HIV Screening Clinical Guidelines Implementation Guide
0.1.0 - CI Build Unknown region code '840'

HIV Screening Clinical Guidelines Implementation Guide, published by National Association of Community Health Centers, Inc. (NACHC). This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/hiv-cds/ and changes regularly. See the Directory of published versions

Resource Profile: Pregnancy Encounters

Official URL: http://fhir.org/guides/nachc/hiv-cds/StructureDefinition/pregnancy-encounters Version: 0.1.0
Draft as of 2024-08-12 Computable Name: PregnancyEncounters

Usage:Workflow Task: Pregnancy

Copyright/Legal: Copyright National Association of Community Health Centers, Inc. (NACHC)

Pregnancy Encounters

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from QICoreEncounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* QICoreEncounter An interaction during which services are provided to the patient
... type S 1..1 CodeableConcept Pregnancy Encounters
Binding: Pregnancy Encounters Codes (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Encounter.typerequiredPregnancyEncountersCodes
http://fhir.org/guides/nachc/hiv-cds/ValueSet/nachc-f2-de2
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* QICoreEncounter An interaction during which services are provided to the patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... statusReason S 0..1 CodeableConcept Reason for current status
URL: http://hl7.org/fhir/StructureDefinition/request-statusReason
Binding: (unbound) (example): Codes identifying the reason for the current state of an event.


.... procedure S 0..* (Complex) Encounter Procedure Extension
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-procedure
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
... status ?!Σ 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

... class SΣ 1..1 Coding Classification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.

... type SΣ 1..1 CodeableConcept Pregnancy Encounters
Binding: Pregnancy Encounters Codes (required)
... subject SΣ 1..1 Reference(QICorePatient) The patient or group present at the encounter
... participant SΣ 0..* BackboneElement List of participants involved in the encounter
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type SΣ 0..* CodeableConcept Role of participant in encounter
Binding: ParticipantType (extensible): Role of participant in encounter.


.... period S 0..1 Period Period of time during the encounter that the participant participated
.... individual SΣ 0..1 Reference(QICorePractitioner) Persons involved in the encounter other than the patient
... period S 0..1 Period The start and end time of the encounter
... length S 0..1 Duration Quantity of time the encounter lasted (less time absent)
... reasonCode SΣ 0..* CodeableConcept Coded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.


... diagnosis SΣ 0..* BackboneElement The list of diagnosis relevant to this encounter
.... Slices for extension Content/Rules for all slices
..... diagnosisPresentOnAdmission S 1..1 CodeableConcept onAdmission
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission
Binding: ExampleDiagnosisOnAdmissionCodes (required): Indicator of whether the Encounter diagnosis was present at the time of admission


.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... condition SΣ 1..1 Reference(QICoreCondition | QICoreProcedure) The diagnosis or procedure relevant to the encounter
.... use S 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

.... rank S 0..1 positiveInt Ranking of the diagnosis (for each role type)
... hospitalization S 0..1 BackboneElement Details about the admission to a healthcare service
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... admitSource S 0..1 CodeableConcept From where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred): From where the patient was admitted.

.... reAdmission S 0..1 CodeableConcept The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter.

.... dischargeDisposition S 0..1 CodeableConcept Category or kind of location after discharge
Binding: DischargeDisposition (example): Discharge Disposition.

... location S 0..* BackboneElement List of locations where the patient has been
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... location S 1..1 Reference(QICoreLocation) Location the encounter takes place
... serviceProvider S 0..1 Reference(QICoreOrganization) The organization (facility) responsible for this encounter

