Skip to content

Encounter Profile

Canonical../StructureDefinition/nexus-emr-core-encounter
Statusdraft · 1.26.0
BaseEncounter (constraint)
SourceFSH · JSON

Defines the Encounter resource constraints for the Nexus EMR project (CII), conforming to CA-Core+ requirements.

Elements / Details

Every element this profile touches, with its full definition. Element names in the tables link here.

Encounter

Short Nexus EMR Encounter Core
Definition Represents patient interactions with healthcare providers, capturing key details like status, class, type, participants, and timing using standard Nexus EMR references. Uses instance-specific identifiers for tracking encounters across systems.
Cardinality 0..*
Invariants dom-2, dom-3, dom-4, dom-5, dom-6, encounter-appointment-single-in-primary-care
Also called Visit

Encounter.id

Short Logical id of this artifact
Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.meta

Short Metadata about the resource
Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Cardinality 0..1
Type Meta
Invariants ele-1

Encounter.meta.id

Short Unique id for inter-element referencing
Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.meta.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.meta.versionId

Short Version specific identifier
Definition The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
Comments The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
Cardinality 0..1
Type id
Invariants ele-1

Encounter.meta.lastUpdated

Short When the resource version last changed
Definition When the resource last changed - e.g. when the version changed.
Comments This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
Cardinality 0..1
Type instant
Invariants ele-1

Encounter.meta.source

Short Identifies EMR instance & pipeline version the resource came from
Definition A URI that identifies the EMR pipeline and version from which this resource originated. This tells you which EMR instance (recommend using the instance identifier), and the version of the pipeline code/transformations.
Comments In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Cardinality 0..1
Type uri
Must Support yes
Invariants ele-1

Encounter.meta.profile

Short Profiles this resource claims to conform to
Definition A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.
Comments It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Cardinality 0..*
Type canonical
Invariants ele-1

Encounter.meta.security

Short Security Labels applied to this resource
Definition Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
Comments The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Cardinality 0..*
Type Coding
Binding security-labels (extensible)
Invariants ele-1

Encounter.meta.tag

Short Tags applied to this resource
Definition Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
Comments The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Cardinality 0..*
Type Coding
Binding common-tags (example)
Invariants ele-1

Encounter.implicitRules

Short A set of rules under which this content was created
Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Comments Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Cardinality 0..1
Type uri
Modifier yes — This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Invariants ele-1

Encounter.language

Short Language of the resource content
Definition The base language in which the resource is written.
Comments Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Cardinality 0..1
Type code
Binding languages (preferred)
Invariants ele-1

Encounter.text

Short Narrative
Definition A human-readable narrative summary of the NexusEmrCoreEncounter resource for human interpretation.
Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Cardinality 0..1
Type Narrative
Must Support yes
Invariants ele-1
Also called narrative, html, xhtml, display

Encounter.contained

Short Contained, inline Resources
Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Comments This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Cardinality 0..*
Type Resource
Also called inline resources, anonymous resources, contained resources

Encounter.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.modifierExtension

Short Extensions that cannot be ignored
Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Modifier yes — Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.identifier

Short Business identifier(s) for encounter
Definition Unique identifiers for the encounter. A business identifier is recommended but not required (identifier is 0..*). Where available, carry the source-system identifier using the most appropriate system URI. No specific canonical system is mandated.
Comments A source system's own identifier SHOULD be carried alongside this one, flagged use = secondary. See Carrying the raw code.
Cardinality 0..*
Type Identifier
Must Support yes
Invariants ele-1

Encounter.identifier.id

Short Unique id for inter-element referencing
Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.identifier.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.identifier.use

Short usual | official | temp | secondary | old (If known)
Definition The purpose of this identifier.
Requirements Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Comments Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Cardinality 0..1
Type code
Modifier yes — This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Binding identifier-use (required)
Invariants ele-1

