De-Identification, Anonymization, Redaction Toolkit Services
0.1.0 - STU1 Release 1 - Standard for Trial-Use United States of America flag

De-Identification, Anonymization, Redaction Toolkit Services, published by HL7 International / Cross Group Projects. 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/HL7/fhir-darts/ and changes regularly. See the Directory of published versions

Resource Profile: De-Identified UDS Plus Encounter

Official URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-encounter Version: 0.1.0
Standards status: Trial-use Maturity Level: 1 Computable Name: UDSPlusEncounter

The UDS+ profile is based on the Encounter resource and establishes the core elements, extensions, vocabularies and value sets for representing encounters,visit information for UDS+ program.

All canonical (Official) URLs will be changed in the future and are not available currently on the web.

Introduction

This profile is used to represent de-identified Encounter information. The de-identification process has to remove all data elements not explicitly identified as "SUPPORTED" in the profile.

The HHS De-identification Guidance is to be followed to ensure appropriate level of de-identification is performed.

According to the HHS guidance, dates should not have a precision of more than the year. This means month and day cannot be included. This includes diagnosis dates, visit dates, onset dates etc.

In FHIR Resources, text elements and reference.display elements which provide human readable information to the providers may be generated using programs and tools from the data present within the resource. For e.g a Encounter resource text element may contain information such as the visit date. This type of information will enable identification of the individuals. In order to avoid inadvertent revealing of PII/PHI, text elements cannot be included in the De-identified FHIR resource and the submission will be rejected when text elements are present by the validation process.

Age Computation

The Data Submitter has to compute the age using the visit date of the encounter to be included in the UDS+ report.

Capturing Location Information

The Encounter.location.location points to a Location Resource. The Location.type element can be used to indicate the type of location where the service was provided. The existing Location.type value set can be used to indicate that the service was provided in a SCHOOL based setting. This will be used to compute Table 4, LINE 24 of the UDS Report. For Table 4, Line 26 use the public-housing code defined in UDS+ value set that is referenced in the UDS+ Location profile.

Ids and References

The original Encounter resource id should not be included in the De-identified Encounter instance. Instead a new id should be created and provided as part of the FHIR resource. This Data Submitter should be capable of using the generated id to relink the data to the original Encounter. All resource references to the Encounter submitted as part of the UDS+ report should refer to newly generated id.

Resource references cannot contain text element as it may contain PHI/PII. The text element for following references are not allowed

  • subject
  • reasonReference

Date Truncation

The Data Submitter has to truncate the following dates to only have a precision of year

  • period and its sub elements.
  • participant.period

Examples

Examples of identifiable data and its corresponding de-identifiable data is present in Reporting Guidance.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Encounter 0..* Encounter De-Identified UDS Plus Encounter
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:uds-plus-age-extension S 1..1 Quantity Age of the Patient computed using birthDate and the visit dates of the encounter
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-age-extension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... class SΣ 1..1 Coding Classification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.
... type SΣ 1..* CodeableConcept ​Specific type of encounter
Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type (extensible): The set of codes indicating the type of encounter
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) The patient or group present at the encounter
... participant SΣ 0..1 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(US Core Practitioner Profile) Persons involved in the encounter other than the patient
... period S 0..1 Period The start and end time of the encounter
... reasonCode SΣ 0..* CodeableConcept Coded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.
... reasonReference SΣ 0..* Reference(De-Identified UDS Plus Diagnosis) Reason the encounter takes place (reference)
... diagnosis SΣ 0..* BackboneElement The list of diagnosis relevant to this encounter
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... condition SΣ 1..1 Reference(De-Identified UDS Plus Diagnosis) 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
.... dischargeDisposition S 0..1 CodeableConcept ​Category or kind of location after discharge
Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition (preferred): The set of codes indicating the 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(UDS Plus Location) Location the encounter takes place
... serviceProvider S 0..1 Reference(US Core Organization Profile) The organization (facility) responsible for this encounter

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Encounter.status Base required EncounterStatus 📍4.0.1 FHIR Std.
Encounter.class Base extensible ActEncounterCode 📦3.0.0 THO v7.1
Encounter.type Base extensible ​ http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type Not State Unknown
Encounter.participant.​type Base extensible Participant type 📍4.0.1 FHIR Std.
Encounter.reasonCode Base preferred Encounter Reason Codes 📍4.0.1 FHIR Std.
Encounter.diagnosis.​use Base preferred DiagnosisRole 📍4.0.1 FHIR Std.
Encounter.hospitalization.​dischargeDisposition Base preferred ​ http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition Not State Unknown

