United States Health Information Knowledgebase

 

Clinical Encounters


Name:Clinical Encounters
Type:Model View
Definition:An encounter serves as a focal point linking clinical, administrative and financial information. Encounters occur in many different settings -- ambulatory care, inpatient care, emergency-care, home health care, field and virtual (telemedicine). The definition for clinical encounter is from ASTM E1384-02a -- Standard Guide for Content and Structure of the Electronic Health Record: "(1) an instance of direct provider/practitioner to patient interaction, regardless of the setting, between a patient and a practitioner vested with primary responsibility for diagnosing, evaluating or treating the patients condition, or both, or providing social worker services. (2) A contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment." The ASTM definition excludes ancillary service visit, which is defined as "the appearance of an outpatient in a unit of a hospital or outpatient facility to receive service(s), test(s), or procedures." The clinical encounter definition also excludes practitioner actions in the absence of a patient such as practitioner-to-practitioner interaction and practitioner-to-records interaction. This includes the sub-domains of admission information, transfer (patient movement) information, discharge information, provider information, accident information, and death and autopsy information. The CHI clinical encounters standards are from Health Level Seven, Version 2.4 and higher. Usability gaps noted included explicit support for home health, field, and virtual encounters; support for clinical services that do not meet definition of clinical encounter; National Provider System identifiers for practitioners and healthcare organizations; standard location identifiers; and standard hospital service names.
Registration Authority:Centers for Medicare & Medicaid Services
Effective Date:2004-05-06
Status:Recorded
Administrative Attributes
Responsible Organization:Centers for Medicare & Medicaid Services
Submitting Organization:Consolidated Health Informatics
Steward Organization:Consolidated Health Informatics
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Relationship Organization Item
is the parent view of CMS Accident Information Compare these items   
is the parent view of CMS Death and Autopsy Information Compare these items   
is the parent view of CMS Encounter Information Compare these items   
is a sub view of CMS HL7 Compare these items   
is the parent view of CMS Provider Information Compare these items   
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