Encounter.identifier.type

Short Description of identifier
Definition A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
Requirements Allows users to make use of identifiers when the identifier system is not known.
Comments This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Cardinality 0..1
Type CodeableConcept
Binding identifier-type (extensible)
Invariants ele-1

Encounter.identifier.system

Short The namespace for the identifier value
Definition Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Requirements There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
Comments Identifier.system is always case sensitive.
Cardinality 1..1
Type uri
Invariants ele-1

Encounter.identifier.value

Short The value that is unique
Definition The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Comments If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
Cardinality 1..1
Type string
Invariants ele-1

Encounter.identifier.period

Short Time period when id is/was valid for use
Definition Time period during which identifier is/was valid for use.
Cardinality 0..1
Type Period
Invariants ele-1

Encounter.identifier.assigner

Short Organization that issued id (may be just text)
Definition Organization that issued/manages the identifier.
Comments The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
Cardinality 0..1
Type Reference(Organization)
Invariants ele-1

Encounter.status

Short Where the encounter is in its lifecycle
Definition The current status of the encounter. Tracks the lifecycle of the encounter.
Comments This is a modifier element. The status affects how the encounter should be interpreted.
Cardinality 1..1
Type code
Must Support yes
Modifier yes — This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Binding encounter-status (required)
Invariants ele-1

Encounter.statusHistory

Short List of past encounter statuses
Definition The status history permits the encounter resource to contain the status history without needing to read through the historical versions of the resource, or even have the server store them.
Comments The current status is always found in the current version of the resource, not the status history.
Cardinality 0..*
Type BackboneElement
Invariants ele-1

Encounter.statusHistory.id

Short Unique id for inter-element referencing
Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.statusHistory.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.statusHistory.modifierExtension

Short Extensions that cannot be ignored even if unrecognized
Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Modifier yes — Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Invariants ele-1, ext-1
Also called extensions, user content, modifiers

Encounter.statusHistory.status

Short planned | arrived | triaged | in-progress | onleave | finished | cancelled +
Definition planned | arrived | triaged | in-progress | onleave | finished | cancelled +.
Cardinality 1..1
Type code
Binding encounter-status (required)
Invariants ele-1

Encounter.statusHistory.period

Short The time that the episode was in the specified status
Definition The time that the episode was in the specified status.
Cardinality 1..1
Type Period
Invariants ele-1

Encounter.class

Short Classification of patient encounter
Definition Classification of patient encounter, from the required v3-ActEncounterCode binding. Ambulatory (AMB) is the common case and the expected default for a clinic visit. It is NOT fixed: a virtual encounter is VR and an admission is IMP, and writing AMB for either asserts something the record does not support.
Comments Map from the appointment's modality, where one is known. In-person becomes AMB; video, telephone and secure-message all become VR. That mapping is the one this guide states, and it is the reason this element is not fixed to AMB -- the modality axis exists precisely to distinguish a video consult from one in the room, and collapsing it here would leave that distinction living only on an extension of the Appointment, which not every Encounter has. A reader should NOT infer scope from the breadth of the binding. Nexus EMR encounters are predominantly ambulatory; IMP is admitted so that an admission a discharge summary refers to can be represented at all, not as a statement that inpatient workflows are modelled here.
Cardinality 1..1
Type Coding
Must Support yes
Binding v3-ActEncounterCode (required)
Invariants ele-1

Encounter.classHistory

Short List of past encounter classes
Definition The class history permits the tracking of the encounters transitions without needing to go through the resource history. This would be used for a case where an admission starts of as an emergency encounter, then transitions into an inpatient scenario. Doing this and not restarting a new encounter ensures that any lab/diagnostic results can more easily follow the patient and not require re-processing and not get lost or cancelled during a kind of discharge from emergency to inpatient.
Cardinality 0..*
Type BackboneElement
Invariants ele-1

Encounter.classHistory.id

Short Unique id for inter-element referencing
Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.classHistory.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.classHistory.modifierExtension

