Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build

Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

## Logical Model: Encounter Activity

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/EncounterActivity | Version: 2.1
Draft as of 2023-09-29 | Computable Name: EncounterActivity
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01

This clinical statement describes an interaction between a patient and clinician. Interactions may include in-person encounters, telephone conversations, and email exchanges.

Usage:

- Use this Logical Model: Encounters Section, Intervention Act and Planned Intervention Act

### Formal Views of Profile Content

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

- Differential Table
- Key Elements Table
- Snapshot Table
- Statistics/References
- All

This structure is derived from CDAR2.Encounter

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Encounter |  |  | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
classCode |  | 1..1 | cs |
moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49
extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 1..* | II |
code |  | 1..1 | CD | Binding: EncounterTypeCode (preferred)
originalText |  | 0..1 | ED |
reference |  | 0..1 | TEL |
value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972).
translation |  | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
effectiveTime |  | 1..1 | IVL_TS |
sdtcDischargeDispositionCode | C | 0..1 | CE | The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5.
performer |  | 0..* | Performer2 |
assignedEntity |  | 1..1 | AssignedEntity |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
Slices for participant |  | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode
participant:location |  | 0..* | Participant2 |
typeCode |  | 1..1 | cs | Fixed Value: LOC
participantRole |  | 1..1 | ServiceDeliveryLocation | Base for all types and resources
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:act
entryRelationship:indication |  | 0..* | EntryRelationship |
typeCode |  | 1..1 | cs | Fixed Value: RSON
observation |  | 1..1 | Indication | Base for all types and resources
entryRelationship:diagnosis |  | 0..* | EntryRelationship |
act |  | 1..1 | EncounterDiagnosis | Base for all types and resources
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
Encounter.code | preferred | EncounterTypeCode
Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : |
1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : |
1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Encounter |  | 1..1 | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources
@classCode |  | 1..1 | cs | Binding: ActClass (required) Fixed Value: ENC
@moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 1..* | II |
code |  | 1..1 | CD | Binding: EncounterTypeCode (preferred)
originalText |  | 0..1 | ED |
reference |  | 0..1 | TEL |
@value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972).
translation |  | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
effectiveTime |  | 1..1 | IVL_TS |
sdtcDischargeDispositionCode | C | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element XML: dischargeDispositionCode (urn:hl7-org:sdtc) 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5.
performer |  | 0..* | Performer2 |
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
Slices for participant |  | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode
participant:location |  | 0..* | Participant2 |
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: LOC
participantRole |  | 1..1 | ServiceDeliveryLocation | Base for all types and resources
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:act
entryRelationship:indication |  | 0..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON
observation |  | 1..1 | Indication | Base for all types and resources
entryRelationship:diagnosis |  | 0..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required)
act |  | 1..1 | EncounterDiagnosis | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Encounter.classCode | required | Fixed Value: ENC
Encounter.code | preferred | EncounterTypeCode
Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
Encounter.participant:location.typeCode | required | Fixed Value: LOC
Encounter.entryRelationship:indication.typeCode | required | Fixed Value: RSON
Encounter.entryRelationship:diagnosis.typeCode | required | XActRelationshipEntryRelationship