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Encounter.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.statusrequiredEncounterStatus
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.classextensibleActEncounterCode
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.typerequiredPregnancyEncountersCodes
http://fhir.org/guides/nachc/hiv-cds/ValueSet/nachc-f2-de2
from this IG
Encounter.participant.typeextensibleParticipantType
http://hl7.org/fhir/ValueSet/encounter-participant-type
from the FHIR Standard
Encounter.reasonCodepreferredEncounterReasonCodes
http://hl7.org/fhir/ValueSet/encounter-reason
from the FHIR Standard
Encounter.diagnosis.usepreferredDiagnosisRole
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.hospitalization.admitSourcepreferredAdmitSource
http://hl7.org/fhir/ValueSet/encounter-admit-source
from the FHIR Standard
Encounter.hospitalization.reAdmissionexampleHl7VSReAdmissionIndicator
http://terminology.hl7.org/ValueSet/v2-0092
Encounter.hospitalization.dischargeDispositionexampleDischargeDisposition
http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorEncounterIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorEncounterIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorEncounterIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorEncounterIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceEncounterA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* QICoreEncounter An interaction during which services are provided to the patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... statusReason S 0..1 CodeableConcept Reason for current status
URL: http://hl7.org/fhir/StructureDefinition/request-statusReason
Binding: (unbound) (example): Codes identifying the reason for the current state of an event.


.... procedure S 0..* (Complex) Encounter Procedure Extension
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-procedure
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Identifier(s) by which this encounter is known
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!Σ 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

... statusHistory 0..* BackboneElement List of past encounter statuses
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... status 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

.... period 1..1 Period The time that the episode was in the specified status
... class SΣ 1..1 Coding Classification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.

... classHistory 0..* BackboneElement List of past encounter classes
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... class 1..1 Coding inpatient | outpatient | ambulatory | emergency +
Binding: ActEncounterCode (extensible): Classification of the encounter.

.... period 1..1 Period The time that the episode was in the specified class
... type SΣ 1..1 CodeableConcept Pregnancy Encounters
Binding: Pregnancy Encounters Codes (required)
... serviceType Σ 0..1 CodeableConcept Specific type of service
Binding: ServiceType (example): Broad categorization of the service that is to be provided.

... priority 0..1 CodeableConcept Indicates the urgency of the encounter
Binding: SNOMED CT Priorities Codes (preferred): The priority of the encounter (e.g., Urgent, Normal, etc.)

... subject SΣ 1..1 Reference(QICorePatient) The patient or group present at the encounter
... episodeOfCare Σ 0..* Reference(EpisodeOfCare) Episode(s) of care that this encounter should be recorded against
... basedOn 0..* Reference(QICoreServiceRequest) The ServiceRequest that initiated this encounter
... participant SΣ 0..* BackboneElement List of participants involved in the encounter
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type SΣ 0..* CodeableConcept Role of participant in encounter
Binding: ParticipantType (extensible): Role of participant in encounter.


.... period S 0..1 Period Period of time during the encounter that the participant participated
.... individual SΣ 0..1 Reference(QICorePractitioner) Persons involved in the encounter other than the patient
... appointment Σ 0..* Reference(Appointment) The appointment that scheduled this encounter
... period S 0..1 Period The start and end time of the encounter
... length S 0..1 Duration Quantity of time the encounter lasted (less time absent)
... reasonCode SΣ 0..* CodeableConcept Coded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.


... reasonReference Σ 0..* Reference(Condition | Procedure | Observation | ImmunizationRecommendation) Reason the encounter takes place (reference)
... diagnosis SΣ 0..* BackboneElement The list of diagnosis relevant to this encounter
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... diagnosisPresentOnAdmission S 1..1 CodeableConcept onAdmission
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission
Binding: ExampleDiagnosisOnAdmissionCodes (required): Indicator of whether the Encounter diagnosis was present at the time of admission


.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... condition SΣ 1..1 Reference(QICoreCondition | QICoreProcedure) The diagnosis or procedure relevant to the encounter
.... use S 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

.... rank S 0..1 positiveInt Ranking of the diagnosis (for each role type)
... account 0..* Reference(Account) The set of accounts that may be used for billing for this Encounter
... hospitalization S 0..1 BackboneElement Details about the admission to a healthcare service
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... preAdmissionIdentifier 0..1 Identifier Pre-admission identifier
.... origin 0..1 Reference(QICoreLocation) The location/organization from which the patient came before admission
.... admitSource S 0..1 CodeableConcept From where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred): From where the patient was admitted.