Constraints

Id Grade Path(s) Description Expression
dom-2 error Encounter If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Encounter If 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-4 error Encounter If 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-5 error Encounter If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Encounter A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from Encounter

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Encounter 0..* Encounter De-Identified UDS Plus Encounter
... Slices for extension Content/Rules for all slices
.... extension:uds-plus-age-extension S 1..1 Quantity Age of the Patient computed using birthDate and the visit dates of the encounter
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-age-extension
... status S 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
... class S 1..1 Coding Classification of patient encounter
.... text 0..0 Plain text representation of the concept
... subject S 1..1 Reference(De-Identified UDS Plus Patient) The patient or group present at the encounter
.... display 0..0 Text alternative for the resource
... participant S 0..1 BackboneElement List of participants involved in the encounter
.... type S 0..* CodeableConcept Role of participant in encounter
..... text 0..0 Plain text representation of the concept
.... period S 0..1 Period Period of time during the encounter that the participant participated
.... individual S 0..1 Reference(US Core Practitioner Profile) Persons involved in the encounter other than the patient
... period S 0..1 Period The start and end time of the encounter
... reasonCode S 0..* CodeableConcept Coded reason the encounter takes place
.... text 0..0 Plain text representation of the concept
... reasonReference S 0..* Reference(De-Identified UDS Plus Diagnosis) Reason the encounter takes place (reference)
.... display 0..0 Text alternative for the resource
... diagnosis S 0..* BackboneElement The list of diagnosis relevant to this encounter
.... condition S 1..1 Reference(De-Identified UDS Plus Diagnosis) 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 …)
.... 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
.... dischargeDisposition S 0..1 CodeableConcept ​Category or kind of location after discharge
Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition (preferred): The set of codes indicating the discharge disposition
..... text 0..0 Plain text representation of the concept
... location S 0..* BackboneElement List of locations where the patient has been
.... location S 1..1 Reference(UDS Plus Location) Location the encounter takes place
... serviceProvider S 0..1 Reference(US Core Organization Profile) The organization (facility) responsible for this encounter

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Encounter.type Base extensible ​ http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type Not State Unknown
Encounter.hospitalization.​dischargeDisposition Base preferred ​ http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition Not State Unknown
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Encounter 0..* Encounter De-Identified UDS Plus Encounter
... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:uds-plus-age-extension S 1..1 Quantity Age of the Patient computed using birthDate and the visit dates of the encounter
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-age-extension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Identifier(s) by which this encounter is known
... status ?!SΣ 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..* CodeableConcept ​Specific type of encounter
Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type (extensible): The set of codes indicating the type of encounter
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... 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: ActPriority (example): Indicates the urgency of the encounter.
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) The patient or group present at the encounter
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... episodeOfCare Σ 0..* Reference(EpisodeOfCare) Episode(s) of care that this encounter should be recorded against
... basedOn 0..* Reference(ServiceRequest) The ServiceRequest that initiated this encounter
... participant SΣ 0..1 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.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
.... period S 0..1 Period Period of time during the encounter that the participant participated
.... individual SΣ 0..1 Reference(US Core Practitioner Profile) 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 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.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... reasonReference SΣ 0..* Reference(De-Identified UDS Plus Diagnosis) Reason the encounter takes place (reference)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... diagnosis SΣ 0..* BackboneElement The list of diagnosis relevant to this 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
.... condition SΣ 1..1 Reference(De-Identified UDS Plus Diagnosis) 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(Location | Organization) The location/organization from which the patient came before admission
.... admitSource 0..1 CodeableConcept From where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred): From where the patient was admitted.
.... reAdmission 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(Location | Organization) Location/organization to which the patient is discharged
.... dischargeDisposition S 0..1 CodeableConcept ​Category or kind of location after discharge
Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition (preferred): The set of codes indicating the discharge disposition
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
... 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(UDS Plus Location) 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(US Core Organization Profile) The organization (facility) responsible for this encounter
... partOf 0..1 Reference(Encounter) Another Encounter this encounter is part of

