record the diagnosis codes as reported by admitting practitioner. This could be different or in addition to the conditions reported as reason-condition(s) for the encounter.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Condition" } ] }, { "path": "Encounter.hospitalization.reAdmission", "short": "The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission", "definition": "Whether this hospitalization is a readmission and why if known.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "The reason for re-admission of this hospitalization encounter." }, "mapping": [ { "identity": "v2", "map": "PV1-13" }, { "identity": "rim", "map": "Propose at harmonization" } ] }, { "comments": "For example a patient may request both a dairy-free and nut-free diet preference (not mutually exclusive).", "path": "Encounter.hospitalization.dietPreference", "short": "Diet preferences reported by the patient", "definition": "Diet preferences reported by the patient.", "requirements": "Used to track patient's diet restrictions and/or preference. For a complete description of the nutrition needs of a patient during their stay, one should use the nutritionOrder resource which links to Encounter.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "Medical, cultural or ethical food preferences to help with catering requirements.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-diet" } }, "mapping": [ { "identity": "v2", "map": "PV1-38" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=COMP].target[classCode=SBADM, moodCode=EVN, code=\"diet\"]" } ] }, { "path": "Encounter.hospitalization.specialCourtesy", "short": "Special courtesies (VIP, board member)", "definition": "Special courtesies (VIP, board member).", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "preferred", "description": "Special courtesies", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-special-courtesy" } }, "mapping": [ { "identity": "v2", "map": "PV1-16" }, { "identity": "rim", "map": ".specialCourtesiesCode" } ] }, { "path": "Encounter.hospitalization.specialArrangement", "short": "Wheelchair, translator, stretcher, etc.", "definition": "Wheelchair, translator, stretcher, etc.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "preferred", "description": "Special arrangements", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-special-arrangements" } }, "mapping": [ { "identity": "v2", "map": "PV1-15 / OBR-30 / OBR-43" }, { "identity": "rim", "map": ".specialArrangementCode" } ] }, { "path": "Encounter.hospitalization.destination", "short": "Location to which the patient is discharged", "definition": "Location to which the patient is discharged.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Location" } ], "mapping": [ { "identity": "v2", "map": "PV1-37" }, { "identity": "rim", "map": ".participation[typeCode=DST]" } ] }, { "path": "Encounter.hospitalization.dischargeDisposition", "short": "Category or kind of location after discharge", "definition": "Category or kind of location after discharge.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "preferred", "description": "Discharge Disposition", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-discharge-disposition" } }, "mapping": [ { "identity": "v2", "map": "PV1-36" }, { "identity": "rim", "map": ".dischargeDispositionCode" } ] }, { "path": "Encounter.hospitalization.dischargeDiagnosis", "short": "The final diagnosis given a patient before release from the hospital after all testing, surgery, and workup are complete", "definition": "The final diagnosis given a patient before release from the hospital after all testing, surgery, and workup are complete.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Condition" } ], "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=OUT].target[classCode=OBS, moodCode=EVN, code=ASSERTION].value" } ] }, { "comments": "Virtual encounters can be recorded in the Encounter by specifying a location reference to a location of type \"kind\" such as \"client's home\" and an encounter.class = \"virtual\".", "path": "Encounter.location", "short": "List of locations where the patient has been", "definition": "List of locations where the patient has been during this encounter.", "min": 0, "max": "*", "mapping": [ { "identity": "rim", "map": ".participation[typeCode=LOC]" } ] }, { "path": "Encounter.location.location", "short": "Location the encounter takes place", "definition": "The location where the encounter takes place.", "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Location" } ], "mapping": [ { "identity": "v2", "map": "PV1-3 / PV1-6 / PV1-11 / PV1-42 / PV1-43" }, { "identity": "rim", "map": ".role" }, { "identity": "w5", "map": "where" } ] }, { "comments": "When the patient is no longer active at a location, then the period end date is entered, and the status may be changed to completed.", "path": "Encounter.location.status", "short": "planned | active | reserved | completed", "definition": "The status of the participants' presence at the specified location during the period specified. If the participant is is no longer at the location, then the period will have an end date/time.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "strength": "required", "description": "The status of the location.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/encounter-location-status" } } }, { "path": "Encounter.location.period", "short": "Time period during which the patient was present at the location", "definition": "Time period during which the patient was present at the location.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mapping": [ { "identity": "rim", "map": ".time" } ] }, { "path": "Encounter.serviceProvider", "short": "The custodian organization of this Encounter record", "definition": "An organization that is in charge of maintaining the information of this Encounter (e.g. who maintains the report or the master service catalog item, etc.). This MAY be the same as the organization on the Patient record, however it could be different. This MAY not be not the Service Delivery Location's Organization.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "mapping": [ { "identity": "v2", "map": "PV1-10 / PL.6 & PL.1 (note: HL7 v2 definition is \"the treatment or type of surgery that the patient is scheduled to receive\"; seems slightly out of alignment with the concept name 'hospital service'. Would not trust that implementations apply this semantic by default)" }, { "identity": "rim", "map": ".particiaption[typeCode=PFM].role" } ] }, { "path": "Encounter.partOf", "short": "Another Encounter this encounter is part of", "definition": "Another Encounter of which this encounter is a part of (administratively or in time).", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Encounter" } ], "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[classCode=COMP, moodCode=EVN]" } ] } ] } }