3.15 Encounters

The template identifier for the encounters section is 2.16.840.1.113883.10.20.1.3.

This section is used to list and describe any healthcare encounters pertinent to the patient’s current health status or historical health history. An Encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient’s condition. It may include visits, appointments, as well as non face-to-face interactions. It is also 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. This section may contain all encounters for the time period being summarized, but should include notable encounters.

CONF-453: CCDSHOULD contain exactly one and SHALL NOT contain more than one Encounters section (templateId 2.16.840.1.113883.10.20.1.3). The Encounters section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more encounter activities (templateId 2.16.840.1.113883.10.20.1.21).

3.15.1 Section conformance

CONF-454: The encounters section SHALL contain Section / code.
CONF-455: The value for “Section / code” SHALL be “46240-8” “History of encounters” 2.16.840.1.113883.6.1 LOINC STATIC.
CONF-456: The encounters section SHALL contain Section / title.
CONF-457: Section / titleSHOULD be valued with a case-insensitive language-insensitive text string containing “encounters”.

3.15.2 Clinical statement conformance

The following figure shows a subset of the CDA Clinical Statement model containing those classes being constrained or referred to in the conformance statements that follow.

Figure 14. CDA R2 clinical statement model for encounters

3.15.2.1 Encounter activities

The template identifier for an encounter activity is 2.16.840.1.113883.10.20.1.21.

CONF-458: An encounter activity (templateId 2.16.840.1.113883.10.20.1.21) SHALL be represented with Encounter.
CONF-459: The value for “Encounter / @classCode” in an encounter activity SHALL be “ENC” 2.16.840.1.113883.5.6 ActClass STATIC.
CONF-460: The value for “Encounter / @moodCode” in an encounter activity SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-461: An encounter activity SHALL contain at least one Encounter / id.
CONF-462: An encounter activity SHOULD contain exactly one Encounter / code.
CONF-463: The value for “Encounter / code” in an encounter activity SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.13955 EncounterCode 2.16.840.1.113883.5.4 ActCode DYNAMIC.
CONF-464: An encounter activity MAY contain exactly one Encounter / effectiveTime, to indicate date, time, and/or duration of an encounter.
CONF-465: An encounter activity MAY contain one or more Encounter / entryRelationship, whose value for “entryRelationship / @typeCode” SHALL be “RSON” “Has reason” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC, where the target of the relationship represents the indication for the activity.
CONF-466: An encounter activity MAY contain one or more Encounter / performer, used to define the practioners involved in an encounter.
CONF-467: Encounter / performerMAY contain exactly one Encounter / performer / assignedEntity / code, to define the role of the practioner.
CONF-468: An encounter activity MAY contain one or more patient instructions (templateId 2.16.840.1.113883.10.20.1.49).
CONF-469: The value for “Encounter / entryRelationship / @typeCode” in an encounter activity MAY be “SUBJ” “Subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC to reference an age observation (templateId 2.16.840.1.113883.10.20.1.38).
CONF-470: An encounter activity SHALL contain one or more sources of information, as defined in section 5.2 Source.

3.15.2.2 Encounter location

The template identifier for a location participation is 2.16.840.1.113883.10.20.1.45.

CONF-471: An encounter activity MAY contain one or more location participations.
CONF-472: A location participation (templateId 2.16.840.1.113883.10.20.1.45) SHALL be represented with the participant participation.
CONF-473: The value for “participant / @typeCode” in a location participation SHALL be “LOC” 2.16.840.1.113883.5.90 ParticipationType STATIC.
CONF-474: A location participation SHALL contain exactly one participant / participantRole.
CONF-475: The value for “participant / participantRole / @classCode” in a location participation SHALL be “SDLOC” “Service delivery location” 2.16.840.1.113883.5.110 RoleClass STATIC.
CONF-476: Participant / participantRole in a location participation MAY contain exactly one participant / participantRole / code.
CONF-477: The value for “participant / participantRole / code” in a location participation SHOULD be selected from ValueSet 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType 2.16.840.1.113883.5.111 RoleCode DYNAMIC.
CONF-478: Participant / participantRole in a location participation MAY contain exactly one participant / participantRole / playingEntity.
CONF-479: The value for “participant / participantRole / playingEntity / @classCode” in a location participation SHALL be “PLC” “Place” 2.16.840.1.113883.5.41 EntityClass STATIC.