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Encounter.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Encounter.status Base required EncounterStatus 📍4.0.1 FHIR Std.
Encounter.statusHistory.​status Base required EncounterStatus 📍4.0.1 FHIR Std.
Encounter.class Base extensible ActEncounterCode 📦3.0.0 THO v7.1
Encounter.classHistory.​class Base extensible ActEncounterCode 📦3.0.0 THO v7.1
Encounter.type Base extensible ​ http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type Not State Unknown
Encounter.serviceType Base example Service type 📍4.0.1 FHIR Std.
Encounter.priority Base example ActPriority 📦3.0.0 THO v7.1
Encounter.subject.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Encounter.participant.​type Base extensible Participant type 📍4.0.1 FHIR Std.
Encounter.reasonCode Base preferred Encounter Reason Codes 📍4.0.1 FHIR Std.
Encounter.reasonReference.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Encounter.diagnosis.​use Base preferred DiagnosisRole 📍4.0.1 FHIR Std.
Encounter.hospitalization.​admitSource Base preferred Admit source 📍4.0.1 FHIR Std.
Encounter.hospitalization.​reAdmission Base example hl7VS-re-admissionIndicator 📦3.0.0 THO v7.1
Encounter.hospitalization.​dietPreference Base example Diet 📍4.0.1 FHIR Std.
Encounter.hospitalization.​specialCourtesy Base preferred Special courtesy 📍4.0.1 FHIR Std.
Encounter.hospitalization.​specialArrangement Base preferred Special arrangements 📍4.0.1 FHIR Std.
Encounter.hospitalization.​dischargeDisposition Base preferred ​ http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition Not State Unknown
Encounter.location.status Base required EncounterLocationStatus 📍4.0.1 FHIR Std.
Encounter.location.physicalType Base example Location type 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Encounter If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Encounter If 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-4 error Encounter If 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-5 error Encounter If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Encounter A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Encounter 0..* Encounter De-Identified UDS Plus Encounter
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:uds-plus-age-extension S 1..1 Quantity Age of the Patient computed using birthDate and the visit dates of the encounter
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-age-extension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... class SΣ 1..1 Coding Classification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.
... type SΣ 1..* CodeableConcept ​Specific type of encounter
Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type (extensible): The set of codes indicating the type of encounter
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) The patient or group present at the encounter
... participant SΣ 0..1 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(US Core Practitioner Profile) Persons involved in the encounter other than the patient
... period S 0..1 Period The start and end time of the encounter
... reasonCode SΣ 0..* CodeableConcept Coded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.
... reasonReference SΣ 0..* Reference(De-Identified UDS Plus Diagnosis) Reason the encounter takes place (reference)
... diagnosis SΣ 0..* BackboneElement The list of diagnosis relevant to this encounter
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... condition SΣ 1..1 Reference(De-Identified UDS Plus Diagnosis) 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
.... dischargeDisposition S 0..1 CodeableConcept ​Category or kind of location after discharge
Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition (preferred): The set of codes indicating the 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(UDS Plus Location) Location the encounter takes place
... serviceProvider S 0..1 Reference(US Core Organization Profile) The organization (facility) responsible for this encounter

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Encounter.status Base required EncounterStatus 📍4.0.1 FHIR Std.
Encounter.class Base extensible ActEncounterCode 📦3.0.0 THO v7.1
Encounter.type Base extensible ​ http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type Not State Unknown
Encounter.participant.​type Base extensible Participant type 📍4.0.1 FHIR Std.
Encounter.reasonCode Base preferred Encounter Reason Codes 📍4.0.1 FHIR Std.
Encounter.diagnosis.​use Base preferred DiagnosisRole 📍4.0.1 FHIR Std.
Encounter.hospitalization.​dischargeDisposition Base preferred ​ http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition Not State Unknown

Constraints

Id Grade Path(s) Description Expression
dom-2 error Encounter If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Encounter If 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-4 error Encounter If 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-5 error Encounter If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Encounter A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from Encounter

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Encounter 0..* Encounter De-Identified UDS Plus Encounter
... Slices for extension Content/Rules for all slices
.... extension:uds-plus-age-extension S 1..1 Quantity Age of the Patient computed using birthDate and the visit dates of the encounter
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-age-extension
... status S 1..1 code planned | arrived | triaged | in-progress | onleave | finished | cancelled +
... class S 1..1 Coding Classification of patient encounter
.... text 0..0 Plain text representation of the concept
... subject S 1..1 Reference(De-Identified UDS Plus Patient) The patient or group present at the encounter
.... display 0..0 Text alternative for the resource
... participant S 0..1 BackboneElement List of participants involved in the encounter
.... type S 0..* CodeableConcept Role of participant in encounter
..... text 0..0 Plain text representation of the concept
.... period S 0..1 Period Period of time during the encounter that the participant participated
.... individual S 0..1 Reference(US Core Practitioner Profile) Persons involved in the encounter other than the patient
... period S 0..1 Period The start and end time of the encounter
... reasonCode S 0..* CodeableConcept Coded reason the encounter takes place
.... text 0..0 Plain text representation of the concept
... reasonReference S 0..* Reference(De-Identified UDS Plus Diagnosis) Reason the encounter takes place (reference)
.... display 0..0 Text alternative for the resource
... diagnosis S 0..* BackboneElement The list of diagnosis relevant to this encounter
.... condition S 1..1 Reference(De-Identified UDS Plus Diagnosis) 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 …)
.... 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
.... dischargeDisposition S 0..1 CodeableConcept ​Category or kind of location after discharge
Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition (preferred): The set of codes indicating the discharge disposition
..... text 0..0 Plain text representation of the concept
... location S 0..* BackboneElement List of locations where the patient has been
.... location S 1..1 Reference(UDS Plus Location) Location the encounter takes place
... serviceProvider S 0..1 Reference(US Core Organization Profile) The organization (facility) responsible for this encounter

