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cimi.encounter

The Encounter domain contains definitions that capture interactions between the person of record and healthcare providers, including inpatient, ambulatory care, and telecare.

DetailedEncounter

A detailed description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

Based On Encounter

SubjectOfInformation must be a PatientOrGroup
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
EncounterClass optional Concepts representing classification of patient encounter such as ambulatory (outpatient), inpatient, emergency, home health or others due to local variations.
EncounterType 0 or more Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation).
TimePeriod optional A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
Status must be from http://hl7.org/fhir/ValueSet/encounter-status
required The current standing or state.
PartOf must be a Encounter
optional The larger entity that this is a portion of. For example, an organization might be part of a larger organization, or an encounter with a hospitalist might be part of a larger hospitalization encounter.
Diagnosis 0 or more A diagnosis, which is a disease or injury determined to be present through evaluation of patient history, examination, and/or review of laboratory data.
ClinicalNote optional An entry concerning a patient where the result is a narrative text. Can be related to a specific Focus, such as a condition; and evidence and interpretation from FindingTopic.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

Diagnosis

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

Value:  code
PriorityRank optional An indication of the importance of an action.
Type should be from http://hl7.org/fhir/ValueSet/diagnosis-role
optional The most specific code (lowest level term) describing the kind or sort of thing being represented.

Encounter

A description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

Based On InformationEntry

SubjectOfInformation must be a PatientOrGroup
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
EncounterClass optional Concepts representing classification of patient encounter such as ambulatory (outpatient), inpatient, emergency, home health or others due to local variations.
EncounterType 0 or more Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation).
TimePeriod optional A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
Status must be from http://hl7.org/fhir/ValueSet/encounter-status
required The current standing or state.
PartOf must be a Encounter
optional The larger entity that this is a portion of. For example, an organization might be part of a larger organization, or an encounter with a hospitalist might be part of a larger hospitalization encounter.
Diagnosis 0 or more A diagnosis, which is a disease or injury determined to be present through evaluation of patient history, examination, and/or review of laboratory data.
ClinicalNote optional An entry concerning a patient where the result is a narrative text. Can be related to a specific Focus, such as a condition; and evidence and interpretation from FindingTopic.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

EncounterClass

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

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

EncounterType

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

Value:  CodeableConcept from http://hl7.org/fhir/ValueSet/v3-ActEncounterCode
(if covered)
A set of codes drawn from different coding systems, representing the same concept.

PatientOrGroup

A subject of information that is constrained to be either a patient or a group.

Based On SubjectOfInformation

Value:  Choice required
         |  Patient A person in the role of a patient, including extended demographic information about the subject of this health record.
         |  Group A set of entities (personnel, material, or places) to be considered together. May be a pool of like-type resources, a team, or combination of personnel, material and places.
RelationshipToPersonOfRecord optional The relationship of the SubjectOfInformation to the subject of record.