Short Extensions that cannot be ignored even if unrecognized
Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Modifier yes — Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Invariants ele-1, ext-1
Also called extensions, user content, modifiers

Encounter.classHistory.class

Short inpatient | outpatient | ambulatory | emergency +
Definition inpatient | outpatient | ambulatory | emergency +.
Cardinality 1..1
Type Coding
Binding v3-ActEncounterCode (extensible)
Invariants ele-1

Encounter.classHistory.period

Short The time that the episode was in the specified class
Definition The time that the episode was in the specified class.
Cardinality 1..1
Type Period
Invariants ele-1

Encounter.type

Short Encounter type with raw code support
Definition Specific type of encounter (e.g., consultation, follow-up, emergency). RECOMMENDED: Standard terminology codes when available OPTIONAL: Raw EMR codes for source system preservation Where this code was mapped from a source system's own vocabulary, carry the raw coding alongside the mapped one, flagged userSelected = true. See Carrying the raw code.
Comments Since there are many ways to further classify encounters, this element is 0..*.
Cardinality 0..*
Type CodeableConcept
Must Support yes
Binding encounter-type (example)
Invariants ele-1

Encounter.serviceType

Short Service type with raw code support
Definition Broad categorization of the service that is to be provided during this encounter. RECOMMENDED: Standard terminology codes when available OPTIONAL: Raw EMR codes for source system preservation
Comments Where this code was mapped from a source system's own vocabulary, carry the raw coding alongside the mapped one, flagged userSelected = true. See Carrying the raw code.
Cardinality 0..1
Type CodeableConcept
Must Support yes
Binding service-type (example)
Invariants ele-1

Encounter.priority

Short Indicates the urgency of the encounter
Definition Indicates the urgency of the encounter.
Cardinality 0..1
Type CodeableConcept
Binding v3-ActPriority (example)
Invariants ele-1

Encounter.subject

Short The patient present at the encounter
Definition The patient who is the focus of the encounter. Must reference using Nexus EMR patient identifier.
Comments References should use identifier-based references following Nexus EMR patterns.
Cardinality 1..1
Type Reference(Patient Profile)
Must Support yes
Invariants ele-1
Also called patient

Encounter.episodeOfCare

Short Episode(s) of care that this encounter should be recorded against
Definition Where a specific encounter should be classified as a part of a specific episode(s) of care this field should be used. This association can facilitate grouping of related encounters together for a specific purpose, such as government reporting, issue tracking, association via a common problem. The association is recorded on the encounter as these are typically created after the episode of care and grouped on entry rather than editing the episode of care to append another encounter to it (the episode of care could span years).
Cardinality 0..*
Type Reference(EpisodeOfCare)
Invariants ele-1

Encounter.basedOn

Short The ServiceRequest that initiated this encounter
Definition The request this encounter satisfies (e.g. incoming referral or procedure request).
Cardinality 0..*
Type Reference(ServiceRequest)
Invariants ele-1
Also called incomingReferral

Encounter.participant

Short List of participants involved in the encounter
Definition The healthcare professionals and organizations participating in the encounter.
Cardinality 0..1
Type BackboneElement
Must Support yes
Invariants ele-1

Encounter.participant.id

Short Unique id for inter-element referencing
Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.participant.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.participant.modifierExtension

Short Extensions that cannot be ignored even if unrecognized
Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Modifier yes — Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Invariants ele-1, ext-1
Also called extensions, user content, modifiers

Encounter.participant.type

Short Role of participant in encounter
Definition Role of participant in encounter.
Comments The participant type indicates how an individual participates in an encounter. It includes non-practitioner participants, and for practitioners this is to describe the action type in the context of this encounter (e.g. Admitting Dr, Attending Dr, Translator, Consulting Dr). This is different to the practitioner roles which are functional roles, derived from terms of employment, education, licensing, etc.
Cardinality 0..*
Type CodeableConcept
Binding encounter-participant-type (extensible)
Invariants ele-1

