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0.1.0 - ci-build

Encounter Record

The interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient is stored as an Encounter (MY Core) record.

The Encounter record defines the setting of the interaction but is mainly used as an index resource that will reference or be referenced by other records which store most of the other details.

Sample Data and API

Sample Description Sample Body API Method API
Create/Update Encounter record JSON PUT [base]/Encounter/@encounterId
Retrieve Encounter record by ID - GET [base]/Encounter/@encounterId
Retrieve Encounter record by identifier - GET [base]/Encounter?identifier=@encounterIdentifier
Retrieve Encounter record with patient ID - GET [base]/Encounter?subject=@patientId
Retrieve Encounter record with patient identifier - GET [base]/Encounter?subject.identifier=@patientIdentifier
Where:

- [base] = address url e.g. "https://fhir.hie.moh.gov.my/baseR4/"
- [type] = resource type e.g. "Patient | Encounter | Composition"
- @encounterId = unique encounter ID defined from source system e.g. "encounter-sample"
- @encounterIdentifier = encounter registration number defined from source system e.g "HTJ-ENC-2211000036"
- @patientId = unique patient ID defined from source system e.g "patient-sample"
- @patientIdentifier = patient identifier such as MyKad number or MRN e.g "HIE-00000003"

Encounter Classification

Encounter (MY Core) classifies an encounter in 3 level:

  • the first level is class Encounter.class, defines the broadest concept of a encounter
    • example: Outpatient (Ambulatory), Inpatient, Emergency or a Virtual encounter (based on base FHIR terminology).
    • Related ValueSet: ValueSetEncounterClass (MY Core).
  • the second level is serviceType Encounter.serviceType, defines the specific type of service that is be delivered or performed.
  • the third level is services Encounter.serviceType, defines the main services performed during the encounter.
    • example: Internal Medicine, General Surgery, Cardiology, Family Medicine, Smoking Cessation, Communicable Disease, Non-communicable Disease (based on multiple combination of service terminology)
    • Related ValueSet: ValueSetSpecialty (MY Core).

Below is a diagram related to classification of encounter to further explain the description above

encounter-class-1 encounter-class-2

Encounter Diagnosis

Diagnosis captured during an encounter will be referenced by related encounter Encounter.diagnosis.condition.reference. The Diagnosis itself is store as a Condition (MY Core) record. However, the role of the diagnosis (example: main diagnosis, discharge diagnosis, admission diagnosis) is stored in Encounter.diagnosis.use.coding.code.

Related Diagnosis Role ValueSet: ValueSetDiagnosisRole (My Core)