.... reAdmission S 0..1 CodeableConcept The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter.

.... dietPreference 0..* CodeableConcept Diet preferences reported by the patient
Binding: Diet (example): Medical, cultural or ethical food preferences to help with catering requirements.


.... specialCourtesy 0..* CodeableConcept Special courtesies (VIP, board member)
Binding: SpecialCourtesy (preferred): Special courtesies.


.... specialArrangement 0..* CodeableConcept Wheelchair, translator, stretcher, etc.
Binding: SpecialArrangements (preferred): Special arrangements.


.... destination 0..1 Reference(QICoreLocation) Location/organization to which the patient is discharged
.... dischargeDisposition S 0..1 CodeableConcept Category or kind of location after discharge
Binding: DischargeDisposition (example): Discharge Disposition.

... location S 0..* BackboneElement List of locations where the patient has been
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... location S 1..1 Reference(QICoreLocation) Location the encounter takes place
.... status 0..1 code planned | active | reserved | completed
Binding: EncounterLocationStatus (required): The status of the location.

.... physicalType 0..1 CodeableConcept The physical type of the location (usually the level in the location hierachy - bed room ward etc.)
Binding: LocationType (example): Physical form of the location.

.... period 0..1 Period Time period during which the patient was present at the location
... serviceProvider S 0..1 Reference(QICoreOrganization) The organization (facility) responsible for this encounter
... partOf 0..1 Reference(QICoreEncounter) Another Encounter this encounter is part of

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Encounter.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Encounter.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Encounter.statusrequiredEncounterStatus
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.statusHistory.statusrequiredEncounterStatus
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.classextensibleActEncounterCode
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.classHistory.classextensibleActEncounterCode
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.typerequiredPregnancyEncountersCodes
http://fhir.org/guides/nachc/hiv-cds/ValueSet/nachc-f2-de2
from this IG
Encounter.serviceTypeexampleServiceType
http://hl7.org/fhir/ValueSet/service-type
from the FHIR Standard
Encounter.prioritypreferredQICorePriority
http://hl7.org/fhir/us/qicore/ValueSet/qicore-priority
Encounter.participant.typeextensibleParticipantType
http://hl7.org/fhir/ValueSet/encounter-participant-type
from the FHIR Standard
Encounter.reasonCodepreferredEncounterReasonCodes
http://hl7.org/fhir/ValueSet/encounter-reason
from the FHIR Standard
Encounter.diagnosis.usepreferredDiagnosisRole
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.hospitalization.admitSourcepreferredAdmitSource
http://hl7.org/fhir/ValueSet/encounter-admit-source
from the FHIR Standard
Encounter.hospitalization.reAdmissionexampleHl7VSReAdmissionIndicator
http://terminology.hl7.org/ValueSet/v2-0092
Encounter.hospitalization.dietPreferenceexampleDiet
http://hl7.org/fhir/ValueSet/encounter-diet
from the FHIR Standard
Encounter.hospitalization.specialCourtesypreferredSpecialCourtesy
http://hl7.org/fhir/ValueSet/encounter-special-courtesy
from the FHIR Standard
Encounter.hospitalization.specialArrangementpreferredSpecialArrangements
http://hl7.org/fhir/ValueSet/encounter-special-arrangements
from the FHIR Standard
Encounter.hospitalization.dischargeDispositionexampleDischargeDisposition
http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
from the FHIR Standard
Encounter.location.statusrequiredEncounterLocationStatus
http://hl7.org/fhir/ValueSet/encounter-location-status|4.0.1
from the FHIR Standard
Encounter.location.physicalTypeexampleLocationType
http://hl7.org/fhir/ValueSet/location-physical-type
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorEncounterIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorEncounterIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorEncounterIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorEncounterIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceEncounterA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from QICoreEncounter