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : |
1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : |
1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Encounter |  | 1..1 | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources
@classCode |  | 1..1 | cs | Binding: ActClass (required) Fixed Value: ENC
@moodCode |  | 1..1 | cs | Fixed Value: EVN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 1..* | II |
code |  | 1..1 | CD | Binding: EncounterTypeCode (preferred)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs |
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@charset |  | 0..1 | cs |
@compression |  | 0..1 | cs | Binding: CompressionAlgorithm (required)
@integrityCheck |  | 0..1 | bin |
@integrityCheckAlgorithm |  | 0..1 | cs | Binding: IntegrityCheckAlgorithm (required)
@language |  | 0..1 | cs |
@mediaType |  | 0..1 | cs |
@representation |  | 0..1 | cs |
data[x] |  | 0..1 |  |
dataString |  |  | string(st) |
dataBase64Binary |  |  | base64Binary(bin) |
reference |  | 0..1 | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972).
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..* | cs | Binding: AddressUse (required)
thumbnail |  | 0..1 | ED |
qualifier |  | 0..* | CR |
translation |  | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
text |  | 0..1 | ED |
statusCode |  | 0..1 | CS | Binding: ActStatus (required)
effectiveTime |  | 1..1 | IVL_TS |
sdtcDischargeDispositionCode | C | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element XML: dischargeDispositionCode (urn:hl7-org:sdtc) 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5.
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationPhysicalPerformer (required) Fixed Value: PRF
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
sdtcFunctionCode |  | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc)
time |  | 0..1 | IVL_TS |
modeCode |  | 0..1 | CE |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
Slices for participant |  | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode
participant:location |  | 0..* | Participant2 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: LOC
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
sdtcFunctionCode |  | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc)
time |  | 0..1 | IVL_TS |
awarenessCode |  | 0..1 | CE |
participantRole |  | 1..1 | ServiceDeliveryLocation | Base for all types and resources
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:act
entryRelationship:indication |  | 0..* | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON
@inversionInd |  | 0..1 | bl |
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | Indication | Base for all types and resources
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
entryRelationship:diagnosis |  | 0..* | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required)
@inversionInd |  | 0..1 | bl |
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 1..1 | EncounterDiagnosis | Base for all types and resources
encounter |  | 0..1 | Encounter |
observation |  | 0..1 | Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
reference |  | 0..* | Reference |
precondition |  | 0..* | Precondition |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Encounter.classCode | required | Fixed Value: ENC
Encounter.templateId:primary.nullFlavor | required | NullFlavor
Encounter.code | preferred | EncounterTypeCode
Encounter.code.nullFlavor | required | NullFlavor
Encounter.code.originalText.nullFlavor | required | NullFlavor
Encounter.code.originalText.compression | required | CompressionAlgorithm
Encounter.code.originalText.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm
Encounter.code.originalText.reference.nullFlavor | required | NullFlavor
Encounter.code.originalText.reference.use | required | AddressUse
Encounter.statusCode | required | ActStatus
Encounter.priorityCode | extensible | ActPriority
Encounter.performer.nullFlavor | required | NullFlavor
Encounter.performer.typeCode | required | Fixed Value: PRF
Encounter.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
Encounter.participant:location.nullFlavor | required | NullFlavor
Encounter.participant:location.typeCode | required | Fixed Value: LOC
Encounter.participant:location.contextControlCode | required | Fixed Value: OP
Encounter.entryRelationship:indication.nullFlavor | required | NullFlavor
Encounter.entryRelationship:indication.typeCode | required | Fixed Value: RSON
Encounter.entryRelationship:diagnosis.nullFlavor | required | NullFlavor
Encounter.entryRelationship:diagnosis.typeCode | required | XActRelationshipEntryRelationship

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : |
1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : |
1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |

This structure is derived from CDAR2.Encounter

Summary

Mandatory: 7 elements (3 nested mandatory elements)
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

- Service Delivery Location (http://hl7.org/cda/us/ccda/StructureDefinition/ServiceDeliveryLocation)
- Indication (http://hl7.org/cda/us/ccda/StructureDefinition/Indication)
- Encounter Diagnosis (http://hl7.org/cda/us/ccda/StructureDefinition/EncounterDiagnosis)

Slices

This structure defines the following Slices:

- The element Encounter.templateId is sliced based on the values of value:root, value:extension
- The element Encounter.participant is sliced based on the values of value:participantRole, value:typeCode
- The element Encounter.entryRelationship is sliced based on the value of value:act