Encounter.participant.period

Short Period of participation
Definition The period of time that the specified participant participated in the encounter. These can overlap or be sub-sets of the overall encounter's period.
Cardinality 0..1
Type Period
Invariants ele-1

Encounter.participant.individual

Short Persons involved in the encounter
Definition Persons involved in the encounter other than the patient.
Cardinality 0..1
Type Reference(PractitionerRole Profile | Practitioner Profile)
Invariants ele-1

Encounter.appointment

Short The appointment this encounter fulfils (1:1 in primary care)
Definition The Appointment that scheduled this Encounter. Primary care: exactly one. The booked appointment and the visit that happened are the same event seen from the scheduling and clinical sides, and consumers may assume one appointment per encounter for primary-care data. Not guaranteed in general. Zero is valid (a walk-in or unscheduled visit has no appointment). More than one is valid (an Encounter fulfilling several bookings). And several Encounters MAY reference the same Appointment -- that is how a booked visit that becomes multiple encounters is represented, and nothing here forbids it. Clinical resources arising from the visit associate to the Encounter, not to the Appointment. Encounter is the anchor; the Appointment is how the visit got scheduled.
Comments A reader wanting 'the appointment for this visit' takes the single entry in primary-care data and MUST tolerate zero. A reader wanting 'the encounter(s) for this appointment' must SEARCH Encounter by this element -- R4 has no reverse element on Appointment. See the query-capability note: search support for that direction is not yet declared in a CapabilityStatement.
Cardinality 0..*
Type Reference(Appointment Profile)
Must Support yes
Invariants ele-1

Encounter.period

Short The start and end time of the encounter
Definition The start and end time of the encounter. Start time is required, end time is optional for ongoing encounters.
Comments If the encounter is ongoing, the end date will be empty.
Cardinality 1..1
Type Period
Must Support yes
Invariants ele-1

Encounter.period.id

Short Unique id for inter-element referencing
Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.period.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.period.start

Short When the encounter started
Definition The start of the period. The boundary is inclusive.
Comments If the low element is missing, the meaning is that the low boundary is not known.
Cardinality 1..1
Type dateTime
Must Support yes
Invariants ele-1

Encounter.period.end

Short When the encounter ended (if finished)
Definition The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.
Comments The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
Cardinality 0..1
Type dateTime
Must Support yes
Invariants ele-1

Encounter.length

Short Quantity of time the encounter lasted (less time absent)
Definition Quantity of time the encounter lasted. This excludes the time during leaves of absence.
Comments May differ from the time the Encounter.period lasted because of leave of absence.
Cardinality 0..1
Type Duration
Invariants ele-1

Encounter.reasonCode

Short Encounter reason with raw code support
Definition Coded reason the encounter takes place. RECOMMENDED: SNOMED CT or other standard terminology when available OPTIONAL: Raw EMR codes for source system preservation Where this code was mapped from a source system's own vocabulary, carry the raw coding alongside the mapped one, flagged userSelected = true. See Carrying the raw code.
Comments For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).
Cardinality 0..*
Type CodeableConcept
Must Support yes
Binding encounter-reason (preferred)
Invariants ele-1
Also called Indication, Admission diagnosis

Encounter.reasonReference

Short Reason the encounter takes place (reference)
Definition Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis.
Comments For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).
Cardinality 0..*
Type Reference(Condition | Procedure | Observation | ImmunizationRecommendation)
Invariants ele-1
Also called Indication, Admission diagnosis

Encounter.diagnosis

Short The list of diagnoses relevant to this encounter
Definition The diagnoses relevant to this encounter. These may be conditions identified during the encounter.
Cardinality 0..*
Type BackboneElement
Must Support yes
Invariants ele-1

Encounter.diagnosis.id

Short Unique id for inter-element referencing
Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.diagnosis.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.diagnosis.modifierExtension

Short Extensions that cannot be ignored even if unrecognized
Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Modifier yes — Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Invariants ele-1, ext-1
Also called extensions, user content, modifiers