Summary

Mandatory: 1 element
Must-Support: 1 element

Differential View

This structure is derived from QICoreEncounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* QICoreEncounter An interaction during which services are provided to the patient
... type S 1..1 CodeableConcept Pregnancy Encounters
Binding: Pregnancy Encounters Codes (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Encounter.typerequiredPregnancyEncountersCodes
http://fhir.org/guides/nachc/hiv-cds/ValueSet/nachc-f2-de2
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* QICoreEncounter An interaction during which services are provided to the patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... statusReason S 0..1 CodeableConcept Reason for current status
URL: http://hl7.org/fhir/StructureDefinition/request-statusReason
Binding: (unbound) (example): Codes identifying the reason for the current state of an event.


.... procedure S 0..* (Complex) Encounter Procedure Extension
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-procedure
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
... status ?!Σ 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

... class SΣ 1..1 Coding Classification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.

... type SΣ 1..1 CodeableConcept Pregnancy Encounters
Binding: Pregnancy Encounters Codes (required)
... subject SΣ 1..1 Reference(QICorePatient) The patient or group present at the encounter
... participant SΣ 0..* BackboneElement List of participants involved in the encounter
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type SΣ 0..* CodeableConcept Role of participant in encounter
Binding: ParticipantType (extensible): Role of participant in encounter.


.... period S 0..1 Period Period of time during the encounter that the participant participated
.... individual SΣ 0..1 Reference(QICorePractitioner) Persons involved in the encounter other than the patient
... period S 0..1 Period The start and end time of the encounter
... length S 0..1 Duration Quantity of time the encounter lasted (less time absent)
... reasonCode SΣ 0..* CodeableConcept Coded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.


... diagnosis SΣ 0..* BackboneElement The list of diagnosis relevant to this encounter
.... Slices for extension Content/Rules for all slices
..... diagnosisPresentOnAdmission S 1..1 CodeableConcept onAdmission
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission
Binding: ExampleDiagnosisOnAdmissionCodes (required): Indicator of whether the Encounter diagnosis was present at the time of admission


.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... condition SΣ 1..1 Reference(QICoreCondition | QICoreProcedure) The diagnosis or procedure relevant to the encounter
.... use S 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

.... rank S 0..1 positiveInt Ranking of the diagnosis (for each role type)
... hospitalization S 0..1 BackboneElement Details about the admission to a healthcare service
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... admitSource S 0..1 CodeableConcept From where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred): From where the patient was admitted.

.... reAdmission S 0..1 CodeableConcept The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter.

.... dischargeDisposition S 0..1 CodeableConcept Category or kind of location after discharge
Binding: DischargeDisposition (example): Discharge Disposition.

... location S 0..* BackboneElement List of locations where the patient has been
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... location S 1..1 Reference(QICoreLocation) Location the encounter takes place
... serviceProvider S 0..1 Reference(QICoreOrganization) The organization (facility) responsible for this encounter

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Encounter.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.statusrequiredEncounterStatus
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.classextensibleActEncounterCode
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.typerequiredPregnancyEncountersCodes
http://fhir.org/guides/nachc/hiv-cds/ValueSet/nachc-f2-de2
from this IG
Encounter.participant.typeextensibleParticipantType
http://hl7.org/fhir/ValueSet/encounter-participant-type
from the FHIR Standard
Encounter.reasonCodepreferredEncounterReasonCodes
http://hl7.org/fhir/ValueSet/encounter-reason
from the FHIR Standard
Encounter.diagnosis.usepreferredDiagnosisRole
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.hospitalization.admitSourcepreferredAdmitSource
http://hl7.org/fhir/ValueSet/encounter-admit-source
from the FHIR Standard
Encounter.hospitalization.reAdmissionexampleHl7VSReAdmissionIndicator
http://terminology.hl7.org/ValueSet/v2-0092
Encounter.hospitalization.dischargeDispositionexampleDischargeDisposition
http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorEncounterIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorEncounterIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorEncounterIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorEncounterIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceEncounterA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..* QICoreEncounter An interaction during which services are provided to the patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... statusReason S 0..1 CodeableConcept Reason for current status
URL: http://hl7.org/fhir/StructureDefinition/request-statusReason
Binding: (unbound) (example): Codes identifying the reason for the current state of an event.