Differential View

This structure is derived from CDAR2.Encounter

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Encounter |  |  | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
classCode |  | 1..1 | cs |
moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49
extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 1..* | II |
code |  | 1..1 | CD | Binding: EncounterTypeCode (preferred)
originalText |  | 0..1 | ED |
reference |  | 0..1 | TEL |
value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972).
translation |  | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
effectiveTime |  | 1..1 | IVL_TS |
sdtcDischargeDispositionCode | C | 0..1 | CE | The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5.
performer |  | 0..* | Performer2 |
assignedEntity |  | 1..1 | AssignedEntity |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
Slices for participant |  | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode
participant:location |  | 0..* | Participant2 |
typeCode |  | 1..1 | cs | Fixed Value: LOC
participantRole |  | 1..1 | ServiceDeliveryLocation | Base for all types and resources
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:act
entryRelationship:indication |  | 0..* | EntryRelationship |
typeCode |  | 1..1 | cs | Fixed Value: RSON
observation |  | 1..1 | Indication | Base for all types and resources
entryRelationship:diagnosis |  | 0..* | EntryRelationship |
act |  | 1..1 | EncounterDiagnosis | Base for all types and resources
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet
Encounter.code | preferred | EncounterTypeCode
Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : |
1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : |
1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : |

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Encounter |  | 1..1 | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources
@classCode |  | 1..1 | cs | Binding: ActClass (required) Fixed Value: ENC
@moodCode |  | 1..1 | cs | Fixed Value: EVN
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 1..* | II |
code |  | 1..1 | CD | Binding: EncounterTypeCode (preferred)
originalText |  | 0..1 | ED |
reference |  | 0..1 | TEL |
@value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972).
translation |  | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
effectiveTime |  | 1..1 | IVL_TS |
sdtcDischargeDispositionCode | C | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element XML: dischargeDispositionCode (urn:hl7-org:sdtc) 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5.
performer |  | 0..* | Performer2 |
assignedEntity |  | 1..1 | AssignedEntity |
id |  | 1..* | II |
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
Slices for participant |  | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode
participant:location |  | 0..* | Participant2 |
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: LOC
participantRole |  | 1..1 | ServiceDeliveryLocation | Base for all types and resources
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:act
entryRelationship:indication |  | 0..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON
observation |  | 1..1 | Indication | Base for all types and resources
entryRelationship:diagnosis |  | 0..* | EntryRelationship |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required)
act |  | 1..1 | EncounterDiagnosis | Base for all types and resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Encounter.classCode | required | Fixed Value: ENC
Encounter.code | preferred | EncounterTypeCode
Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
Encounter.participant:location.typeCode | required | Fixed Value: LOC
Encounter.entryRelationship:indication.typeCode | required | Fixed Value: RSON
Encounter.entryRelationship:diagnosis.typeCode | required | XActRelationshipEntryRelationship

