An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

Angabe OPTIONAL, vom Server automatisch vergebene system-abhängige ID

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Angabe OPTIONAL zur Provenance und zum Profil

A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.

In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.

This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

An Extension

OPTIONAL, Aufnahmegrund entsprechend Schlüssel 1 der Anlage 2 der Datenübermittlung nach § 301 Abs. 3 SGB V

OPTIONAL, Aufnahmegrund (1. und 2. Stelle), Datenübermittlung nach § 301 Abs. 3 SGB V.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

OPTIONAL, Aufnahmegrund (3. Stelle), Datenübermittlung nach § 301 Abs. 3 SGB V.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

OPTIONAL, Aufnahmegrund (4. Stelle), Datenübermittlung nach § 301 Abs. 3 SGB V.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

The planned start date/time (or admission date) of the encounter

The planned end date/time (or discharge date) of the encounter

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Kennung/en, unter der/denen dieser Kontakt bekannt ist.

OPTIONAL, Ein eindeutiger Identifier, der einem Patienten bei der Aufnahmeplanung oder bei der Aufnahme selbst zugewiesen wird. Jeder Encounter SOLLTE seine eigene eindeutige Aufnahmenummer haben. Die Aufnahmenummer ist nicht die Fallnummer, welche sich auf den kompletten Abrechnungsfall bezieht. Hier wird ein Identifier angegeben, der den Kontakt eindeutig identifiziert.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

Allows users to make use of identifiers when the identifier system is not known.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

VERPFLICHTEND, required Binding auf http://fhir.de/ValueSet/EncounterStatusDe

Note that internal business rules will determine the appropriate transitions that may occur between statuses (and also classes).

VERPFLICHTEND, Kontaktklasse. Required Binding auf http://fhir.de/ValueSet/EncounterClassDE. Klassifizierung des Kontaktes in stationär, ambulant, teilstationär oder andere.

Spezifischer Typ des Kontaktes

Since there are many ways to further classify encounters, this element is 0..*.

The type of encounter.

OPTIONAL, Unterscheidung der Kontakt-Hierarchieebenen Einrichtungskontakt, Abteilungskontakt, Versorgungsstellenkontakt. Die Gliederung gilt für stationäre Kontakte. Required Binding auf http://fhir.de/ValueSet/kontaktebene-de

Since there are many ways to further classify encounters, this element is 0..*.

Kontaktebene

OPTIONAL, Differenzierung zwischen verschiedenen Arten von Kontakten (z.B. vorstationär, nachstationär, intensivstationär). Required Binding auf http://fhir.de/ValueSet/kontaktart-de

Since there are many ways to further classify encounters, this element is 0..*.

Die Fachdisziplin bzw. Fachabteilung wird durch einen vierstelligen Fachabteilungsschlüssel klassifiziert.

Broad categorization of the service that is to be provided.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

OPTIONAL, required Binding auf http://fhir.de/ValueSet/dkgev/Fachabteilungsschluessel Fachabteilungen gemäß Anhang 1 der BPflV in der am 31.12.2003 geltenden Fassung

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

OPTIONAL, required Binding auf http://fhir.de/ValueSet/dkgev/Fachabteilungsschluessel-erweitert Fachabteilungen gemäß Anhang 1 der BPflV in der am 31.12.2003 geltenden Fassung inkl. Spezialisierungen.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

VERPFLICHTEND, Referenz auf Patient:in.

While the encounter is always about the patient, the patient might not actually be known in all contexts of use, and there may be a group of patients that could be anonymous (such as in a group therapy for Alcoholics Anonymous - where the recording of the encounter could be used for billing on the number of people/staff and not important to the context of the specific patients) or alternately in veterinary care a herd of sheep receiving treatment (where the animals are not individually tracked).

Beginn- und Endzeitpunkt des Kontaktes. DARF NICHT vorhanden sein, kann OPTIONAL oder VERPFLICHTEND sein, abhängig vom Status des Kontaktes - siehe Invarianten auf Ebene Encounter.