.... procedure S 0..* (Complex) Encounter Procedure Extension
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-procedure
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Identifier(s) by which this encounter is known
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!Σ 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

... statusHistory 0..* BackboneElement List of past encounter statuses
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... status 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

.... period 1..1 Period The time that the episode was in the specified status
... class SΣ 1..1 Coding Classification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.

... classHistory 0..* BackboneElement List of past encounter classes
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... class 1..1 Coding inpatient | outpatient | ambulatory | emergency +
Binding: ActEncounterCode (extensible): Classification of the encounter.

.... period 1..1 Period The time that the episode was in the specified class
... type SΣ 1..1 CodeableConcept Pregnancy Encounters
Binding: Pregnancy Encounters Codes (required)
... serviceType Σ 0..1 CodeableConcept Specific type of service
Binding: ServiceType (example): Broad categorization of the service that is to be provided.

... priority 0..1 CodeableConcept Indicates the urgency of the encounter
Binding: SNOMED CT Priorities Codes (preferred): The priority of the encounter (e.g., Urgent, Normal, etc.)

... subject SΣ 1..1 Reference(QICorePatient) The patient or group present at the encounter
... episodeOfCare Σ 0..* Reference(EpisodeOfCare) Episode(s) of care that this encounter should be recorded against
... basedOn 0..* Reference(QICoreServiceRequest) The ServiceRequest that initiated this encounter
... participant SΣ 0..* BackboneElement List of participants involved in the encounter
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type SΣ 0..* CodeableConcept Role of participant in encounter
Binding: ParticipantType (extensible): Role of participant in encounter.


.... period S 0..1 Period Period of time during the encounter that the participant participated
.... individual SΣ 0..1 Reference(QICorePractitioner) Persons involved in the encounter other than the patient
... appointment Σ 0..* Reference(Appointment) The appointment that scheduled this encounter
... period S 0..1 Period The start and end time of the encounter
... length S 0..1 Duration Quantity of time the encounter lasted (less time absent)
... reasonCode SΣ 0..* CodeableConcept Coded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.


... reasonReference Σ 0..* Reference(Condition | Procedure | Observation | ImmunizationRecommendation) Reason the encounter takes place (reference)
... diagnosis SΣ 0..* BackboneElement The list of diagnosis relevant to this encounter
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... diagnosisPresentOnAdmission S 1..1 CodeableConcept onAdmission
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter-diagnosisPresentOnAdmission
Binding: ExampleDiagnosisOnAdmissionCodes (required): Indicator of whether the Encounter diagnosis was present at the time of admission


.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... condition SΣ 1..1 Reference(QICoreCondition | QICoreProcedure) The diagnosis or procedure relevant to the encounter
.... use S 0..1 CodeableConcept Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

.... rank S 0..1 positiveInt Ranking of the diagnosis (for each role type)
... account 0..* Reference(Account) The set of accounts that may be used for billing for this Encounter
... hospitalization S 0..1 BackboneElement Details about the admission to a healthcare service
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... preAdmissionIdentifier 0..1 Identifier Pre-admission identifier
.... origin 0..1 Reference(QICoreLocation) The location/organization from which the patient came before admission
.... admitSource S 0..1 CodeableConcept From where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred): From where the patient was admitted.

.... reAdmission S 0..1 CodeableConcept The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter.

.... dietPreference 0..* CodeableConcept Diet preferences reported by the patient
Binding: Diet (example): Medical, cultural or ethical food preferences to help with catering requirements.


