HRSA 2023 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG
1.0.1 - STU1 Release 1 - Standard for Trial-Use International flag

This page is part of the HRSA Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+ or uds-plus) FHIR IG (v1.0.1: STU1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: De-Identified UDS Plus Encounter

Official URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-encounter Version: 1.0.1
Standards status: Trial-use Maturity Level: 2 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.

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.

Usage:

Formal Views of Profile Content

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

This structure is derived from Encounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..*EncounterDe-Identified UDS Plus Encounter
... uds-plus-age-extension S1..1QuantityAge of the Patient computed using birthDate and the visit dates of the encounter
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-age-extension
... status S1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
... class S1..1CodingClassification of patient encounter
.... text 0..0
... subject S1..1Reference(De-Identified UDS Plus Patient)The patient or group present at the encounter
.... display 0..0
... participant S0..1BackboneElementList of participants involved in the encounter
.... type S0..*CodeableConceptRole of participant in encounter
..... text 0..0
.... period S0..1PeriodPeriod of time during the encounter that the participant participated
.... individual S0..1Reference(US Core Practitioner Profile)Persons involved in the encounter other than the patient
... period S0..1PeriodThe start and end time of the encounter
... reasonCode S0..*CodeableConceptCoded reason the encounter takes place
.... text 0..0
... reasonReference S0..*Reference(De-Identified UDS Plus Diagnosis)Reason the encounter takes place (reference)
.... display 0..0
... diagnosis S0..*BackboneElementThe list of diagnosis relevant to this encounter
.... condition S1..1Reference(De-Identified UDS Plus Diagnosis)The diagnosis or procedure relevant to the encounter
.... use S0..1CodeableConceptRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
.... rank S0..1positiveIntRanking of the diagnosis (for each role type)
... hospitalization S0..1BackboneElementDetails about the admission to a healthcare service
.... dischargeDisposition S0..1CodeableConceptCategory or kind of location after discharge
Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition

..... text 0..0
... location S0..*BackboneElementList of locations where the patient has been
.... location S1..1Reference(UDS Plus Location)Location the encounter takes place
... serviceProvider S0..1Reference(US Core Organization Profile)The organization (facility) responsible for this encounter

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Encounter.typeextensibleUSCoreEncounterType
Encounter.hospitalization.dischargeDispositionpreferredUSCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge)
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..*EncounterDe-Identified UDS Plus Encounter
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... uds-plus-age-extension S1..1QuantityAge of the Patient computed using birthDate and the visit dates of the encounter
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-age-extension
... status ?!SΣ1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

... class SΣ1..1CodingClassification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.

... type SΣ1..*CodeableConceptSpecific type of encounter
Binding: US Core Encounter Type (extensible): The set of codes indicating the type of encounter


... subject SΣ1..1Reference(De-Identified UDS Plus Patient)The patient or group present at the encounter
... participant SΣ0..1BackboneElementList of participants involved in the encounter
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ0..*CodeableConceptRole of participant in encounter
Binding: ParticipantType (extensible): Role of participant in encounter.


.... period S0..1PeriodPeriod of time during the encounter that the participant participated
.... individual SΣ0..1Reference(US Core Practitioner Profile)Persons involved in the encounter other than the patient
... period S0..1PeriodThe start and end time of the encounter
... reasonCode SΣ0..*CodeableConceptCoded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.


... reasonReference SΣ0..*Reference(De-Identified UDS Plus Diagnosis)Reason the encounter takes place (reference)
... diagnosis SΣ0..*BackboneElementThe list of diagnosis relevant to this encounter
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... condition SΣ1..1Reference(De-Identified UDS Plus Diagnosis)The diagnosis or procedure relevant to the encounter
.... use S0..1CodeableConceptRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

.... rank S0..1positiveIntRanking of the diagnosis (for each role type)
... hospitalization S0..1BackboneElementDetails about the admission to a healthcare service
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... dischargeDisposition S0..1CodeableConceptCategory or kind of location after discharge
Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition

... location S0..*BackboneElementList of locations where the patient has been
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... location S1..1Reference(UDS Plus Location)Location the encounter takes place
... serviceProvider S0..1Reference(US Core Organization Profile)The organization (facility) responsible for this encounter

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Encounter.statusrequiredEncounterStatus
Encounter.classextensibleActEncounterCode
Encounter.typeextensibleUSCoreEncounterType
Encounter.participant.typeextensibleParticipantType
Encounter.reasonCodepreferredEncounterReasonCodes
Encounter.diagnosis.usepreferredDiagnosisRole
Encounter.hospitalization.dischargeDispositionpreferredUSCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge)

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorEncounterIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorEncounterIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorEncounterIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorEncounterIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceEncounterA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..*EncounterDe-Identified UDS Plus Encounter
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... uds-plus-age-extension S1..1QuantityAge of the Patient computed using birthDate and the visit dates of the encounter
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-age-extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierIdentifier(s) by which this encounter is known
... status ?!SΣ1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

... statusHistory 0..*BackboneElementList of past encounter statuses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... status 1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

.... period 1..1PeriodThe time that the episode was in the specified status
... class SΣ1..1CodingClassification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.