Encounter.diagnosis.condition

Short The diagnosis or condition relevant to the encounter
Definition Reason the encounter takes place, as specified using information from another resource. For admissions, this is the admission diagnosis. The indication will typically be a Condition (with other resources referenced in the evidence.detail), or a Procedure.
Comments For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).
Cardinality 1..1
Type Reference(Condition Profile)
Must Support yes
Invariants ele-1
Also called Admission diagnosis, discharge diagnosis, indication

Encounter.diagnosis.use

Short Role of diagnosis in encounter (e.g., admission, billing, discharge)
Definition Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …).
Cardinality 0..1
Type CodeableConcept
Must Support yes
Binding diagnosis-role (preferred)
Invariants ele-1

Encounter.diagnosis.rank

Short Ranking of the diagnosis (primary, secondary, etc.)
Definition Ranking of the diagnosis (for each role type).
Cardinality 0..1
Type positiveInt
Must Support yes
Invariants ele-1

Encounter.account

Short The set of accounts that may be used for billing for this Encounter
Definition The set of accounts that may be used for billing for this Encounter.
Comments The billing system may choose to allocate billable items associated with the Encounter to different referenced Accounts based on internal business rules.
Cardinality 0..*
Type Reference(Account)
Invariants ele-1

Encounter.hospitalization

Short Details about the admission to a healthcare service
Definition Details about the admission to a healthcare service.
Comments An Encounter may cover more than just the inpatient stay. Contexts such as outpatients, community clinics, and aged care facilities are also included. The duration recorded in the period of this encounter covers the entire scope of this hospitalization record.
Cardinality 0..1
Type BackboneElement
Invariants ele-1

Encounter.hospitalization.id

Short Unique id for inter-element referencing
Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.hospitalization.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.hospitalization.modifierExtension

Short Extensions that cannot be ignored even if unrecognized
Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Modifier yes — Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Invariants ele-1, ext-1
Also called extensions, user content, modifiers

Encounter.hospitalization.preAdmissionIdentifier

Short Pre-admission identifier
Definition Pre-admission identifier.
Cardinality 0..1
Type Identifier
Invariants ele-1

Encounter.hospitalization.origin

Short The location/organization from which the patient came before admission
Definition The location/organization from which the patient came before admission.
Cardinality 0..1
Type Reference(Location | Organization)
Invariants ele-1

Encounter.hospitalization.admitSource

Short From where patient was admitted (physician referral, transfer)
Definition From where patient was admitted (physician referral, transfer).
Cardinality 0..1
Type CodeableConcept
Binding encounter-admit-source (preferred)
Invariants ele-1

Encounter.hospitalization.reAdmission

Short The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission
Definition Whether this hospitalization is a readmission and why if known.
Cardinality 0..1
Type CodeableConcept
Binding v2-0092 (example)
Invariants ele-1

Encounter.hospitalization.dietPreference

Short Diet preferences reported by the patient
Definition Diet preferences reported by the patient.
Requirements Used to track patient's diet restrictions and/or preference. For a complete description of the nutrition needs of a patient during their stay, one should use the nutritionOrder resource which links to Encounter.
Comments For example, a patient may request both a dairy-free and nut-free diet preference (not mutually exclusive).
Cardinality 0..*
Type CodeableConcept
Binding encounter-diet (example)
Invariants ele-1

Encounter.hospitalization.specialCourtesy

Short Special courtesies (VIP, board member)
Definition Special courtesies (VIP, board member).
Cardinality 0..*
Type CodeableConcept
Binding encounter-special-courtesy (preferred)
Invariants ele-1

Encounter.hospitalization.specialArrangement

Short Wheelchair, translator, stretcher, etc.
Definition Any special requests that have been made for this hospitalization encounter, such as the provision of specific equipment or other things.
Cardinality 0..*
Type CodeableConcept
Binding encounter-special-arrangements (preferred)
Invariants ele-1