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : |
1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : |
1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Encounter |  | 1..1 | CDAR2.Encounter | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, text, statusCode, effectiveTime, sdtcDischargeDispositionCode, priorityCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources
@classCode |  | 1..1 | cs | Binding: ActClass (required) Fixed Value: ENC
@moodCode |  | 1..1 | cs | Fixed Value: EVN
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
Slices for templateId |  | 1..* | II | Slice: Unordered, Open by value:root, value:extension
templateId:primary |  | 1..1 | II |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@assigningAuthorityName |  | 0..1 | st |
@displayable |  | 0..1 | bl |
@root |  | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.49
@extension |  | 1..1 | st | Required Pattern: 2015-08-01
id |  | 1..* | II |
code |  | 1..1 | CD | Binding: EncounterTypeCode (preferred)
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@code |  | 0..1 | cs |
@codeSystem |  | 0..1 | oid, uuid, ruid |
@codeSystemName |  | 0..1 | st |
@codeSystemVersion |  | 0..1 | st |
@displayName |  | 0..1 | st |
@sdtcValueSet |  | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc)
@sdtcValueSetVersion |  | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc)
originalText |  | 0..1 | ED |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@charset |  | 0..1 | cs |
@compression |  | 0..1 | cs | Binding: CompressionAlgorithm (required)
@integrityCheck |  | 0..1 | bin |
@integrityCheckAlgorithm |  | 0..1 | cs | Binding: IntegrityCheckAlgorithm (required)
@language |  | 0..1 | cs |
@mediaType |  | 0..1 | cs |
@representation |  | 0..1 | cs |
data[x] |  | 0..1 |  |
dataString |  |  | string(st) |
dataBase64Binary |  |  | base64Binary(bin) |
reference |  | 0..1 | TEL |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@value | C | 0..1 | url | 1198-15972: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972).
useablePeriod |  | 0..* |  |
useablePeriod |  |  | IVL_TS |
useablePeriod |  |  | EIVL_TS |
useablePeriod |  |  | PIVL_TS |
useablePeriod |  |  | SXPR_TS |
@use |  | 0..* | cs | Binding: AddressUse (required)
thumbnail |  | 0..1 | ED |
qualifier |  | 0..* | CR |
translation |  | 0..1 | CD | The translation may exist to map the code of EncounterTypeCode (2.16.840.1.113883.3.88.12.80.32) value set to the code of Encounter Planned (2.16.840.1.113883.11.20.9.52) value set.
text |  | 0..1 | ED |
statusCode |  | 0..1 | CS | Binding: ActStatus (required)
effectiveTime |  | 1..1 | IVL_TS |
sdtcDischargeDispositionCode | C | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc The prefix sdtc: SHALL be bound to the namespace “urn:hl7-org:sdtc”. The use of the namespace provides a necessary extension to CDA R2 for the use of the dischargeDispositionCode element XML: dischargeDispositionCode (urn:hl7-org:sdtc) 1198-32177: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. 1198-32377: This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5.
priorityCode |  | 0..1 | CE | Binding: ActPriority (extensible)
subject |  | 0..1 | Subject |
specimen |  | 0..* | Specimen |
performer |  | 0..* | Performer2 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 0..1 | cs | Binding: ParticipationPhysicalPerformer (required) Fixed Value: PRF
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
sdtcFunctionCode |  | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc)
time |  | 0..1 | IVL_TS |
modeCode |  | 0..1 | CE |
assignedEntity |  | 1..1 | AssignedEntity |
@classCode |  | 0..1 | cs | Binding: RoleClassAssignedEntity (required) Fixed Value: ASSIGNED
templateId |  | 0..* | II |
id |  | 1..* | II |
sdtcIdentifiedBy |  | 0..* | IdentifiedBy | XML Namespace: urn:hl7-org:sdtc XML: identifiedBy (urn:hl7-org:sdtc)
code |  | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred)
addr |  | 0..* | AD |
telecom |  | 0..* | TEL |
assignedPerson |  | 0..1 | Person |
representedOrganization |  | 0..1 | Organization |
author |  | 0..* | Author |
informant |  | 0..* | Informant |
Slices for participant |  | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode
participant:location |  | 0..* | Participant2 |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
@typeCode |  | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: LOC
@contextControlCode |  | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
sdtcFunctionCode |  | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc)
time |  | 0..1 | IVL_TS |
awarenessCode |  | 0..1 | CE |
participantRole |  | 1..1 | ServiceDeliveryLocation | Base for all types and resources
Slices for entryRelationship |  | 0..* | EntryRelationship | Slice: Unordered, Open by value:act
entryRelationship:indication |  | 0..* | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON
@inversionInd |  | 0..1 | bl |
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 0..1 | Act |
encounter |  | 0..1 | Encounter |
observation |  | 1..1 | Indication | Base for all types and resources
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
entryRelationship:diagnosis |  | 0..* | EntryRelationship |
@nullFlavor |  | 0..1 | cs | Binding: NullFlavor (required)
realmCode |  | 0..* | CS |
typeId |  | 0..1 | II |
templateId |  | 0..* | II |
@typeCode |  | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required)
@inversionInd |  | 0..1 | bl |
@contextConductionInd |  | 0..1 | bl |
@negationInd |  | 0..1 | bl |
sequenceNumber |  | 0..1 | INT |
seperatableInd |  | 0..1 | BL |
act |  | 1..1 | EncounterDiagnosis | Base for all types and resources
encounter |  | 0..1 | Encounter |
observation |  | 0..1 | Observation |
observationMedia |  | 0..1 | ObservationMedia |
organizer |  | 0..1 | Organizer |
procedure |  | 0..1 | Procedure |
regionOfInterest |  | 0..1 | RegionOfInterest |
substanceAdministration |  | 0..1 | SubstanceAdministration |
supply |  | 0..1 | Supply |
reference |  | 0..* | Reference |
precondition |  | 0..* | Precondition |
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code
Encounter.classCode | required | Fixed Value: ENC
Encounter.templateId:primary.nullFlavor | required | NullFlavor
Encounter.code | preferred | EncounterTypeCode
Encounter.code.nullFlavor | required | NullFlavor
Encounter.code.originalText.nullFlavor | required | NullFlavor
Encounter.code.originalText.compression | required | CompressionAlgorithm
Encounter.code.originalText.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm
Encounter.code.originalText.reference.nullFlavor | required | NullFlavor
Encounter.code.originalText.reference.use | required | AddressUse
Encounter.statusCode | required | ActStatus
Encounter.priorityCode | extensible | ActPriority
Encounter.performer.nullFlavor | required | NullFlavor
Encounter.performer.typeCode | required | Fixed Value: PRF
Encounter.performer.assignedEntity.classCode | required | Fixed Value: ASSIGNED
Encounter.performer.assignedEntity.code | preferred | Healthcare Provider Taxonomy (a valid code from `http://nucc.org/provider-taxonomy`)
Encounter.participant:location.nullFlavor | required | NullFlavor
Encounter.participant:location.typeCode | required | Fixed Value: LOC
Encounter.participant:location.contextControlCode | required | Fixed Value: OP
Encounter.entryRelationship:indication.nullFlavor | required | NullFlavor
Encounter.entryRelationship:indication.typeCode | required | Fixed Value: RSON
Encounter.entryRelationship:diagnosis.nullFlavor | required | NullFlavor
Encounter.entryRelationship:diagnosis.typeCode | required | XActRelationshipEntryRelationship

