FHIR R4
Patient Administration Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the Encounter resource.

Encounter
Element IdEncounter
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。
Cardinality0..*
TypeDomainResource
Alternate NamesVisit
Encounter.identifier
Element IdEncounter.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)
Cardinality0..*
TypeIdentifier
Summarytrue
Encounter.status
Element IdEncounter.status
Definition

planned | arrived | triaged | in-progress | onleave | finished | cancelled +.

Cardinality1..1
Terminology BindingEncounterStatus (Required)
Typecode
Is Modifiertrue (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)
Summarytrue
Comments

Note that internal business rules will determine the appropriate transitions that may occur between statuses (and also classes).

Encounter.statusHistory
Element IdEncounter.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。
Cardinality0..*
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 IdEncounter.statusHistory.status
Definition

planned | arrived | triaged | in-progress | onleave | finished | cancelled +.

Cardinality1..1
Terminology BindingEncounterStatus (Required)
Typecode
Encounter.statusHistory.period
Element IdEncounter.statusHistory.period
Definition 处于此状态的时间段。
Cardinality1..1
TypePeriod
Encounter.class
Element IdEncounter.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。
Cardinality1..1
Terminology BindingV3 Value SetActEncounterCode (Extensible)
TypeCoding
Summarytrue
Encounter.classHistory
Element IdEncounter.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。
Cardinality0..*
Encounter.classHistory.class
Element IdEncounter.classHistory.class
Definition

inpatient | outpatient | ambulatory | emergency +.

Cardinality1..1
Terminology BindingV3 Value SetActEncounterCode (Extensible)
TypeCoding
Encounter.classHistory.period
Element IdEncounter.classHistory.period
Definition

The time that the episode was in the specified class.

Cardinality1..1
TypePeriod
Encounter.type
Element IdEncounter.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。
Cardinality0..*
Terminology BindingEncounter type (Example)
TypeCodeableConcept
Summarytrue
Comments

Since there are many ways to further classify encounters, this element is 0..*.

Encounter.serviceType
Element IdEncounter.serviceType
Definition 所提供服务的广义分类,如心脏病学。
Cardinality0..1
Terminology BindingService type (Example)
TypeCodeableConcept
Summarytrue
Encounter.priority
Element IdEncounter.priority
Definition表示医疗就诊活动的紧迫性
Cardinality0..1
Terminology Bindingv3 Code System ActPriority (Example)
TypeCodeableConcept
Encounter.subject
Element IdEncounter.subject
Definition 此医疗活动的服务对象:患者或群体。
Cardinality0..1
TypeReference(Patient | Group)
Alternate Namespatient
Summarytrue
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 IdEncounter.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。
Cardinality0..*
TypeReference(EpisodeOfCare)
Summarytrue
Encounter.basedOn
Element IdEncounter.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)。
Cardinality0..*
TypeReference(ServiceRequest)
Alternate NamesincomingReferral
Encounter.participant
Element IdEncounter.participant
Definition 负责提供服务的人员名单。
Cardinality0..*
Summarytrue
Encounter.participant.type
Element IdEncounter.participant.type
Definition

从业者在本次医疗活动中充当的角色

Cardinality0..*
Terminology BindingParticipant type (Extensible)
TypeCodeableConcept
Summarytrue
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 IdEncounter.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.

Cardinality0..1
TypePeriod
Encounter.participant.individual
Element IdEncounter.participant.individual
Definition 除了病人之外的其他参与人。
Cardinality0..1
TypeReference(Practitioner | PractitionerRole | RelatedPerson)
Summarytrue
Encounter.appointment
Element IdEncounter.appointment
Definition 安排这次医疗就诊的预约
Cardinality0..*
TypeReference(Appointment)
Summarytrue
Encounter.period
Element IdEncounter.period
Definition 此就诊活动的起止时间
Cardinality0..1
TypePeriod
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 IdEncounter.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。
Cardinality0..1
TypeDuration
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 IdEncounter.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。
Cardinality0..*
Terminology BindingEncounter Reason Codes (Preferred)
TypeCodeableConcept
Alternate NamesIndication; Admission diagnosis
Summarytrue
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 IdEncounter.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.