If not (yet) known, the end of the Period may be omitted.

Start des Kontaktzeitraums. DARF NICHT vorhanden sein, kann OPTIONAL oder VERPFLICHTEND sein, abhängig vom Status des Kontaktes - siehe Invarianten auf Ebene Encounter.

If the low element is missing, the meaning is that the low boundary is not known.

Ende des Kontaktzeitraums. DARF NICHT vorhanden sein, kann OPTIONAL oder VERPFLICHTEND sein, abhängig vom Status des Kontaktes - siehe Invarianten auf Ebene Encounter.

The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.

OPTIONAL, Verweis auf Diagnosen/Prozeduren, die eine besondere Rolle im Kontext eines Encounters haben. Der Fallbezug von Diagnosen und Prozeduren wird über das jeweilige encounter-Element der Condition bzw. Procedure-Ressource hinreichend etabliert. Die zusätzliche Rückverlinkung von Encounter.diagnosis auf Condition/Procedure wird nur dann verwendet, wenn einer Diagnose bzw. Prozedur im Kontext eines Aufenthaltes eine besondere Rolle zugewiesen werden soll, z.B. Haupt-/Neben-/Aufnahme- oder Überweisungsdiagnose).

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

VERPFLICHTEND, wenn Diagnosedaten angegeben werden, dann MUSS diese referenziert werden. Bei ICD-10 Primär- und Sekundärcodes SOLLTE nur die Primärdiagnose referenziert werden.

For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis).

Attribute wie Aufnahme- oder Entlassdiagnose sind immer im Kontext eines stationären Aufenthaltes zu betrachten und werden daher als Eigenschaft des Encounters modelliert. VERPFLICHTEND mindestens die Angabe eines Codings. EMPFOHLEN ist die Angabe mittels Diagnosetyp- und DiagnosesubTyp-Coding. Weitere Codings OPTIONAL. Extensible Binding auf http://hl7.org/fhir/ValueSet/diagnosis-role

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

Einweisungs-/Überweisungsdiagnose | Behandlungsrelevante Diagnosen

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

Operationsdiagnose | Abteilung Hauptdiagnose | Todesursache | Infektionsschutzdiagnose +

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

OPTIONAL, Rangfolge der Diagnose

OPTIONAL. Referenz auf den Abrechnungsfall. Eine logische Referenz ist ausreichend zur Abbildung des Abrechnungskontextes.

The billing system may choose to allocate billable items associated with the Encounter to different referenced Accounts based on internal business rules.

OPTIONAL, Details zur Aufnahme und Entlassung

An Encounter may cover more than just the inpatient stay. Contexts such as outpatients, community clinics, and aged care facilities are also included.

The duration recorded in the period of this encounter covers the entire scope of this hospitalization record.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

VERPFLICHTEND, Aufnahmeanlass. Preferred Binding auf http://fhir.de/ValueSet/dgkev/Aufnahmeanlass

OPTIONAL Daten zur Entlassung

Discharge Disposition.

OPTIONAL, Entlassungs-/Verlegungsgrund nach § 301 Abs. 3 SGB V

OPTIONAL, Details zum Kontaktort wie Zimmer, Bett, Station

Virtual encounters can be recorded in the Encounter by specifying a location reference to a location of type "kind" such as "client's home" and an encounter.class = "virtual".

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The location where the encounter takes place.

SOLL, extensible Binding auf https://www.medizininformatik-initiative.de/fhir/core/modul-fall/ValueSet/location-physical-type

This information is de-normalized from the Location resource to support the easier understanding of the encounter resource and processing in messaging or query.

There may be many levels in the hierachy, and this may only pic specific levels that are required for a specific usage scenario.

Von Patient oder Patientin während des Kontaktes belegtes Zimmer auf einer Station.