... classHistory 0..*BackboneElementList of past encounter classes
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... class 1..1Codinginpatient | outpatient | ambulatory | emergency +
Binding: ActEncounterCode (extensible): Classification of the encounter.

.... period 1..1PeriodThe time that the episode was in the specified class
... type SΣ1..*CodeableConceptSpecific type of encounter
Binding: US Core Encounter Type (extensible): The set of codes indicating the type of encounter


.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
... serviceType Σ0..1CodeableConceptSpecific type of service
Binding: ServiceType (example): Broad categorization of the service that is to be provided.

... priority 0..1CodeableConceptIndicates the urgency of the encounter
Binding: ActPriority (example): Indicates the urgency of the encounter.

... subject SΣ1..1Reference(De-Identified UDS Plus Patient)The patient or group present at the encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
... episodeOfCare Σ0..*Reference(EpisodeOfCare)Episode(s) of care that this encounter should be recorded against
... basedOn 0..*Reference(ServiceRequest)The ServiceRequest that initiated this encounter
... participant SΣ0..1BackboneElementList of participants involved in the encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ0..*CodeableConceptRole of participant in encounter
Binding: ParticipantType (extensible): Role of participant in encounter.


..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
.... period S0..1PeriodPeriod of time during the encounter that the participant participated
.... individual SΣ0..1Reference(US Core Practitioner Profile)Persons involved in the encounter other than the patient
... appointment Σ0..*Reference(Appointment)The appointment that scheduled this encounter
... period S0..1PeriodThe start and end time of the encounter
... length 0..1DurationQuantity of time the encounter lasted (less time absent)
... reasonCode SΣ0..*CodeableConceptCoded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.


.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
... reasonReference SΣ0..*Reference(De-Identified UDS Plus Diagnosis)Reason the encounter takes place (reference)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
... diagnosis SΣ0..*BackboneElementThe list of diagnosis relevant to this encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... condition SΣ1..1Reference(De-Identified UDS Plus Diagnosis)The diagnosis or procedure relevant to the encounter
.... use S0..1CodeableConceptRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

.... rank S0..1positiveIntRanking 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 S0..1BackboneElementDetails about the admission to a healthcare service
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... preAdmissionIdentifier 0..1IdentifierPre-admission identifier
.... origin 0..1Reference(Location | Organization)The location/organization from which the patient came before admission
.... admitSource 0..1CodeableConceptFrom where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred): From where the patient was admitted.

.... reAdmission 0..1CodeableConceptThe 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..*CodeableConceptDiet preferences reported by the patient
Binding: Diet (example): Medical, cultural or ethical food preferences to help with catering requirements.


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


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


.... destination 0..1Reference(Location | Organization)Location/organization to which the patient is discharged
.... dischargeDisposition S0..1CodeableConceptCategory or kind of location after discharge
Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
... location S0..*BackboneElementList of locations where the patient has been
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... location S1..1Reference(UDS Plus Location)Location the encounter takes place
.... status 0..1codeplanned | active | reserved | completed
Binding: EncounterLocationStatus (required): The status of the location.

.... physicalType 0..1CodeableConceptThe 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..1PeriodTime period during which the patient was present at the location
... serviceProvider S0..1Reference(US Core Organization Profile)The organization (facility) responsible for this encounter
... partOf 0..1Reference(Encounter)Another Encounter this encounter is part of

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Encounter.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Encounter.statusrequiredEncounterStatus
Encounter.statusHistory.statusrequiredEncounterStatus
Encounter.classextensibleActEncounterCode
Encounter.classHistory.classextensibleActEncounterCode
Encounter.typeextensibleUSCoreEncounterType
Encounter.serviceTypeexampleServiceType
Encounter.priorityexampleActPriority
Encounter.subject.typeextensibleResourceType
Encounter.participant.typeextensibleParticipantType
Encounter.reasonCodepreferredEncounterReasonCodes
Encounter.reasonReference.typeextensibleResourceType
Encounter.diagnosis.usepreferredDiagnosisRole
Encounter.hospitalization.admitSourcepreferredAdmitSource
Encounter.hospitalization.reAdmissionexampleHl7VSReAdmissionIndicator
Encounter.hospitalization.dietPreferenceexampleDiet
Encounter.hospitalization.specialCourtesypreferredSpecialCourtesy
Encounter.hospitalization.specialArrangementpreferredSpecialArrangements
Encounter.hospitalization.dischargeDispositionpreferredUSCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge)
Encounter.location.statusrequiredEncounterLocationStatus
Encounter.location.physicalTypeexampleLocationType