Encounter.hospitalization.destination

Short Location/organization to which the patient is discharged
Definition Location/organization to which the patient is discharged.
Cardinality 0..1
Type Reference(Location | Organization)
Invariants ele-1

Encounter.hospitalization.dischargeDisposition

Short Category or kind of location after discharge
Definition Category or kind of location after discharge.
Cardinality 0..1
Type CodeableConcept
Binding encounter-discharge-disposition (example)
Invariants ele-1

Encounter.location

Short List of locations where the encounter occurred
Definition List of locations where the patient has been during this encounter.
Comments Multiple locations may indicate patient movement during the encounter.
Cardinality 0..*
Type BackboneElement
Must Support yes
Invariants ele-1

Encounter.location.id

Short Unique id for inter-element referencing
Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.location.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.location.modifierExtension

Short Extensions that cannot be ignored even if unrecognized
Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Modifier yes — Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Invariants ele-1, ext-1
Also called extensions, user content, modifiers

Encounter.location.location

Short Location the encounter takes place
Definition The location where the encounter takes place.
Cardinality 1..1
Type Reference(Location Profile)
Must Support yes
Invariants ele-1

Encounter.location.status

Short planned | active | reserved | completed
Definition The status of the participants' presence at the specified location during the period specified. If the participant is no longer at the location, then the period will have an end date/time.
Comments When the patient is no longer active at a location, then the period end date is entered, and the status may be changed to completed.
Cardinality 0..1
Type code
Must Support yes
Binding encounter-location-status (required)
Invariants ele-1

Encounter.location.physicalType

Short The physical type of the location (usually the level in the location hierachy - bed room ward etc.)
Definition This will be used to specify the required levels (bed/ward/room/etc.) desired to be recorded to simplify either messaging or query.
Comments This information is de-normalized from the Location resource to support the easier understanding of the encounter resource and processing in messaging or query. There may be many levels in the hierachy, and this may only pic specific levels that are required for a specific usage scenario.
Cardinality 0..1
Type CodeableConcept
Binding location-physical-type (example)
Invariants ele-1

Encounter.location.period

Short Time period during which the patient was at location
Definition Time period during which the patient was present at the location.
Cardinality 0..1
Type Period
Must Support yes
Invariants ele-1

Encounter.serviceProvider

Short The organization providing the service
Definition The organization that is primarily responsible for this encounter's services.
Comments This may be different from the location's managing organization.
Cardinality 0..1
Type Reference(Organization Profile)
Must Support yes
Invariants ele-1

Encounter.serviceProvider.id

Short Unique id for inter-element referencing
Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality 0..1
Type http://hl7.org/fhirpath/System.String

Encounter.serviceProvider.extension

Short Additional content defined by implementations
Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality 0..*
Type Extension
Invariants ele-1, ext-1
Also called extensions, user content

Encounter.serviceProvider.reference

Short Literal reference, Relative, internal or absolute URL
Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Cardinality 0..1
Type string
Invariants ele-1

Encounter.serviceProvider.type

Short Type the reference refers to (e.g. "Patient")
Definition The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
Comments This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Cardinality 0..1
Type uri
Binding resource-types (extensible)
Invariants ele-1

Encounter.serviceProvider.identifier

Short Nexus EMR organization identifier reference
Definition An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Cardinality 0..1
Type Identifier
Must Support yes
Invariants ele-1

Encounter.serviceProvider.display

Short Text alternative for the resource
Definition Plain text narrative that identifies the resource in addition to the resource reference.
Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Cardinality 0..1
Type string
Invariants ele-1

Encounter.partOf

Short Another Encounter this encounter is part of
Definition Another Encounter of which this encounter is a part of (administratively or in time).
Comments This is also used for associating a child's encounter back to the mother's encounter. Refer to the Notes section in the Patient resource for further details.
Cardinality 0..1
Type Reference(Encounter)
Invariants ele-1