HRSA 2023 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG
1.0.1 - STU1 Release 1 - Standard for Trial-Use
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
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.
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
Date Truncation
The Data Submitter has to truncate the following dates to only have a precision of year
Examples
Examples of identifiable data and its corresponding de-identifiable data is present in Reporting Guidance.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Encounter
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Encounter | 0..* | Encounter | De-Identified UDS Plus Encounter | |
uds-plus-age-extension | S | 1..1 | Quantity | Age 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 | S | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + |
class | S | 1..1 | Coding | Classification of patient encounter |
type | S | 1..* | CodeableConcept | Specific type of encounter Binding: US Core Encounter Type (extensible): The set of codes indicating the type of encounter |
text | 0..0 | |||
subject | S | 1..1 | Reference(De-Identified UDS Plus Patient) | The patient or group present at the encounter |
display | 0..0 | |||
participant | S | 0..1 | BackboneElement | List of participants involved in the encounter |
type | S | 0..* | CodeableConcept | Role of participant in encounter |
text | 0..0 | |||
period | S | 0..1 | Period | Period of time during the encounter that the participant participated |
individual | S | 0..1 | Reference(US Core Practitioner Profile) | Persons involved in the encounter other than the patient |
period | S | 0..1 | Period | The start and end time of the encounter |
reasonCode | S | 0..* | CodeableConcept | Coded reason the encounter takes place |
text | 0..0 | |||
reasonReference | S | 0..* | Reference(De-Identified UDS Plus Diagnosis) | Reason the encounter takes place (reference) |
display | 0..0 | |||
diagnosis | S | 0..* | BackboneElement | The list of diagnosis relevant to this encounter |
condition | S | 1..1 | Reference(De-Identified UDS Plus Diagnosis) | The diagnosis or procedure relevant to the encounter |
use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) |
rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) |
hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service |
dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition |
text | 0..0 | |||
location | S | 0..* | BackboneElement | List of locations where the patient has been |
location | S | 1..1 | Reference(UDS Plus Location) | Location the encounter takes place |
serviceProvider | S | 0..1 | Reference(US Core Organization Profile) | The organization (facility) responsible for this encounter |
Documentation for this format |
Path | Conformance | ValueSet |
Encounter.type | extensible | USCoreEncounterType |
Encounter.hospitalization.dischargeDisposition | preferred | USCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge ) |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Encounter | 0..* | Encounter | De-Identified UDS Plus Encounter | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
uds-plus-age-extension | S | 1..1 | Quantity | Age 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..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. |
class | SΣ | 1..1 | Coding | Classification of patient encounter Binding: ActEncounterCode (extensible): Classification of the encounter. |
type | SΣ | 1..* | CodeableConcept | Specific type of encounter Binding: US Core Encounter Type (extensible): The set of codes indicating the type of encounter |
subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | The patient or group present at the encounter |
participant | SΣ | 0..1 | BackboneElement | List of participants involved in the encounter |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | SΣ | 0..* | CodeableConcept | Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. |
period | S | 0..1 | Period | Period of time during the encounter that the participant participated |
individual | SΣ | 0..1 | Reference(US Core Practitioner Profile) | Persons involved in the encounter other than the patient |
period | S | 0..1 | Period | The start and end time of the encounter |
reasonCode | SΣ | 0..* | CodeableConcept | Coded reason the encounter takes place Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place. |
reasonReference | SΣ | 0..* | Reference(De-Identified UDS Plus Diagnosis) | Reason the encounter takes place (reference) |
diagnosis | SΣ | 0..* | BackboneElement | The list of diagnosis relevant to this encounter |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
condition | SΣ | 1..1 | Reference(De-Identified UDS Plus Diagnosis) | The diagnosis or procedure relevant to the encounter |
use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents. |
rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) |
hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition |
location | S | 0..* | BackboneElement | List of locations where the patient has been |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
location | S | 1..1 | Reference(UDS Plus Location) | Location the encounter takes place |
serviceProvider | S | 0..1 | Reference(US Core Organization Profile) | The organization (facility) responsible for this encounter |
Documentation for this format |
Path | Conformance | ValueSet |
Encounter.status | required | EncounterStatus |
Encounter.class | extensible | ActEncounterCode |
Encounter.type | extensible | USCoreEncounterType |
Encounter.participant.type | extensible | ParticipantType |