Cardinality0..*
TypeReference(Condition | Procedure | Observation | ImmunizationRecommendation)
Alternate NamesIndication; Admission diagnosis
Summarytrue
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 IdEncounter.diagnosis
Definition 与此医疗就诊相关的所有诊断
Cardinality0..*
Summarytrue
Encounter.diagnosis.condition
Element IdEncounter.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.

Cardinality1..1
TypeReference(Condition | Procedure)
Alternate NamesAdmission diagnosis; discharge diagnosis; indication
Summarytrue
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 IdEncounter.diagnosis.use
Definition

Role that this diagnosis has within the encounter (e.g. admission, billing, discharge …).

Cardinality0..1
Terminology BindingDiagnosisRole (Preferred)
TypeCodeableConcept
Encounter.diagnosis.rank
Element IdEncounter.diagnosis.rank
Definition

Ranking of the diagnosis (for each role type).

Cardinality0..1
TypepositiveInt
Encounter.account
Element IdEncounter.account
Definition 可用于对为此就诊活动进行支付与结算的一组帐户
Cardinality0..*
TypeReference(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 IdEncounter.hospitalization
Definition 医疗服务详情

Details about the admission to a healthcare service.

Cardinality0..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 IdEncounter.hospitalization.preAdmissionIdentifier
Definition 预入院标识符。
Cardinality0..1
TypeIdentifier
Encounter.hospitalization.origin
Element IdEncounter.hospitalization.origin
Definition患者入院前所在的地点或机构。
Cardinality0..1
TypeReference(Location | Organization)
Encounter.hospitalization.admitSource
Element IdEncounter.hospitalization.admitSource
Definition 患者入院途径(医生转诊、转院)
Cardinality0..1
Terminology BindingAdmit source (Preferred)
TypeCodeableConcept
Encounter.hospitalization.reAdmission
Element IdEncounter.hospitalization.reAdmission
Definition 是否属于非计划再入院,以及再入院的原因。
Cardinality0..1
Terminology Bindingv2 RE-ADMISSION INDICATOR (Example)
TypeCodeableConcept
Encounter.hospitalization.dietPreference
Element IdEncounter.hospitalization.dietPreference
Definition 患者报告的饮食偏好
Cardinality0..*
Terminology BindingDiet (Example)
TypeCodeableConcept
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 IdEncounter.hospitalization.specialCourtesy
Definition特别礼遇(贵宾、董事会成员)。
Cardinality0..*
Terminology BindingSpecial courtesy (Preferred)
TypeCodeableConcept
Encounter.hospitalization.specialArrangement
Element IdEncounter.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。
Cardinality0..*
Terminology BindingSpecial arrangements (Preferred)
TypeCodeableConcept
Encounter.hospitalization.destination
Element IdEncounter.hospitalization.destination
Definition 患者出院到哪里(地点、机构)
Cardinality0..1
TypeReference(Location | Organization)
Encounter.hospitalization.dischargeDisposition
Element IdEncounter.hospitalization.dischargeDisposition
Definition 患者出院后所处地点的类别
Cardinality0..1
Terminology BindingDischarge disposition (Example)
TypeCodeableConcept
Encounter.location
Element IdEncounter.location
Definition 患者在此就诊期间去过哪些位置。
Cardinality0..*
Comments
Encounter.location.location
Element IdEncounter.location.location
Definition 此医疗就诊活动的发生地点
Cardinality1..1
TypeReference(Location)
Encounter.location.status
Element IdEncounter.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)。
Cardinality0..1
Terminology BindingEncounterLocationStatus (Required)
Typecode
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 IdEncounter.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。
Cardinality0..1
Terminology BindingLocation type (Example)
TypeCodeableConcept
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 IdEncounter.location.period
Definition 患者在此位置的时间段。
Cardinality0..1
TypePeriod
Encounter.serviceProvider
Element IdEncounter.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。
Cardinality0..1
TypeReference(Organization)
Encounter.partOf
Element IdEncounter.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)。
Cardinality0..1
TypeReference(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。