Release 4 5 Draft Ballot
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Encounter-example-f203-20130311

Patient Administration Work Group Maturity Level : N/A Standards Status : Informative Compartments : Encounter , Patient , Practitioner , RelatedPerson

This is the narrative for the resource. See also the XML , JSON or Turtle format. This example conforms to the profile Encounter .


Generated Narrative with Details

id : f203 identifier : id: Encounter_Roel_20130311 (TEMP)

status : finished completed

StatusHistories

- Status Period
* arrived in-progress 08/03/2013 2013-03-08 --> (ongoing)

class : inpatient encounter (Details: http://terminology.hl7.org/CodeSystem/v3-ActCode code IMP = 'inpatient encounter', stated as 'inpatient encounter')

type : Inpatient stay for nine days (Details : {SNOMED CT code '183807002' = 'Inpatient stay 9 days', given as 'Inpatient stay for nine days'})

priority : High priority (Details : {SNOMED CT code '394849002' = 'High priority', given as 'High priority'})

subject : Roel Roel. Generated Summary: BSN: 123456789 (OFFICIAL), BSN: 123456789 (OFFICIAL); active; Roel(OFFICIAL); Phone: +31612345678, Phone: +31201234567; gender: male; birthDate: 1960-03-13; Legally married ;

episodeOfCare : EpisodeOfCare/example Generated Summary: id: 123; status: active; Home and Community Care ; period: 2014-09-01 --> (ongoing)

basedOn : ServiceRequest/myringotomy Generated Summary: id: ret4421; id: 1234; status: active; intent: order; Patient referral to specialist ; priority: routine; Insertion of grommets ; occurrence: ?ngen-2? --> 2014-03-14; authoredOn: 2014-02-14; ENT ; In the past 2 years Beverly has had 6 instances of rt-sided Otitis media. She is falling behind her peers at school, and displaying some learning difficulties. (By Serena Shrink @2014-02-14)

Participants

- Type Individual
* Participation (Details : {http://terminology.hl7.org/CodeSystem/v3-ParticipationType code 'PART' = 'Participation) Practitioner/f201 Generated Summary: UZI-nummer: 12345678901 (OFFICIAL); active; Dokter Bronsig(OFFICIAL); Phone: +31715269111; gender: male; birthDate: 1956-12-24

appointment : Appointment/example Generated Summary: status: booked; General Practice ; General Discussion ; General practice ; A follow up visit from a previous appointment ; description: Discussion on the results of your recent MRI; start: Dec 10, 2013 9:00:00 AM; end: Dec 10, 2013 11:00:00 AM; created: 2013-10-10; comment: Further expand on the results of the MRI and determine the next actions that may be appropriate.

period : 11/03/2013 2013-03-11 --> 20/03/2013 2013-03-20

Reasons

reasonCode : The patient seems to suffer from bilateral pneumonia and renal insufficiency, most likely due to chemotherapy. (Details )
-
*

diagnosis

condition : Condition/stroke Generated Summary: Active ; Confirmed ; Encounter Diagnosis ; Stroke ; onset: 2010-07-18

use : Admission diagnosis (Details : {http://terminology.hl7.org/CodeSystem/diagnosis-role code 'AD' = 'Admission diagnosis', given as 'Admission diagnosis'})

rank : 1

diagnosis

condition : Condition/f201 Generated Summary: id: 12345; Resolved ; Confirmed ; Problem ; Mild ; Fever ; Entire body as a whole ; onset: 2013-04-02; abatement: around April 9, 2013; recordedDate: 2013-04-04

use : Discharge diagnosis (Details : {http://terminology.hl7.org/CodeSystem/diagnosis-role code 'DD' = 'Discharge diagnosis', given as 'Discharge diagnosis'})

account : Account/example Generated Summary: id: 654321; status: active; patient ; name: HACC Funded Billing for Peter James Chalmers; servicePeriod: 2016-01-01 --> 2016-06-30; description: Hospital charges

Hospitalizations

- Origin AdmitSource ReAdmission DietPreference SpecialCourtesy SpecialArrangement Destination
* Location/2 Generated Summary: id: B1-S.F2.1.00; status: suspended; Housekeeping ; name: South Wing Neuro OR 1; alias: South Wing OR 5, alias: Main Wing OR 2; description: Old South Wing, Neuro Radiology Operation Room 1 on second floor; mode: instance; Neuroradiology unit ; Phone: 2329; Room Clinical Oncology Department (Details : {SNOMED CT code '309902002' = 'Clinical oncology department', given as 'Clinical Oncology Department'}) readmitted (Details : {[not stated] code 'null' = 'null', given as 'readmitted'}) Fluid balance regulation (Details : {SNOMED CT code '276026009' = 'Fluid balance regulation', given as 'Fluid balance regulation'}) normal courtesy (Details : {http://terminology.hl7.org/CodeSystem/v3-EncounterSpecialCourtesy code 'NRM' = 'normal courtesy', given as 'normal courtesy'}) Wheelchair (Details : {http://terminology.hl7.org/CodeSystem/encounter-special-arrangements code 'wheel' = 'Wheelchair', given as 'Wheelchair'}) Location/2 Generated Summary: id: B1-S.F2.1.00; status: suspended; Housekeeping ; name: South Wing Neuro OR 1; alias: South Wing OR 5, alias: Main Wing OR 2; description: Old South Wing, Neuro Radiology Operation Room 1 on second floor; mode: instance; Neuroradiology unit ; Phone: 2329; Room

serviceProvider : Organization/2 Generated Summary: id: 666666; name: XYZ Insurance; alias: ABC Insurance

partOf : Encounter/f203 Generated Summary: id: Encounter_Roel_20130311 (TEMP); status: completed; inpatient encounter ; Inpatient stay for nine days ; High priority ; period: 2013-03-11 --> 2013-03-20


 

Other examples that reference this example:

  • Condition/Sepsis
  • Condition/Renal insufficiency
  • Encounter/March 11th 2013
  • MedicationStatement/Nullified MedicationUsage/Nullified
  •  

    Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.