Encounter.reasonCode | preferred | EncounterReasonCodes |
Encounter.diagnosis.use | preferred | DiagnosisRole |
Encounter.hospitalization.dischargeDisposition | preferred | USCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge ) |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Encounter | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Encounter | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Encounter | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Encounter | 0..* | Encounter | De-Identified UDS Plus Encounter | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
uds-plus-age-extension | S | 1..1 | Quantity | Age 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..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Identifier(s) by which this encounter is known | ||||
status | ?!SΣ | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. | ||||
statusHistory | 0..* | BackboneElement | List of past encounter statuses | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
status | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. | |||||
period | 1..1 | Period | The time that the episode was in the specified status | |||||
class | SΣ | 1..1 | Coding | Classification of patient encounter Binding: ActEncounterCode (extensible): Classification of the encounter. | ||||
classHistory | 0..* | BackboneElement | List of past encounter classes | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
class | 1..1 | Coding | inpatient | outpatient | ambulatory | emergency + Binding: ActEncounterCode (extensible): Classification of the encounter. | |||||
period | 1..1 | Period | The time that the episode was in the specified class | |||||
type | SΣ | 1..* | CodeableConcept | Specific type of encounter Binding: US Core Encounter Type (extensible): The set of codes indicating the type of encounter | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
serviceType | Σ | 0..1 | CodeableConcept | Specific type of service Binding: ServiceType (example): Broad categorization of the service that is to be provided. | ||||
priority | 0..1 | CodeableConcept | Indicates the urgency of the encounter Binding: ActPriority (example): Indicates the urgency of the encounter. | |||||
subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | The patient or group present at the encounter | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
episodeOfCare | Σ | 0..* | Reference(EpisodeOfCare) | Episode(s) of care that this encounter should be recorded against | ||||
basedOn | 0..* | Reference(ServiceRequest) | The ServiceRequest that initiated this encounter | |||||
participant | SΣ | 0..1 | BackboneElement | List of participants involved in the encounter | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | SΣ | 0..* | CodeableConcept | Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
period | S | 0..1 | Period | Period of time during the encounter that the participant participated | ||||
individual | SΣ | 0..1 | Reference(US Core Practitioner Profile) | Persons involved in the encounter other than the patient | ||||
appointment | Σ | 0..* | Reference(Appointment) | The appointment that scheduled this encounter | ||||
period | S | 0..1 | Period | The start and end time of the encounter | ||||
length | 0..1 | Duration | Quantity of time the encounter lasted (less time absent) | |||||
reasonCode | SΣ | 0..* | CodeableConcept | Coded reason the encounter takes place Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
reasonReference | SΣ | 0..* | Reference(De-Identified UDS Plus Diagnosis) | Reason the encounter takes place (reference) | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
diagnosis | SΣ | 0..* | BackboneElement | The list of diagnosis relevant to this encounter | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
condition | SΣ | 1..1 | Reference(De-Identified UDS Plus Diagnosis) | The diagnosis or procedure relevant to the encounter | ||||
use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents. | ||||
rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) | ||||
account | 0..* | Reference(Account) | The set of accounts that may be used for billing for this Encounter | |||||
hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
preAdmissionIdentifier | 0..1 | Identifier | Pre-admission identifier | |||||
origin | 0..1 | Reference(Location | Organization) | The location/organization from which the patient came before admission | |||||
admitSource | 0..1 | CodeableConcept | From where patient was admitted (physician referral, transfer) Binding: AdmitSource (preferred): From where the patient was admitted. | |||||
reAdmission | 0..1 | CodeableConcept | The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter. | |||||
dietPreference | 0..* | CodeableConcept | Diet preferences reported by the patient Binding: Diet (example): Medical, cultural or ethical food preferences to help with catering requirements. | |||||
specialCourtesy | 0..* | CodeableConcept | Special courtesies (VIP, board member) Binding: SpecialCourtesy (preferred): Special courtesies. | |||||
specialArrangement | 0..* | CodeableConcept | Wheelchair, translator, stretcher, etc. Binding: SpecialArrangements (preferred): Special arrangements. | |||||
destination | 0..1 | Reference(Location | Organization) | Location/organization to which the patient is discharged | |||||
dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
location | S | 0..* | BackboneElement | List of locations where the patient has been | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
location | S | 1..1 | Reference(UDS Plus Location) | Location the encounter takes place | ||||
status | 0..1 | code | planned | active | reserved | completed Binding: EncounterLocationStatus (required): The status of the location. | |||||
physicalType | 0..1 | CodeableConcept | The physical type of the location (usually the level in the location hierachy - bed room ward etc.) Binding: LocationType (example): Physical form of the location. | |||||
period | 0..1 | Period | Time period during which the patient was present at the location | |||||
serviceProvider | S | 0..1 | Reference(US Core Organization Profile) | The organization (facility) responsible for this encounter | ||||
partOf | 0..1 | Reference(Encounter) | Another Encounter this encounter is part of | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Encounter.language | preferred | CommonLanguages
| ||||
Encounter.status | required | EncounterStatus | ||||
Encounter.statusHistory.status | required | EncounterStatus | ||||
Encounter.class | extensible | ActEncounterCode | ||||
Encounter.classHistory.class | extensible | ActEncounterCode | ||||
Encounter.type | extensible | USCoreEncounterType | ||||
Encounter.serviceType | example | ServiceType | ||||
Encounter.priority | example | ActPriority | ||||
Encounter.subject.type | extensible | ResourceType | ||||
Encounter.participant.type | extensible | ParticipantType | ||||
Encounter.reasonCode | preferred | EncounterReasonCodes | ||||
Encounter.reasonReference.type | extensible | ResourceType | ||||
Encounter.diagnosis.use | preferred | DiagnosisRole | ||||
Encounter.hospitalization.admitSource | preferred | AdmitSource | ||||
Encounter.hospitalization.reAdmission | example | Hl7VSReAdmissionIndicator | ||||
Encounter.hospitalization.dietPreference | example | Diet | ||||
Encounter.hospitalization.specialCourtesy | preferred | SpecialCourtesy | ||||
Encounter.hospitalization.specialArrangement | preferred | SpecialArrangements | ||||
Encounter.hospitalization.dischargeDisposition | preferred | USCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge ) | ||||
Encounter.location.status | required | EncounterLocationStatus | ||||
Encounter.location.physicalType | example | LocationType |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Encounter | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Encounter | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Encounter | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Encounter
Summary
Mandatory: 5 elements (2 nested mandatory elements)
Must-Support: 21 elements
Prohibited: 6 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Differential View
This structure is derived from Encounter
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Encounter | 0..* | Encounter | De-Identified UDS Plus Encounter | |
uds-plus-age-extension | S | 1..1 | Quantity | Age 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 | S | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + |
class | S | 1..1 | Coding | Classification of patient encounter |
type | S | 1..* | CodeableConcept | Specific type of encounter Binding: US Core Encounter Type (extensible): The set of codes indicating the type of encounter |
text | 0..0 | |||
subject | S | 1..1 | Reference(De-Identified UDS Plus Patient) | The patient or group present at the encounter |
display | 0..0 | |||
participant | S | 0..1 | BackboneElement | List of participants involved in the encounter |
type | S | 0..* | CodeableConcept | Role of participant in encounter |
text | 0..0 | |||
period | S | 0..1 | Period | Period of time during the encounter that the participant participated |
individual | S | 0..1 | Reference(US Core Practitioner Profile) | Persons involved in the encounter other than the patient |
period | S | 0..1 | Period | The start and end time of the encounter |
reasonCode | S | 0..* | CodeableConcept | Coded reason the encounter takes place |
text | 0..0 | |||
reasonReference | S | 0..* | Reference(De-Identified UDS Plus Diagnosis) | Reason the encounter takes place (reference) |
display | 0..0 | |||
diagnosis | S | 0..* | BackboneElement | The list of diagnosis relevant to this encounter |
condition | S | 1..1 | Reference(De-Identified UDS Plus Diagnosis) | The diagnosis or procedure relevant to the encounter |
use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) |
rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) |
hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service |
dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition |
text | 0..0 | |||
location | S | 0..* | BackboneElement | List of locations where the patient has been |
location | S | 1..1 | Reference(UDS Plus Location) | Location the encounter takes place |
serviceProvider | S | 0..1 | Reference(US Core Organization Profile) | The organization (facility) responsible for this encounter |
Documentation for this format |
Path | Conformance | ValueSet |
Encounter.type | extensible | USCoreEncounterType |
Encounter.hospitalization.dischargeDisposition | preferred | USCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge ) |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Encounter | 0..* | Encounter | De-Identified UDS Plus Encounter | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
uds-plus-age-extension | S | 1..1 | Quantity | Age 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..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. |
class | SΣ | 1..1 | Coding | Classification of patient encounter Binding: ActEncounterCode (extensible): Classification of the encounter. |
type | SΣ | 1..* | CodeableConcept | Specific type of encounter Binding: US Core Encounter Type (extensible): The set of codes indicating the type of encounter |
subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | The patient or group present at the encounter |
participant | SΣ | 0..1 | BackboneElement | List of participants involved in the encounter |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type | SΣ | 0..* | CodeableConcept | Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. |
period | S | 0..1 | Period | Period of time during the encounter that the participant participated |
individual | SΣ | 0..1 | Reference(US Core Practitioner Profile) | Persons involved in the encounter other than the patient |
period | S | 0..1 | Period | The start and end time of the encounter |
reasonCode | SΣ | 0..* | CodeableConcept | Coded reason the encounter takes place Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place. |
reasonReference | SΣ | 0..* | Reference(De-Identified UDS Plus Diagnosis) | Reason the encounter takes place (reference) |
diagnosis | SΣ | 0..* | BackboneElement | The list of diagnosis relevant to this encounter |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
condition | SΣ | 1..1 | Reference(De-Identified UDS Plus Diagnosis) | The diagnosis or procedure relevant to the encounter |
use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents. |
rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) |
hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition |
location | S | 0..* | BackboneElement | List of locations where the patient has been |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
location | S | 1..1 | Reference(UDS Plus Location) | Location the encounter takes place |
serviceProvider | S | 0..1 | Reference(US Core Organization Profile) | The organization (facility) responsible for this encounter |
Documentation for this format |
Path | Conformance | ValueSet |
Encounter.status | required | EncounterStatus |
Encounter.class | extensible | ActEncounterCode |
Encounter.type | extensible | USCoreEncounterType |
Encounter.participant.type | extensible | ParticipantType |
Encounter.reasonCode | preferred | EncounterReasonCodes |
Encounter.diagnosis.use | preferred | DiagnosisRole |
Encounter.hospitalization.dischargeDisposition | preferred | USCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge ) |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Encounter | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Encounter | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Encounter | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Encounter | 0..* | Encounter | De-Identified UDS Plus Encounter | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
uds-plus-age-extension | S | 1..1 | Quantity | Age 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..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Identifier(s) by which this encounter is known | ||||
status | ?!SΣ | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. | ||||
statusHistory | 0..* | BackboneElement | List of past encounter statuses | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
status | 1..1 | code | planned | arrived | triaged | in-progress | onleave | finished | cancelled + Binding: EncounterStatus (required): Current state of the encounter. | |||||
period | 1..1 | Period | The time that the episode was in the specified status | |||||
class | SΣ | 1..1 | Coding | Classification of patient encounter Binding: ActEncounterCode (extensible): Classification of the encounter. | ||||
classHistory | 0..* | BackboneElement | List of past encounter classes | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
class | 1..1 | Coding | inpatient | outpatient | ambulatory | emergency + Binding: ActEncounterCode (extensible): Classification of the encounter. | |||||
period | 1..1 | Period | The time that the episode was in the specified class | |||||
type | SΣ | 1..* | CodeableConcept | Specific type of encounter Binding: US Core Encounter Type (extensible): The set of codes indicating the type of encounter | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
serviceType | Σ | 0..1 | CodeableConcept | Specific type of service Binding: ServiceType (example): Broad categorization of the service that is to be provided. | ||||
priority | 0..1 | CodeableConcept | Indicates the urgency of the encounter Binding: ActPriority (example): Indicates the urgency of the encounter. | |||||
subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | The patient or group present at the encounter | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
episodeOfCare | Σ | 0..* | Reference(EpisodeOfCare) | Episode(s) of care that this encounter should be recorded against | ||||
basedOn | 0..* | Reference(ServiceRequest) | The ServiceRequest that initiated this encounter | |||||
participant | SΣ | 0..1 | BackboneElement | List of participants involved in the encounter | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | SΣ | 0..* | CodeableConcept | Role of participant in encounter Binding: ParticipantType (extensible): Role of participant in encounter. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
period | S | 0..1 | Period | Period of time during the encounter that the participant participated | ||||
individual | SΣ | 0..1 | Reference(US Core Practitioner Profile) | Persons involved in the encounter other than the patient | ||||
appointment | Σ | 0..* | Reference(Appointment) | The appointment that scheduled this encounter | ||||
period | S | 0..1 | Period | The start and end time of the encounter | ||||
length | 0..1 | Duration | Quantity of time the encounter lasted (less time absent) | |||||
