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Encounter Information

Data Element

Applicable Standard(s)

Encounter Time
Encounter Type
Encounter Diagnosis
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, September 2020 Release
  • International Classification of Diseases ICD-10-CM 2021

Comment

Requirement for Discharge Disposition and/or Encounter Location?

Within the data element descriptions there is specification of applicable standards related to Discharge Disposition and Encounter Location.  Are these specific data elements also meant to be required as part of this data class?

Encounter diagnosis and time

Overall, the addition of Encounter information in the Draft USCDI V2 is a welcome addition. Could you clarify if Encounter Diagnosis is intended to be a "repeatable" (ie. cardinality 0..* or 1..*)? With a repeated structure, additional attributes may be needed to represent Encounter.diagnosis.use and/or Encounter.diagnosis.rank. Note: there is ongoing discussion in the FHIR community about the relationship between encounter diagnoses and other related FHIR resources.   The current Encounter Time data element definition suggests a mix of possible data types (Date? Start + End Timestamp? Period/duration?). It may may helpful to more precisely represent the allowed/expected/required data types. Note 1: Encounter time periods have a lot of complexity in the context of post acute care settings (with different perspectives from payment and clinical views) that may not be fully captured here. Note 2: Comment level data element submissions exist for Encounter Location Associated Time Period and Encounter Participant Time Period and perhaps should be reconciled with this data element.

Additional information needed

We request that additional information about what constitutes an “encounter” is included in the final USCDI version. It is imperative that this data class be more definitively described. Moreover, the data elements under encounter information must be more inclusive of qualified health care professionals, including physical therapists.

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