Constraints

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

Differential View

This structure is derived from Encounter

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..*EncounterDe-Identified UDS Plus Encounter
... uds-plus-age-extension S1..1QuantityAge of the Patient computed using birthDate and the visit dates of the encounter
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-age-extension
... status S1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
... class S1..1CodingClassification of patient encounter
.... text 0..0
... subject S1..1Reference(De-Identified UDS Plus Patient)The patient or group present at the encounter
.... display 0..0
... participant S0..1BackboneElementList of participants involved in the encounter
.... type S0..*CodeableConceptRole of participant in encounter
..... text 0..0
.... period S0..1PeriodPeriod of time during the encounter that the participant participated
.... individual S0..1Reference(US Core Practitioner Profile)Persons involved in the encounter other than the patient
... period S0..1PeriodThe start and end time of the encounter
... reasonCode S0..*CodeableConceptCoded reason the encounter takes place
.... text 0..0
... reasonReference S0..*Reference(De-Identified UDS Plus Diagnosis)Reason the encounter takes place (reference)
.... display 0..0
... diagnosis S0..*BackboneElementThe list of diagnosis relevant to this encounter
.... condition S1..1Reference(De-Identified UDS Plus Diagnosis)The diagnosis or procedure relevant to the encounter
.... use S0..1CodeableConceptRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
.... rank S0..1positiveIntRanking of the diagnosis (for each role type)
... hospitalization S0..1BackboneElementDetails about the admission to a healthcare service
.... dischargeDisposition S0..1CodeableConceptCategory or kind of location after discharge
Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition

..... text 0..0
... location S0..*BackboneElementList of locations where the patient has been
.... location S1..1Reference(UDS Plus Location)Location the encounter takes place
... serviceProvider S0..1Reference(US Core Organization Profile)The organization (facility) responsible for this encounter

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Encounter.typeextensibleUSCoreEncounterType
Encounter.hospitalization.dischargeDispositionpreferredUSCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge)

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..*EncounterDe-Identified UDS Plus Encounter
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... uds-plus-age-extension S1..1QuantityAge of the Patient computed using birthDate and the visit dates of the encounter
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-age-extension
... status ?!SΣ1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

... class SΣ1..1CodingClassification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.

... type SΣ1..*CodeableConceptSpecific type of encounter
Binding: US Core Encounter Type (extensible): The set of codes indicating the type of encounter


... subject SΣ1..1Reference(De-Identified UDS Plus Patient)The patient or group present at the encounter
... participant SΣ0..1BackboneElementList of participants involved in the encounter
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ0..*CodeableConceptRole of participant in encounter
Binding: ParticipantType (extensible): Role of participant in encounter.


.... period S0..1PeriodPeriod of time during the encounter that the participant participated
.... individual SΣ0..1Reference(US Core Practitioner Profile)Persons involved in the encounter other than the patient
... period S0..1PeriodThe start and end time of the encounter
... reasonCode SΣ0..*CodeableConceptCoded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.


... reasonReference SΣ0..*Reference(De-Identified UDS Plus Diagnosis)Reason the encounter takes place (reference)
... diagnosis SΣ0..*BackboneElementThe list of diagnosis relevant to this encounter
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... condition SΣ1..1Reference(De-Identified UDS Plus Diagnosis)The diagnosis or procedure relevant to the encounter
.... use S0..1CodeableConceptRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

.... rank S0..1positiveIntRanking of the diagnosis (for each role type)
... hospitalization S0..1BackboneElementDetails about the admission to a healthcare service
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... dischargeDisposition S0..1CodeableConceptCategory or kind of location after discharge
Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition

... location S0..*BackboneElementList of locations where the patient has been
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... location S1..1Reference(UDS Plus Location)Location the encounter takes place
... serviceProvider S0..1Reference(US Core Organization Profile)The organization (facility) responsible for this encounter

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Encounter.statusrequiredEncounterStatus
Encounter.classextensibleActEncounterCode
Encounter.typeextensibleUSCoreEncounterType
Encounter.participant.typeextensibleParticipantType
Encounter.reasonCodepreferredEncounterReasonCodes
Encounter.diagnosis.usepreferredDiagnosisRole
Encounter.hospitalization.dischargeDispositionpreferredUSCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge)

Constraints

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

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter 0..*EncounterDe-Identified UDS Plus Encounter
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... uds-plus-age-extension S1..1QuantityAge of the Patient computed using birthDate and the visit dates of the encounter
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-age-extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierIdentifier(s) by which this encounter is known
... status ?!SΣ1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

... statusHistory 0..*BackboneElementList of past encounter statuses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... status 1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
Binding: EncounterStatus (required): Current state of the encounter.