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Encounter.type Base extensible ​ http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type Not State Unknown
Encounter.hospitalization.​dischargeDisposition Base preferred ​ http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition Not State Unknown

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Encounter 0..* Encounter De-Identified UDS Plus Encounter
... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:uds-plus-age-extension S 1..1 Quantity Age of the Patient computed using birthDate and the visit dates of the encounter
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-age-extension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Identifier(s) by which this encounter is known
... status ?!SΣ 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..* CodeableConcept ​Specific type of encounter
Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type (extensible): The set of codes indicating the type of encounter
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... 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: ActPriority (example): Indicates the urgency of the encounter.
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) The patient or group present at the encounter
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... episodeOfCare Σ 0..* Reference(EpisodeOfCare) Episode(s) of care that this encounter should be recorded against
... basedOn 0..* Reference(ServiceRequest) The ServiceRequest that initiated this encounter
... participant SΣ 0..1 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.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
.... period S 0..1 Period Period of time during the encounter that the participant participated
.... individual SΣ 0..1 Reference(US Core Practitioner Profile) 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 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.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... reasonReference SΣ 0..* Reference(De-Identified UDS Plus Diagnosis) Reason the encounter takes place (reference)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... diagnosis SΣ 0..* BackboneElement The list of diagnosis relevant to this 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
.... condition SΣ 1..1 Reference(De-Identified UDS Plus Diagnosis) 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(Location | Organization) The location/organization from which the patient came before admission
.... admitSource 0..1 CodeableConcept From where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred): From where the patient was admitted.
.... reAdmission 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(Location | Organization) Location/organization to which the patient is discharged
.... dischargeDisposition S 0..1 CodeableConcept ​Category or kind of location after discharge
Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition (preferred): The set of codes indicating the discharge disposition
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
... 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(UDS Plus Location) 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(US Core Organization Profile) The organization (facility) responsible for this encounter
... partOf 0..1 Reference(Encounter) Another Encounter this encounter is part of

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Encounter.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Encounter.status Base required EncounterStatus 📍4.0.1 FHIR Std.
Encounter.statusHistory.​status Base required EncounterStatus 📍4.0.1 FHIR Std.
Encounter.class Base extensible ActEncounterCode 📦3.0.0 THO v7.1
Encounter.classHistory.​class Base extensible ActEncounterCode 📦3.0.0 THO v7.1
Encounter.type Base extensible ​ http://hl7.org/fhir/us/core/ValueSet/us-core-encounter-type Not State Unknown
Encounter.serviceType Base example Service type 📍4.0.1 FHIR Std.
Encounter.priority Base example ActPriority 📦3.0.0 THO v7.1
Encounter.subject.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Encounter.participant.​type Base extensible Participant type 📍4.0.1 FHIR Std.
Encounter.reasonCode Base preferred Encounter Reason Codes 📍4.0.1 FHIR Std.
Encounter.reasonReference.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Encounter.diagnosis.​use Base preferred DiagnosisRole 📍4.0.1 FHIR Std.
Encounter.hospitalization.​admitSource Base preferred Admit source 📍4.0.1 FHIR Std.
Encounter.hospitalization.​reAdmission Base example hl7VS-re-admissionIndicator 📦3.0.0 THO v7.1
Encounter.hospitalization.​dietPreference Base example Diet 📍4.0.1 FHIR Std.
Encounter.hospitalization.​specialCourtesy Base preferred Special courtesy 📍4.0.1 FHIR Std.
Encounter.hospitalization.​specialArrangement Base preferred Special arrangements 📍4.0.1 FHIR Std.
Encounter.hospitalization.​dischargeDisposition Base preferred ​ http://hl7.org/fhir/us/core/ValueSet/us-core-discharge-disposition Not State Unknown
Encounter.location.status Base required EncounterLocationStatus 📍4.0.1 FHIR Std.
Encounter.location.physicalType Base example Location type 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Encounter If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Encounter If 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-4 error Encounter If 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-5 error Encounter If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Encounter A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron