Australian Digital Health Agency FHIR Implementation Guide 1.0.0

Australian Digital Health Agency FHIR Implementation Guide. This is the current published version. It is based on FHIR® version 4.0.1. See the Directory of published versions for a list of available versions.

StructureDefinition: ADHA Core Encounter [Active]

The purpose of this profile is to provide a core representation of an encounter for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile identifies the additional constraints, extensions, and value sets that build on and extend Encounter that are supported.

This profile is designed to set a core Encounter standard for:

  • Query for a patient’s encounters
  • Query for records associated with a specific patient encounter
  • Record or update an encounter and records associated with an encounter

Profile specific guidance

  • Encounter.type supports categorisation and provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
  • In an exchange with the My Health Record system Encounter.status is “finished”.
  • The Encounter resource can represent a reason using either a code with Encounter.reasonCode, or a reference with Encounter.reasonReference to a Condition or other resource.
    • Although both are marked as must support, sending systems are not required to support both a code and a reference, but they SHALL support at least one of these elements.
    • A receiving or persisting system SHALL support both elements.

Boundaries and relationships

This profile is referenced by ADHA Core Condition, ADHA Core DocumentReference, ADHA Australian Immunisation Register Notice, ADHA Core Flag, ADHA Record of Immunisation from Australian Immunisation Register, ADHA Core Immunization, ADHA Core MedicationRequest, ADHA Core Observation, and ADHA Core Procedure.

Formal Views of Profile Content

The official URL for this profile is: 

http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-encounter-core-1

The purpose of this profile is to provide a core representation of an encounter for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile builds on AUBaseEncounter.

This profile was published on 2023-04-14 04:02:01+0000 as a active by Australian Digital Health Agency.

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C0..*AUBaseEncounterAn encounter in an Australian healthcare context
inv-dh-enc-04: If present, the service provider shall at least have a reference or display or a valid identifier
... extension:encounterDescription S0..1EncounterDescriptionDescription, overview or summary of an encounter
... status S1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
... class S1..1CodingClassification of patient encounter
... type S0..*CodeableConceptSpecific type of encounter
Binding: https://healthterminologies.gov.au/fhir/ValueSet/encounter-type-1 (preferred)
... serviceType S0..1CodeableConceptSpecific type of service
Binding: https://healthterminologies.gov.au/fhir/ValueSet/service-type-1 (preferred)
... subject SC1..1Reference(ADHA Core Patient)The patient or group present at the encounter
inv-dh-enc-01: At least reference or a valid identifier shall be present
... participant SC1..*BackboneElementList of participants involved in the encounter
inv-dh-enc-02: If present, an individual shall at least have a reference, an identifier or a display
.... type S0..*CodeableConceptRole of participant in encounter
.... individual SC0..1Reference(ADHA Core PractitionerRole | ADHA Core RelatedPerson)Persons involved in the encounter other than the patient
... period S1..1PeriodThe start and end time of the encounter
... reasonCode S0..*CodeableConceptCoded reason the encounter takes place
... reasonReference[x] S0..*Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure)Reason the encounter takes place (reference)
... hospitalization S0..1BackboneElementDetails about the admission to a healthcare service
.... dischargeDisposition S0..1CodeableConceptSeparation Mode
... location SC0..*BackboneElementList of locations where the patient has been
inv-dh-enc-03: If present, location shall at least have a reference or display or a valid identifier
.... location SC1..1Reference(ADHA Core Location)Location the encounter takes place
... serviceProvider SC0..1Reference(ADHA Core Organization)The organization (facility) responsible for this encounter

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C0..*AUBaseEncounterAn encounter in an Australian healthcare context
inv-dh-enc-04: If present, the service provider shall at least have a reference or display or a valid identifier
... 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 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... encounterDescription S0..1stringDescription, overview or summary of an encounter
URL: http://hl7.org.au/fhir/StructureDefinition/encounter-description
... associatedHealthcareService 0..*Reference(HealthcareService)Associated healthcare service
URL: http://hl7.org.au/fhir/StructureDefinition/associated-healthcareservice
... 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 - AU Extended (extensible)
... 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 SΣ0..*CodeableConceptSpecific type of encounter
Binding: https://healthterminologies.gov.au/fhir/ValueSet/encounter-type-1 (preferred)
... serviceType SΣ0..1CodeableConceptSpecific type of service
Binding: https://healthterminologies.gov.au/fhir/ValueSet/service-type-1 (preferred)
... priority 0..1CodeableConceptIndicates the urgency of the encounter
Binding: ActPriority (example): Indicates the urgency of the encounter.

... subject SΣC1..1Reference(ADHA Core Patient)The patient or group present at the encounter
inv-dh-enc-01: At least reference or a valid identifier shall be present
... 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 SΣC1..*BackboneElementList of participants involved in the encounter
inv-dh-enc-02: If present, an individual shall at least have a reference, an identifier or a display
.... 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.


.... period 0..1PeriodPeriod of time during the encounter that the participant participated
.... individual SΣC0..1Reference(ADHA Core PractitionerRole | ADHA Core RelatedPerson)Persons involved in the encounter other than the patient
... appointment Σ0..*Reference(Appointment)The appointment that scheduled this encounter
... period S1..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.


... reasonReference SΣ0..*Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure)Reason the encounter takes place (reference)
... diagnosis Σ0..*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 Σ1..1Reference(Condition | Procedure)The diagnosis or procedure relevant to the encounter
.... use 0..1CodeableConceptRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

.... rank 0..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..1CodeableConceptSeparation Mode
Binding: https://healthterminologies.gov.au/fhir/ValueSet/separation-mode-1 (extensible)
... location SC0..*BackboneElementList of locations where the patient has been
inv-dh-enc-03: If present, location shall at least have a reference or display or a valid identifier
.... 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 SC1..1Reference(ADHA Core 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 SC0..1Reference(ADHA Core Organization)The organization (facility) responsible for this encounter
... partOf 0..1Reference(Encounter)Another Encounter this encounter is part of

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C0..*AUBaseEncounterAn encounter in an Australian healthcare context
inv-dh-enc-04: If present, the service provider shall at least have a reference or display or a valid identifier
... extension:encounterDescription S0..1EncounterDescriptionDescription, overview or summary of an encounter
... status S1..1codeplanned | arrived | triaged | in-progress | onleave | finished | cancelled +
... class S1..1CodingClassification of patient encounter
... type S0..*CodeableConceptSpecific type of encounter
Binding: https://healthterminologies.gov.au/fhir/ValueSet/encounter-type-1 (preferred)
... serviceType S0..1CodeableConceptSpecific type of service
Binding: https://healthterminologies.gov.au/fhir/ValueSet/service-type-1 (preferred)
... subject SC1..1Reference(ADHA Core Patient)The patient or group present at the encounter
inv-dh-enc-01: At least reference or a valid identifier shall be present
... participant SC1..*BackboneElementList of participants involved in the encounter
inv-dh-enc-02: If present, an individual shall at least have a reference, an identifier or a display
.... type S0..*CodeableConceptRole of participant in encounter
.... individual SC0..1Reference(ADHA Core PractitionerRole | ADHA Core RelatedPerson)Persons involved in the encounter other than the patient
... period S1..1PeriodThe start and end time of the encounter
... reasonCode S0..*CodeableConceptCoded reason the encounter takes place
... reasonReference[x] S0..*Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure)Reason the encounter takes place (reference)
... hospitalization S0..1BackboneElementDetails about the admission to a healthcare service
.... dischargeDisposition S0..1CodeableConceptSeparation Mode
... location SC0..*BackboneElementList of locations where the patient has been
inv-dh-enc-03: If present, location shall at least have a reference or display or a valid identifier
.... location SC1..1Reference(ADHA Core Location)Location the encounter takes place
... serviceProvider SC0..1Reference(ADHA Core Organization)The organization (facility) responsible for this encounter

