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Encounter

Reference:2.2.2.16
Definition:Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.15 for constraints applicable to these data elements. The encounter entry contains data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and e-mail communication.
OID:2.16.840.1.113883.3.88.11.83.16
CDA Data Location HITSP Data Element Identifier and Name O/R Additional Specification
cda:encounter[cda:templateId/@root = '2.16.840.1.113883.10.20.1.21'] Encounter Event Entry See Below24 2.2.2.16.1
cda:id 16.01 - Encounter ID R/Y
cda:code/@code 16.02 - Encounter Type R2/N 2.2.2.16.2
cda:code/cda:originalText/cda:reference/@value 16.03 - Encounter Free Text Type R/N
cda:effectiveTime 16.04 - Encounter Date / Time R/N
sdtc:dischargeDispositionCode 16.09 - Discharge Disposition O/N
cda:priorityCode 16.07 - Admission Type O/N 2.2.2.16.3
cda:performer/cda:assignedEntity 16.05 - Encounter Provider R2/Y
cda:participant[@typeCode='ORG']/cda:code 16.06 - Admission Source O/N 2.2.2.16.4
cda:participant[@typeCode='LOC'] 16.11 - Facility Location O/N
cda:time 16.20 - In facility Location Duration O/N
cda:low 16.12 - Arrival Date / Time O/N
cda:high Departure Date / Time
cda:entryRelationship[@typeCode='RSON'] 16.13 - Reason for Visit O/N
cda:participant[@typeCode='REF'] Referrer O/N
cda:time 16.14 - Order to Admit O/N 2.2.2.16.7
/cda:ClinicalDocument/cda:componentOf/ cda:encompassingEncounter
cda:code/@code 16.10 - Patient Class O/N 2.2.2.16.5
cda:dischargeDispositionCode 16.09 - Discharge Disposition O/N
cda:location/cda:healthCareFacility Healthcare Facility
cda:code/@code Healthcare Facility Location Type
cda:location Healthcare Facility Location Detail
cda:id 16.17 Facility ID O/N
cda:addr 16.19 Facility Address O/N 2.2.2.16.6
cda:name 16.20 Facility Name O/N

Optionality Legend: “R” for Required, “R2” for Required if known, “O” for Optional and Repeat = “Y” for Yes or “N” for No

Encounter Example

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<text><ID
<encounter classCode='ENC' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.21'/>
<templateId root='2.16.840.1.113883.3.88.11.83.16'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.14'
<code code='...' displayName='...' codeSystem='...' codeSystemName='...'> />
<originalText><reference value='#encounter-1'/></originalText>
</code>
<effectiveTime>
<low value='20070610'/>
</effectiveTime>
<performer typeCode='PRF'>
<assignedEntity classCode='ASSIGNED'>
<id .../>
<addr>...</addr>
<telecom>...</telecom>
<assignedPerson>
<name>...</name>
</assignedPerson>
<representedOrganization>
<name>...</name>
</representedOrganization>
</assignedEntity>
</performer>
</encounter>

Section ID Constraint ID Definition
2.2.2.16.1 Encounters Module Constraints Note: Each clinical document describes services performed in an encompassing encounter. This encounter may also be documented in the CDA header in the /cda:ClinicalDocument/cda:componentOf/cda:encompassingEncounter element.
C83-[DE-16-CDA-1] Encounter entries other than the encompassingEncounter SHALL declare conformance for the Encounters module by including a <templateID> element with the root set to the value 2.16.840.1.113883.3.88.11.83.16
C83-[DE-16-CDA-2] Encounter entries other than the encompassingEncounter SHALL declare conformance to the IHE Encounter entry by including a attribute <templateID> element with the root attribute set to the value 1.3.6.1.4.1.19376.1.5.3.1.4.14
2.2.2.16.2 Encounter Type Constraints Encounter Type should be sent when available, and should be coded to the specified value set when possible. If the selected value set is not available but other coded values are, the desire is that these other coded values be sent.
C83-[DE-16.02-1] Encounter Type SHOULD be coded as specified in HITSP/C80 Section 2.2.3.9.3 Encounter Type.
2.2.2.16.3 Admission Type Constraints Not Provided
C154-[DE-16.07-1] Admission Type SHALL be coded as specified in HITSP/C80 Section 2.2.3.9.2 Admission Type.
2.2.2.16.4 Admission Source Constraints Not Provided
C154-[DE-16.06-1] Admission Source SHALL be coded as specified in HITSP/C80 Section 2.2.3.9.1 Admission Source.
2.2.2.16.5 Patient Class Constraints Not Provided
C154-[DE-16.10-1] Patient Class SHALL be coded as specified in HITSP/C80 Section 2.2.3.9.5 Patient Class.
2.2.2.16.6 Facility Address Constraints Not Provided
C154-[DE-16.19-1] The state part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State
C154-[DE-16.19-2] The postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code
C154-[DE-16.19-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
2.2.2.16.7 Order to Admit The order to admit time reflects the time of participation of the provider referring the patient to an inpatient setting. The encounter type should reflect that this is an inpatient encounter.
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