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Encounter

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

Encounter [Entry]

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, independent of the context of requested, planned, performed, etc.

Based On Action

Subject optional The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
ReferralDate optional The date when the provider received a referral for service. A referral includes an oral, written, faxed or electronic request for services made by the client or on the client's behalf.
ReferralSourceType optional The type of person or entity that instigated the encounter.
TypeAsaCoding from http://hl7.org/fhir/ValueSet/v3-ActEncounterCode
(if covered)
optional
ServiceGiven 0 or more Indicates a medical service provided.
ServiceProvider optional The organization that provided the services rendered during this encounter.
TreatmentCooperation optional Whether the patient is undergoing treatment voluntarily, or under a legal order.
PaymentSource optional The source of payment for the current encounter.
HealthConcern (TBD) optional Description TBD
PertinentFindings (TBD) 0 or more Description TBD
Diagnosis (TBD) 0 or more Description TBD
FullClinicalNote (TBD) optional Description TBD
ClinicalSummary (TBD) required Description TBD
TreatmentServiceRendered (TBD) 1 or more Description TBD
CompletionStatus (TBD) optional Description TBD
Type optional The most specific code (lowest level term) describing the kind or sort of thing being represented.
Category 0 or more A class or division of people or things having particular shared characteristics
ActionContext required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

EncounterNotPerformed [Entry]

No Description

Based On Encounter

ActionContext must be a NotPerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Subject optional The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
ReferralDate optional The date when the provider received a referral for service. A referral includes an oral, written, faxed or electronic request for services made by the client or on the client's behalf.
ReferralSourceType optional The type of person or entity that instigated the encounter.
TypeAsaCoding from http://hl7.org/fhir/ValueSet/v3-ActEncounterCode
(if covered)
optional
ServiceGiven 0 or more Indicates a medical service provided.
ServiceProvider optional The organization that provided the services rendered during this encounter.
TreatmentCooperation optional Whether the patient is undergoing treatment voluntarily, or under a legal order.
PaymentSource optional The source of payment for the current encounter.
HealthConcern (TBD) optional Description TBD
PertinentFindings (TBD) 0 or more Description TBD
Diagnosis (TBD) 0 or more Description TBD
FullClinicalNote (TBD) optional Description TBD
ClinicalSummary (TBD) required Description TBD
TreatmentServiceRendered (TBD) 1 or more Description TBD
CompletionStatus (TBD) optional Description TBD
Type optional The most specific code (lowest level term) describing the kind or sort of thing being represented.
Category 0 or more A class or division of people or things having particular shared characteristics
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

EncounterPerformed [Entry]

No Description

Based On Encounter

ActionContext must be a PerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
PerformedContext
         where  Status must be from http://hl7.org/fhir/ValueSet/encounter-status
         where  OccurrenceTimeOrPeriod must be a OccurrencePeriod
         where  Reason should be from http://hl7.org/fhir/ValueSet/encounter-reason
Subject optional The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
ReferralDate optional The date when the provider received a referral for service. A referral includes an oral, written, faxed or electronic request for services made by the client or on the client's behalf.
ReferralSourceType optional The type of person or entity that instigated the encounter.
TypeAsaCoding from http://hl7.org/fhir/ValueSet/v3-ActEncounterCode
(if covered)
optional
ServiceGiven 0 or more Indicates a medical service provided.
ServiceProvider optional The organization that provided the services rendered during this encounter.
TreatmentCooperation optional Whether the patient is undergoing treatment voluntarily, or under a legal order.
PaymentSource optional The source of payment for the current encounter.
HealthConcern (TBD) optional Description TBD
PertinentFindings (TBD) 0 or more Description TBD
Diagnosis (TBD) 0 or more Description TBD
FullClinicalNote (TBD) optional Description TBD
ClinicalSummary (TBD) required Description TBD
TreatmentServiceRendered (TBD) 1 or more Description TBD
CompletionStatus (TBD) optional Description TBD
Type optional The most specific code (lowest level term) describing the kind or sort of thing being represented.
Category 0 or more A class or division of people or things having particular shared characteristics
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

EncounterRequested [Entry]

No Description

Based On Encounter

ActionContext must be a RequestedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Subject optional The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
ReferralDate optional The date when the provider received a referral for service. A referral includes an oral, written, faxed or electronic request for services made by the client or on the client's behalf.
ReferralSourceType optional The type of person or entity that instigated the encounter.
TypeAsaCoding from http://hl7.org/fhir/ValueSet/v3-ActEncounterCode
(if covered)
optional
ServiceGiven 0 or more Indicates a medical service provided.
ServiceProvider optional The organization that provided the services rendered during this encounter.
TreatmentCooperation optional Whether the patient is undergoing treatment voluntarily, or under a legal order.
PaymentSource optional The source of payment for the current encounter.
HealthConcern (TBD) optional Description TBD
PertinentFindings (TBD) 0 or more Description TBD
Diagnosis (TBD) 0 or more Description TBD
FullClinicalNote (TBD) optional Description TBD
ClinicalSummary (TBD) required Description TBD
TreatmentServiceRendered (TBD) 1 or more Description TBD
CompletionStatus (TBD) optional Description TBD
Type optional The most specific code (lowest level term) describing the kind or sort of thing being represented.
Category 0 or more A class or division of people or things having particular shared characteristics
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

PaymentSource

The source of payment for the current encounter. C0680269

Value:  PaymentSourceVS (TBD) Description TBD

ReferralDate

The date when the provider received a referral for service. A referral includes an oral, written, faxed or electronic request for services made by the client or on the client's behalf. C2735614

Value:  date

ReferralSourceType

The type of person or entity that instigated the encounter.

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

ServiceGiven

Indicates a medical service provided.

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

ServiceProvider

The organization that provided the services rendered during this encounter.

Value:  Organization A social or legal structure formed by human beings.

TreatmentCooperation

Whether the patient is undergoing treatment voluntarily, or under a legal order.

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