.... period 1..1PeriodThe time that the episode was in the specified status
... class SΣ1..1CodingClassification of patient encounter
Binding: ActEncounterCode (extensible): Classification of the encounter.

... classHistory 0..*BackboneElementList of past encounter classes
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... class 1..1Codinginpatient | outpatient | ambulatory | emergency +
Binding: ActEncounterCode (extensible): Classification of the encounter.

.... period 1..1PeriodThe time that the episode was in the specified class
... type SΣ1..*CodeableConceptSpecific type of encounter
Binding: US Core Encounter Type (extensible): The set of codes indicating the type of encounter


.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
... serviceType Σ0..1CodeableConceptSpecific type of service
Binding: ServiceType (example): Broad categorization of the service that is to be provided.

... priority 0..1CodeableConceptIndicates the urgency of the encounter
Binding: ActPriority (example): Indicates the urgency of the encounter.

... subject SΣ1..1Reference(De-Identified UDS Plus Patient)The patient or group present at the encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
... episodeOfCare Σ0..*Reference(EpisodeOfCare)Episode(s) of care that this encounter should be recorded against
... basedOn 0..*Reference(ServiceRequest)The ServiceRequest that initiated this encounter
... participant SΣ0..1BackboneElementList of participants involved in the encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ0..*CodeableConceptRole of participant in encounter
Binding: ParticipantType (extensible): Role of participant in encounter.


..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
.... period S0..1PeriodPeriod of time during the encounter that the participant participated
.... individual SΣ0..1Reference(US Core Practitioner Profile)Persons involved in the encounter other than the patient
... appointment Σ0..*Reference(Appointment)The appointment that scheduled this encounter
... period S0..1PeriodThe start and end time of the encounter
... length 0..1DurationQuantity of time the encounter lasted (less time absent)
... reasonCode SΣ0..*CodeableConceptCoded reason the encounter takes place
Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place.


.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
... reasonReference SΣ0..*Reference(De-Identified UDS Plus Diagnosis)Reason the encounter takes place (reference)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
... diagnosis SΣ0..*BackboneElementThe list of diagnosis relevant to this encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... condition SΣ1..1Reference(De-Identified UDS Plus Diagnosis)The diagnosis or procedure relevant to the encounter
.... use S0..1CodeableConceptRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

.... rank S0..1positiveIntRanking 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 S0..1BackboneElementDetails about the admission to a healthcare service
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... preAdmissionIdentifier 0..1IdentifierPre-admission identifier
.... origin 0..1Reference(Location | Organization)The location/organization from which the patient came before admission
.... admitSource 0..1CodeableConceptFrom where patient was admitted (physician referral, transfer)
Binding: AdmitSource (preferred): From where the patient was admitted.

.... reAdmission 0..1CodeableConceptThe 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..*CodeableConceptDiet preferences reported by the patient
Binding: Diet (example): Medical, cultural or ethical food preferences to help with catering requirements.


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


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


.... destination 0..1Reference(Location | Organization)Location/organization to which the patient is discharged
.... dischargeDisposition S0..1CodeableConceptCategory or kind of location after discharge
Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*CodingCode defined by a terminology system
... location S0..*BackboneElementList of locations where the patient has been
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... location S1..1Reference(UDS Plus Location)Location the encounter takes place
.... status 0..1codeplanned | active | reserved | completed
Binding: EncounterLocationStatus (required): The status of the location.

.... physicalType 0..1CodeableConceptThe 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..1PeriodTime period during which the patient was present at the location
... serviceProvider S0..1Reference(US Core Organization Profile)The organization (facility) responsible for this encounter
... partOf 0..1Reference(Encounter)Another Encounter this encounter is part of

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Encounter.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Encounter.statusrequiredEncounterStatus
Encounter.statusHistory.statusrequiredEncounterStatus
Encounter.classextensibleActEncounterCode
Encounter.classHistory.classextensibleActEncounterCode
Encounter.typeextensibleUSCoreEncounterType
Encounter.serviceTypeexampleServiceType
Encounter.priorityexampleActPriority
Encounter.subject.typeextensibleResourceType
Encounter.participant.typeextensibleParticipantType
Encounter.reasonCodepreferredEncounterReasonCodes
Encounter.reasonReference.typeextensibleResourceType
Encounter.diagnosis.usepreferredDiagnosisRole
Encounter.hospitalization.admitSourcepreferredAdmitSource
Encounter.hospitalization.reAdmissionexampleHl7VSReAdmissionIndicator
Encounter.hospitalization.dietPreferenceexampleDiet
Encounter.hospitalization.specialCourtesypreferredSpecialCourtesy
Encounter.hospitalization.specialArrangementpreferredSpecialArrangements
Encounter.hospitalization.dischargeDispositionpreferredUSCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge)
Encounter.location.statusrequiredEncounterLocationStatus
Encounter.location.physicalTypeexampleLocationType

Constraints

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

 

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