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Encounter C0..*AUBaseEncounterAn encounter in an Australian healthcare context
inv-dh-enc-04: If present, the service provider shall at least have a reference or display or a valid identifier
... 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 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... encounterDescription S0..1stringDescription, overview or summary of an encounter
URL: http://hl7.org.au/fhir/StructureDefinition/encounter-description
... associatedHealthcareService 0..*Reference(HealthcareService)Associated healthcare service
URL: http://hl7.org.au/fhir/StructureDefinition/associated-healthcareservice
... 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 - AU Extended (extensible)
... 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 SΣ0..*CodeableConceptSpecific type of encounter
Binding: https://healthterminologies.gov.au/fhir/ValueSet/encounter-type-1 (preferred)
... serviceType SΣ0..1CodeableConceptSpecific type of service
Binding: https://healthterminologies.gov.au/fhir/ValueSet/service-type-1 (preferred)
... priority 0..1CodeableConceptIndicates the urgency of the encounter
Binding: ActPriority (example): Indicates the urgency of the encounter.

... subject SΣC1..1Reference(ADHA Core Patient)The patient or group present at the encounter
inv-dh-enc-01: At least reference or a valid identifier shall be present
... 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 SΣC1..*BackboneElementList of participants involved in the encounter
inv-dh-enc-02: If present, an individual shall at least have a reference, an identifier or a display
.... 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.


.... period 0..1PeriodPeriod of time during the encounter that the participant participated
.... individual SΣC0..1Reference(ADHA Core PractitionerRole | ADHA Core RelatedPerson)Persons involved in the encounter other than the patient
... appointment Σ0..*Reference(Appointment)The appointment that scheduled this encounter
... period S1..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.


... reasonReference SΣ0..*Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure)Reason the encounter takes place (reference)
... diagnosis Σ0..*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 Σ1..1Reference(Condition | Procedure)The diagnosis or procedure relevant to the encounter
.... use 0..1CodeableConceptRole that this diagnosis has within the encounter (e.g. admission, billing, discharge …)
Binding: DiagnosisRole (preferred): The type of diagnosis this condition represents.

.... rank 0..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..1CodeableConceptSeparation Mode
Binding: https://healthterminologies.gov.au/fhir/ValueSet/separation-mode-1 (extensible)
... location SC0..*BackboneElementList of locations where the patient has been
inv-dh-enc-03: If present, location shall at least have a reference or display or a valid identifier
.... 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 SC1..1Reference(ADHA Core 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 SC0..1Reference(ADHA Core Organization)The organization (facility) responsible for this encounter
... partOf 0..1Reference(Encounter)Another Encounter this encounter is part of

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

Terminology Bindings

PathConformanceValueSet
Encounter.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Encounter.statusrequiredEncounterStatus
Encounter.statusHistory.statusrequiredEncounterStatus
Encounter.classextensibleActEncounterCodeAUExtended
Encounter.classHistory.classextensibleActEncounterCode
Encounter.typepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/encounter-type-1
Encounter.serviceTypepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/service-type-1
Encounter.priorityexampleActPriority
Encounter.participant.typeextensibleParticipantType
Encounter.reasonCodepreferredEncounterReasonCodes
Encounter.diagnosis.usepreferredDiagnosisRole
Encounter.hospitalization.admitSourcepreferredAdmitSource
Encounter.hospitalization.reAdmissionexampleHl7VSReAdmissionIndicator
Encounter.hospitalization.dietPreferenceexampleDiet
Encounter.hospitalization.specialCourtesypreferredSpecialCourtesy
Encounter.hospitalization.specialArrangementpreferredSpecialArrangements
Encounter.hospitalization.dischargeDispositionextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/separation-mode-1
Encounter.location.statusrequiredEncounterLocationStatus
Encounter.location.physicalTypeexampleLocationType

Search Parameters

None defined.