.... specialCourtesy 0..* CodeableConcept Special courtesies (VIP, board member)
Binding: SpecialCourtesy (preferred): Special courtesies.


.... specialArrangement 0..* CodeableConcept Wheelchair, translator, stretcher, etc.
Binding: SpecialArrangements (preferred): Special arrangements.


.... destination 0..1 Reference(QICoreLocation) Location/organization to which the patient is discharged
.... dischargeDisposition S 0..1 CodeableConcept Category or kind of location after discharge
Binding: DischargeDisposition (example): Discharge Disposition.

... location S 0..* BackboneElement List of locations where the patient has been
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... location S 1..1 Reference(QICoreLocation) Location the encounter takes place
.... status 0..1 code planned | active | reserved | completed
Binding: EncounterLocationStatus (required): The status of the location.

.... physicalType 0..1 CodeableConcept The physical type of the location (usually the level in the location hierachy - bed room ward etc.)
Binding: LocationType (example): Physical form of the location.

.... period 0..1 Period Time period during which the patient was present at the location
... serviceProvider S 0..1 Reference(QICoreOrganization) The organization (facility) responsible for this encounter
... partOf 0..1 Reference(QICoreEncounter) Another Encounter this encounter is part of

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Encounter.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Encounter.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Encounter.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Encounter.statusrequiredEncounterStatus
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.statusHistory.statusrequiredEncounterStatus
http://hl7.org/fhir/ValueSet/encounter-status|4.0.1
from the FHIR Standard
Encounter.classextensibleActEncounterCode
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.classHistory.classextensibleActEncounterCode
http://terminology.hl7.org/ValueSet/v3-ActEncounterCode
Encounter.typerequiredPregnancyEncountersCodes
http://fhir.org/guides/nachc/hiv-cds/ValueSet/nachc-f2-de2
from this IG
Encounter.serviceTypeexampleServiceType
http://hl7.org/fhir/ValueSet/service-type
from the FHIR Standard
Encounter.prioritypreferredQICorePriority
http://hl7.org/fhir/us/qicore/ValueSet/qicore-priority
Encounter.participant.typeextensibleParticipantType
http://hl7.org/fhir/ValueSet/encounter-participant-type
from the FHIR Standard
Encounter.reasonCodepreferredEncounterReasonCodes
http://hl7.org/fhir/ValueSet/encounter-reason
from the FHIR Standard
Encounter.diagnosis.usepreferredDiagnosisRole
http://hl7.org/fhir/ValueSet/diagnosis-role
from the FHIR Standard
Encounter.hospitalization.admitSourcepreferredAdmitSource
http://hl7.org/fhir/ValueSet/encounter-admit-source
from the FHIR Standard
Encounter.hospitalization.reAdmissionexampleHl7VSReAdmissionIndicator
http://terminology.hl7.org/ValueSet/v2-0092
Encounter.hospitalization.dietPreferenceexampleDiet
http://hl7.org/fhir/ValueSet/encounter-diet
from the FHIR Standard
Encounter.hospitalization.specialCourtesypreferredSpecialCourtesy
http://hl7.org/fhir/ValueSet/encounter-special-courtesy
from the FHIR Standard
Encounter.hospitalization.specialArrangementpreferredSpecialArrangements
http://hl7.org/fhir/ValueSet/encounter-special-arrangements
from the FHIR Standard
Encounter.hospitalization.dischargeDispositionexampleDischargeDisposition
http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
from the FHIR Standard
Encounter.location.statusrequiredEncounterLocationStatus
http://hl7.org/fhir/ValueSet/encounter-location-status|4.0.1
from the FHIR Standard
Encounter.location.physicalTypeexampleLocationType
http://hl7.org/fhir/ValueSet/location-physical-type
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorEncounterIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorEncounterIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorEncounterIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorEncounterIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceEncounterA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from QICoreEncounter

Summary

Mandatory: 1 element
Must-Support: 1 element

 

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