#### Constraints

Id | Grade | Path(s) | Details | Requirements
1198-15972 | error | Encounter.code.originalText.reference.value | This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1198-15972). : |
1198-32177 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *code*, which **SHOULD** be selected from ValueSet 2.16.840.1.113883.3.88.12.80.33 NUBC UB-04 FL17-Patient Status (code system 2.16.840.1.113883.6.301.5) *DYNAMIC*. NOTE: This requires a license from the AHA to access these codes. : |
1198-32377 | warning | Encounter.sdtcDischargeDispositionCode | This sdtc:dischargeDispositionCode **SHOULD** contain exactly [0..1] *codeSystem*, which **SHOULD** be CodeSystem: NUBC 2.16.840.1.113883.6.301.5. : |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |

This structure is derived from CDAR2.Encounter

Summary

Mandatory: 7 elements (3 nested mandatory elements)
Fixed Value: 3 elements

Structures

This structure refers to these other structures:

- Service Delivery Location (http://hl7.org/cda/us/ccda/StructureDefinition/ServiceDeliveryLocation)
- Indication (http://hl7.org/cda/us/ccda/StructureDefinition/Indication)
- Encounter Diagnosis (http://hl7.org/cda/us/ccda/StructureDefinition/EncounterDiagnosis)

Slices

This structure defines the following Slices:

- The element Encounter.templateId is sliced based on the values of value:root, value:extension
- The element Encounter.participant is sliced based on the values of value:participantRole, value:typeCode
- The element Encounter.entryRelationship is sliced based on the value of value:act

Other representations of profile: CSV, Excel