Virtual encounters can be recorded in the Encounter by specifying a location reference to a location of type "kind" such as "client's home" and an encounter.class = "virtual".

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The location where the encounter takes place.

The status of the participants' presence at the specified location during the period specified. If the participant is no longer at the location, then the period will have an end date/time.

When the patient is no longer active at a location, then the period end date is entered, and the status may be changed to completed.

The status of the location.

SOLL, extensible Binding auf https://www.medizininformatik-initiative.de/fhir/core/modul-fall/ValueSet/location-physical-type

This information is de-normalized from the Location resource to support the easier understanding of the encounter resource and processing in messaging or query.

There may be many levels in the hierachy, and this may only pic specific levels that are required for a specific usage scenario.

Von Patient oder Patientin während des Kontaktes belegter Bettenstellplatz.

Virtual encounters can be recorded in the Encounter by specifying a location reference to a location of type "kind" such as "client's home" and an encounter.class = "virtual".

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The location where the encounter takes place.

The status of the participants' presence at the specified location during the period specified. If the participant is no longer at the location, then the period will have an end date/time.

When the patient is no longer active at a location, then the period end date is entered, and the status may be changed to completed.

The status of the location.

SOLL, extensible Binding auf https://www.medizininformatik-initiative.de/fhir/core/modul-fall/ValueSet/location-physical-type

This information is de-normalized from the Location resource to support the easier understanding of the encounter resource and processing in messaging or query.

There may be many levels in the hierachy, and this may only pic specific levels that are required for a specific usage scenario.

Die Station, auf welcher der Patient oder die Patientin während des Kontaktes behandelt wurde.

Virtual encounters can be recorded in the Encounter by specifying a location reference to a location of type "kind" such as "client's home" and an encounter.class = "virtual".

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The location where the encounter takes place.

The status of the participants' presence at the specified location during the period specified. If the participant is no longer at the location, then the period will have an end date/time.

When the patient is no longer active at a location, then the period end date is entered, and the status may be changed to completed.

The status of the location.

SOLL, extensible Binding auf https://www.medizininformatik-initiative.de/fhir/core/modul-fall/ValueSet/location-physical-type

This information is de-normalized from the Location resource to support the easier understanding of the encounter resource and processing in messaging or query.

There may be many levels in the hierachy, and this may only pic specific levels that are required for a specific usage scenario.

OPTIONAL. Leistungserbringer, der für den Kontakt verantwortlich ist. Referenz auf eine Organisation

OPTIONAL. Abbildung der Hierarchie zwischen Kontaktebenen durch Referenz auf weitere Kontakte, wenn bspw. ein Versorgungsstellenkontakt Teil eines Abteilungskontaktes oder ein Abteilungskontakt Teil eines Einrichtungskontaktes ist.

This is also used for associating a child's encounter back to the mother's encounter.

Refer to the Notes section in the Patient resource for further details.

Angabe OPTIONAL, vom Server automatisch vergebene system-abhängige ID

Angabe OPTIONAL zur Provenance und zum Profil

OPTIONAL, Aufnahmegrund entsprechend Schlüssel 1 der Anlage 2 der Datenübermittlung nach § 301 Abs. 3 SGB V

OPTIONAL, Aufnahmegrund (1. und 2. Stelle), Datenübermittlung nach § 301 Abs. 3 SGB V.

OPTIONAL, Aufnahmegrund (3. Stelle), Datenübermittlung nach § 301 Abs. 3 SGB V.

OPTIONAL, Aufnahmegrund (4. Stelle), Datenübermittlung nach § 301 Abs. 3 SGB V.

Kennung/en, unter der/denen dieser Kontakt bekannt ist.

OPTIONAL, Ein eindeutiger Identifier, der einem Patienten bei der Aufnahmeplanung oder bei der Aufnahme selbst zugewiesen wird. Jeder Encounter SOLLTE seine eigene eindeutige Aufnahmenummer haben. Die Aufnahmenummer ist nicht die Fallnummer, welche sich auf den kompletten Abrechnungsfall bezieht. Hier wird ein Identifier angegeben, der den Kontakt eindeutig identifiziert.