reasonCode | SΣ | 0..* | CodeableConcept | Coded reason the encounter takes place Binding: EncounterReasonCodes (preferred): Reason why the encounter takes place. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
reasonReference | SΣ | 0..* | Reference(De-Identified UDS Plus Diagnosis) | Reason the encounter takes place (reference) | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
diagnosis | SΣ | 0..* | BackboneElement | The list of diagnosis relevant to this encounter | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
condition | SΣ | 1..1 | Reference(De-Identified UDS Plus Diagnosis) | The diagnosis or procedure relevant to the encounter | ||||
use | S | 0..1 | CodeableConcept | Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …) Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents. | ||||
rank | S | 0..1 | positiveInt | Ranking of the diagnosis (for each role type) | ||||
account | 0..* | Reference(Account) | The set of accounts that may be used for billing for this Encounter | |||||
hospitalization | S | 0..1 | BackboneElement | Details about the admission to a healthcare service | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
preAdmissionIdentifier | 0..1 | Identifier | Pre-admission identifier | |||||
origin | 0..1 | Reference(Location | Organization) | The location/organization from which the patient came before admission | |||||
admitSource | 0..1 | CodeableConcept | From where patient was admitted (physician referral, transfer) Binding: AdmitSource (preferred): From where the patient was admitted. | |||||
reAdmission | 0..1 | CodeableConcept | The type of hospital re-admission that has occurred (if any). If the value is absent, then this is not identified as a readmission Binding: hl7VS-re-admissionIndicator (example): The reason for re-admission of this hospitalization encounter. | |||||
dietPreference | 0..* | CodeableConcept | Diet preferences reported by the patient Binding: Diet (example): Medical, cultural or ethical food preferences to help with catering requirements. | |||||
specialCourtesy | 0..* | CodeableConcept | Special courtesies (VIP, board member) Binding: SpecialCourtesy (preferred): Special courtesies. | |||||
specialArrangement | 0..* | CodeableConcept | Wheelchair, translator, stretcher, etc. Binding: SpecialArrangements (preferred): Special arrangements. | |||||
destination | 0..1 | Reference(Location | Organization) | Location/organization to which the patient is discharged | |||||
dischargeDisposition | S | 0..1 | CodeableConcept | Category or kind of location after discharge Binding: US Core Discharge Disposition (preferred): The set of codes indicating the discharge disposition | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
location | S | 0..* | BackboneElement | List of locations where the patient has been | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
location | S | 1..1 | Reference(UDS Plus Location) | Location the encounter takes place | ||||
status | 0..1 | code | planned | active | reserved | completed Binding: EncounterLocationStatus (required): The status of the location. | |||||
physicalType | 0..1 | CodeableConcept | The physical type of the location (usually the level in the location hierachy - bed room ward etc.) Binding: LocationType (example): Physical form of the location. | |||||
period | 0..1 | Period | Time period during which the patient was present at the location | |||||
serviceProvider | S | 0..1 | Reference(US Core Organization Profile) | The organization (facility) responsible for this encounter | ||||
partOf | 0..1 | Reference(Encounter) | Another Encounter this encounter is part of | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Encounter.language | preferred | CommonLanguages
| ||||
Encounter.status | required | EncounterStatus | ||||
Encounter.statusHistory.status | required | EncounterStatus | ||||
Encounter.class | extensible | ActEncounterCode | ||||
Encounter.classHistory.class | extensible | ActEncounterCode | ||||
Encounter.type | extensible | USCoreEncounterType | ||||
Encounter.serviceType | example | ServiceType | ||||
Encounter.priority | example | ActPriority | ||||
Encounter.subject.type | extensible | ResourceType | ||||
Encounter.participant.type | extensible | ParticipantType | ||||
Encounter.reasonCode | preferred | EncounterReasonCodes | ||||
Encounter.reasonReference.type | extensible | ResourceType | ||||
Encounter.diagnosis.use | preferred | DiagnosisRole | ||||
Encounter.hospitalization.admitSource | preferred | AdmitSource | ||||
Encounter.hospitalization.reAdmission | example | Hl7VSReAdmissionIndicator | ||||
Encounter.hospitalization.dietPreference | example | Diet | ||||
Encounter.hospitalization.specialCourtesy | preferred | SpecialCourtesy | ||||
Encounter.hospitalization.specialArrangement | preferred | SpecialArrangements | ||||
Encounter.hospitalization.dischargeDisposition | preferred | USCoreDischargeDisposition (a valid code from http://www.nubc.org/patient-discharge ) | ||||
Encounter.location.status | required | EncounterLocationStatus | ||||
Encounter.location.physicalType | example | LocationType |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Encounter | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Encounter | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Encounter | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Encounter | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Encounter
Summary
Mandatory: 5 elements (2 nested mandatory elements)
Must-Support: 21 elements
Prohibited: 6 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron