Encounter - FHIR v4.0.0

8.11.8 Resource Encounter - Detailed Descriptions

Patient Administration

Work Group

Maturity Level: 2

Trial Use

Security Category: Patient

Compartments: Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the Encounter resource.

Encounter
Element Id	Encounter
Definition	患者和卫生健康提供者之间的交互活动，交互目的是提供卫生健康服务或评估患者的健康状况。
Cardinality	0..*
Type	DomainResource
Alternate Names	Visit
Encounter.identifier
Element Id	Encounter.identifier
Definition	本次医疗活动的标志符
Note	这是业务id，并不是资源的标识符 (参见讨论)
Cardinality	0..*
Type	Identifier
Summary	true
Encounter.status
Element Id	Encounter.status
Definition	planned \| arrived \| triaged \| in-progress \| onleave \| finished \| cancelled +.
Cardinality	1..1
Terminology Binding	EncounterStatus (Required)
Type	code
Is Modifier	true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summary	true
Comments	Note that internal business rules will determine the appropriate transitions that may occur between statuses (and also classes).
Encounter.statusHistory
Element Id	Encounter.statusHistory
Definition	状态历史记录了此医疗活动在不同时间段所处的不同状态。
Cardinality	0..*
Comments	当前状态始终位于Encounter.status中，不会在状态历史中记录。
Encounter.statusHistory.status
Element Id	Encounter.statusHistory.status
Definition	planned \| arrived \| triaged \| in-progress \| onleave \| finished \| cancelled +.
Cardinality	1..1
Terminology Binding	EncounterStatus (Required)
Type	code
Encounter.statusHistory.period
Element Id	Encounter.statusHistory.period
Definition	处于此状态的时间段。
Cardinality	1..1
Type	Period
Encounter.class
Element Id	Encounter.class
Definition	患者医疗活动的分类，如门诊、住院、急诊、家庭医疗或其他医疗活动。
Cardinality	1..1
Terminology Binding	V3 Value SetActEncounterCode (Extensible)
Type	Coding
Summary	true
Encounter.classHistory
Element Id	Encounter.classHistory
Definition	就诊类别历史记录可以在不遍历资源历史记录的情况下跟踪医疗就诊活动类别的变化。这将用于这样一种情况：刚开始是急诊，然后通过急诊入院转为住院。用这种方式记录而不是新建一次医疗就诊活动的好处在于此患者的所有检验检查的诊断结果都可以更容易的获取，因为不会在急诊出院又重新入院的过程中造成数据的无法关联，也不需要通过患者索引来重新处理数据。
Cardinality	0..*
Encounter.classHistory.class
Element Id	Encounter.classHistory.class
Definition	inpatient \| outpatient \| ambulatory \| emergency +.
Cardinality	1..1
Terminology Binding	V3 Value SetActEncounterCode (Extensible)
Type	Coding
Encounter.classHistory.period
Element Id	Encounter.classHistory.period
Definition	The time that the episode was in the specified class.
Cardinality	1..1
Type	Period
Encounter.type
Element Id	Encounter.type
Definition	医疗活动的具体类型。例如：电子邮件咨询、外科手术、家庭护理、产后康复。
Cardinality	0..*
Terminology Binding	Encounter type (Example)
Type	CodeableConcept
Summary	true
Comments	Since there are many ways to further classify encounters, this element is 0..*.
Encounter.serviceType
Element Id	Encounter.serviceType
Definition	所提供服务的广义分类，如心脏病学。
Cardinality	0..1
Terminology Binding	Service type (Example)
Type	CodeableConcept
Summary	true
Encounter.priority
Element Id	Encounter.priority
Definition	表示医疗就诊活动的紧迫性
Cardinality	0..1
Terminology Binding	v3 Code System ActPriority (Example)
Type	CodeableConcept
Encounter.subject
Element Id	Encounter.subject
Definition	此医疗活动的服务对象：患者或群体。
Cardinality	0..1
Type	Reference(Patient \| Group)
Alternate Names	patient
Summary	true
Comments	虽然医疗就诊的服务对象总是患者，但在某些场境中，可能并知道患者的真实身份，可能存在一组匿名患者，例如在匿名戒酒者团体治疗中——在这种情况下，医疗就诊的记录可用于对人数/工作人员进行计费，而不并不关注病人的具体信息。在兽医治疗的场景中，服务对象可能是接受治疗的一群羊（在这种情况下,不会单个动物进行追踪）。
Encounter.episodeOfCare
Element Id	Encounter.episodeOfCare
Definition	当医疗就诊活动事件应被归类为某些治疗/照护期的一部分时，应使用此字段。这种关联可以方便地将相关医疗就诊活动按目的进行分组，例如上报数据、问题追踪、常见问题相关性。因为治疗/照护期可能很长（跨越数年），在其结束之前通常不会先创建治疗/照护期资源并通过编辑更新逐步附加相关医疗就诊资源，而是在其结束后创建并按条目分组。所以，为了方便后期创建治疗/照护期资源时获取相关信息，当这种关联信息产生时就先记录在医疗就诊资源里。
Cardinality	0..*
Type	Reference(EpisodeOfCare)
Summary	true
Encounter.basedOn
Element Id	Encounter.basedOn
Definition	此医疗就诊资源是基于哪些申请产生的（例如转入申请或手术申请）。
Cardinality	0..*
Type	Reference(ServiceRequest)
Alternate Names	incomingReferral
Encounter.participant
Element Id	Encounter.participant
Definition	负责提供服务的人员名单。
Cardinality	0..*
Summary	true
Encounter.participant.type
Element Id	Encounter.participant.type
Definition	从业者在本次医疗活动中充当的角色
Cardinality	0..*
Terminology Binding	Participant type (Extensible)
Type	CodeableConcept
Summary	true
Comments	从业者类型说明了医务人员或其它人员如何参与医疗活动的。对于医务人员，描述的是本次医疗活动具体场景下的活动类型（例如，住院医师、主治医师、转诊办理员、咨询师）。它与从业者角色（PractitionerRole）不同，从业者角色是功能性角色，是通过受聘情况、教育背景、执业证等来确定的。
Encounter.participant.period
Element Id	Encounter.participant.period
Definition	The period of time that the specified participant participated in the encounter. These can overlap or be sub-sets of the overall encounter's period.
Cardinality	0..1
Type	Period
Encounter.participant.individual
Element Id	Encounter.participant.individual
Definition	除了病人之外的其他参与人。
Cardinality	0..1
Type	Reference(Practitioner \| PractitionerRole \| RelatedPerson)
Summary	true
Encounter.appointment
Element Id	Encounter.appointment
Definition	安排这次医疗就诊的预约
Cardinality	0..*
Type	Reference(Appointment)
Summary	true
Encounter.period
Element Id	Encounter.period
Definition	此就诊活动的起止时间
Cardinality	0..1
Type	Period
Comments	如果活动尚未结束且不可预知，截止时间可以省略。
Encounter.length
Element Id	Encounter.length
Definition	此就诊活动持续的时间长度。应减去其离院期间的时长。
Cardinality	0..1
Type	Duration
Comments	由于临时离院等因素，可能与Encounter.period的时间跨度的时长不同。
Encounter.reasonCode
Element Id	Encounter.reasonCode
Definition	医疗就诊活动发生的原因，用代码表示。对于入院，这可填写入院诊断编码。
Cardinality	0..*
Terminology Binding	Encounter Reason Codes (Preferred)
Type	CodeableConcept
Alternate Names	Indication; Admission diagnosis
Summary	true
Comments	若要区分主要诊断，需使用标准扩展“主要诊断”（primaryDiagnosis）进行标记，这是一个带顺序的值，第一个值代表主要诊断。不能用一个标志来表示（如：1=主要诊断）
Encounter.reasonReference
Element Id	Encounter.reasonReference
Definition	#以下官方错误# Reason the encounter takes place, expressed as a code. For admissions, this can be used for a coded admission diagnosis.
Cardinality	0..*
Type	Reference(Condition \| Procedure \| Observation \| ImmunizationRecommendation)
Alternate Names	Indication; Admission diagnosis
Summary	true
Comments	For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).
Encounter.diagnosis
Element Id	Encounter.diagnosis
Definition	与此医疗就诊相关的所有诊断
Cardinality	0..*
Summary	true
Encounter.diagnosis.condition
Element Id	Encounter.diagnosis.condition
Definition	使用其他资源的信息来说明就诊活动发生的原因。对于入院，通常用一个Condition资源（其相关资源由Condition.evidence.detail引用）来表示入院诊断。 Reason the encounter takes place, as specified using information from another resource. For admissions, this is the admission diagnosis. The indication will typically be a Condition (with other resources referenced in the evidence.detail), or a Procedure.
Cardinality	1..1
Type	Reference(Condition \| Procedure)
Alternate Names	Admission diagnosis; discharge diagnosis; indication
Summary	true
Comments	For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).
Encounter.diagnosis.use
Element Id	Encounter.diagnosis.use
Definition	Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …).
Cardinality	0..1
Terminology Binding	DiagnosisRole (Preferred)
Type	CodeableConcept
Encounter.diagnosis.rank
Element Id	Encounter.diagnosis.rank
Definition	Ranking of the diagnosis (for each role type).
Cardinality	0..1
Type	positiveInt
Encounter.account
Element Id	Encounter.account
Definition	可用于对为此就诊活动进行支付与结算的一组帐户
