HL7 FHIR Malaysia Core (MY Core) Implementation Guide
2.0.0 - ci-build

HL7 FHIR Malaysia Core (MY Core) Implementation Guide - Local Development build (v2.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Encounter Records

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

Here are some common APIs used in HIE.

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/"
- @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

The Encounter (MY Core) classifies an encounter in 3 levels:

  • the first level is class Encounter.class, which defines the broadest concept of an encounter
    • example: Outpatient (Ambulatory), Inpatient, Emergency or Virtual encounter (according to base FHIR terminology).
    • Related ValueSet: ValueSetEncounterClass (MY Core).
  • the second level is serviceType Encounter.serviceType, which defines the type of service that is delivered or performed.
  • the third level is the specific services Encounter.type, which defines the main services provided 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 are diagrams to demonstrate the classification of an encounter:

Encounter classification by category, service type, then services
Encounter Classification 1

Encounter classification example
Encounter Classification 2

Encounter Diagnosis

The diagnosis captured during an encounter will be referenced by the related Encounter Encounter.diagnosis.condition.reference. The diagnosis itself is stored 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)