Cardinality	0..*
Type	Reference(Account)
Comments	计费系统可根据内部业务规则将与此就诊活动相关联的收费项目分配给不同的引用帐户。
Encounter.hospitalization
Element Id	Encounter.hospitalization
Definition	医疗服务详情 Details about the admission to a healthcare service.
Cardinality	0..1
Comments	医疗就诊活动可能不仅仅包括住院治疗。还包括门诊、社区门诊和老年照护机构等。本次住院记录需覆盖的此期间的全部范围。
Encounter.hospitalization.preAdmissionIdentifier
Element Id	Encounter.hospitalization.preAdmissionIdentifier
Definition	预入院标识符。
Cardinality	0..1
Type	Identifier
Encounter.hospitalization.origin
Element Id	Encounter.hospitalization.origin
Definition	患者入院前所在的地点或机构。
Cardinality	0..1
Type	Reference(Location \| Organization)
Encounter.hospitalization.admitSource
Element Id	Encounter.hospitalization.admitSource
Definition	患者入院途径（医生转诊、转院）
Cardinality	0..1
Terminology Binding	Admit source (Preferred)
Type	CodeableConcept
Encounter.hospitalization.reAdmission
Element Id	Encounter.hospitalization.reAdmission
Definition	是否属于非计划再入院，以及再入院的原因。
Cardinality	0..1
Terminology Binding	v2 RE-ADMISSION INDICATOR (Example)
Type	CodeableConcept
Encounter.hospitalization.dietPreference
Element Id	Encounter.hospitalization.dietPreference
Definition	患者报告的饮食偏好
Cardinality	0..*
Terminology Binding	Diet (Example)
Type	CodeableConcept
Requirements	用于跟踪患者的饮食禁忌或偏好。若要完整描述患者在住院期间的营养需求，应使用一个指向此医疗就诊活动的营养处方资源。
Comments	例如，患者可以同时提出不吃无乳制品和不吃坚果的饮食要求（不相互排斥）。
Encounter.hospitalization.specialCourtesy
Element Id	Encounter.hospitalization.specialCourtesy
Definition	特别礼遇（贵宾、董事会成员）。
Cardinality	0..*
Terminology Binding	Special courtesy (Preferred)
Type	CodeableConcept
Encounter.hospitalization.specialArrangement
Element Id	Encounter.hospitalization.specialArrangement
Definition	本次住院治疗中提出的所有特殊要求，如提供特定设备或其他物品。
Cardinality	0..*
Terminology Binding	Special arrangements (Preferred)
Type	CodeableConcept
Encounter.hospitalization.destination
Element Id	Encounter.hospitalization.destination
Definition	患者出院到哪里（地点、机构）
Cardinality	0..1
Type	Reference(Location \| Organization)
Encounter.hospitalization.dischargeDisposition
Element Id	Encounter.hospitalization.dischargeDisposition
Definition	患者出院后所处地点的类别
Cardinality	0..1
Terminology Binding	Discharge disposition (Example)
Type	CodeableConcept
Encounter.location
Element Id	Encounter.location
Definition	患者在此就诊期间去过哪些位置。
Cardinality	0..*
Comments
Encounter.location.location
Element Id	Encounter.location.location
Definition	此医疗就诊活动的发生地点
Cardinality	1..1
Type	Reference(Location)
Encounter.location.status
Element Id	Encounter.location.status
Definition	在某时段内患者在此地点的状态：已预定、已在位、预留中、已完成（planned \| active \| reserved \| completed）。
Cardinality	0..1
Terminology Binding	EncounterLocationStatus (Required)
Type	code
Comments	如果患者不再在该位置，则Encounter.location.period应填写结束日期/时间。，状态可能更改为“completed”。
Encounter.location.physicalType
Element Id	Encounter.location.physicalType
Definition	用于指定记录位置的级别（病床/病区/病房等），以简化消息传递或查询。
Cardinality	0..1
Terminology Binding	Location type (Example)
Type	CodeableConcept
Comments	此信息可以重新指定位置资源中的物理类型（Location.physicalType），以便在消息传递或查询中更容易理解和处理医疗就诊资源。可能会有层级式的多个级别，也可能只是特定使用场景所需的某些级别。
Encounter.location.period
Element Id	Encounter.location.period
Definition	患者在此位置的时间段。
Cardinality	0..1
Type	Period
Encounter.serviceProvider
Element Id	Encounter.serviceProvider
Definition	对本次就诊服务负主要责任的组织单位，这与患者记录上的医疗机构可能相同，但也可能不同，例如，参与者来自外部组织，并且提供的是单独收费的额外服务。
Cardinality	0..1
Type	Reference(Organization)
Encounter.partOf
Element Id	Encounter.partOf
Definition	另一个医疗活动，此医疗是其中的一部分（在管理上或时间上）。
Cardinality	0..1
Type	Reference(Encounter)
Hierarchy	此引用是严格层级结构中的一部分
Comments	可用于关联新生儿医疗就诊资源与产妇医疗就诊资源。详细信息请参阅“患者资源”中的官方说明。