VERPFLICHTEND, required Binding auf http://fhir.de/ValueSet/EncounterStatusDe

VERPFLICHTEND, Kontaktklasse. Required Binding auf http://fhir.de/ValueSet/EncounterClassDE. Klassifizierung des Kontaktes in stationär, ambulant, teilstationär oder andere.

Spezifischer Typ des Kontaktes

OPTIONAL, Unterscheidung der Kontakt-Hierarchieebenen Einrichtungskontakt, Abteilungskontakt, Versorgungsstellenkontakt. Die Gliederung gilt für stationäre Kontakte. Required Binding auf http://fhir.de/ValueSet/kontaktebene-de

Kontaktebene

OPTIONAL, Differenzierung zwischen verschiedenen Arten von Kontakten (z.B. vorstationär, nachstationär, intensivstationär). Required Binding auf http://fhir.de/ValueSet/kontaktart-de

Die Fachdisziplin bzw. Fachabteilung wird durch einen vierstelligen Fachabteilungsschlüssel klassifiziert.

OPTIONAL, required Binding auf http://fhir.de/ValueSet/dkgev/Fachabteilungsschluessel Fachabteilungen gemäß Anhang 1 der BPflV in der am 31.12.2003 geltenden Fassung

OPTIONAL, required Binding auf http://fhir.de/ValueSet/dkgev/Fachabteilungsschluessel-erweitert Fachabteilungen gemäß Anhang 1 der BPflV in der am 31.12.2003 geltenden Fassung inkl. Spezialisierungen.

VERPFLICHTEND, Referenz auf Patient:in.

Beginn- und Endzeitpunkt des Kontaktes. DARF NICHT vorhanden sein, kann OPTIONAL oder VERPFLICHTEND sein, abhängig vom Status des Kontaktes - siehe Invarianten auf Ebene Encounter.

Start des Kontaktzeitraums. DARF NICHT vorhanden sein, kann OPTIONAL oder VERPFLICHTEND sein, abhängig vom Status des Kontaktes - siehe Invarianten auf Ebene Encounter.

Ende des Kontaktzeitraums. DARF NICHT vorhanden sein, kann OPTIONAL oder VERPFLICHTEND sein, abhängig vom Status des Kontaktes - siehe Invarianten auf Ebene Encounter.

OPTIONAL, Verweis auf Diagnosen/Prozeduren, die eine besondere Rolle im Kontext eines Encounters haben. Der Fallbezug von Diagnosen und Prozeduren wird über das jeweilige encounter-Element der Condition bzw. Procedure-Ressource hinreichend etabliert. Die zusätzliche Rückverlinkung von Encounter.diagnosis auf Condition/Procedure wird nur dann verwendet, wenn einer Diagnose bzw. Prozedur im Kontext eines Aufenthaltes eine besondere Rolle zugewiesen werden soll, z.B. Haupt-/Neben-/Aufnahme- oder Überweisungsdiagnose).

VERPFLICHTEND, wenn Diagnosedaten angegeben werden, dann MUSS diese referenziert werden. Bei ICD-10 Primär- und Sekundärcodes SOLLTE nur die Primärdiagnose referenziert werden.

Attribute wie Aufnahme- oder Entlassdiagnose sind immer im Kontext eines stationären Aufenthaltes zu betrachten und werden daher als Eigenschaft des Encounters modelliert. VERPFLICHTEND mindestens die Angabe eines Codings. EMPFOHLEN ist die Angabe mittels Diagnosetyp- und DiagnosesubTyp-Coding. Weitere Codings OPTIONAL. Extensible Binding auf http://hl7.org/fhir/ValueSet/diagnosis-role

Einweisungs-/Überweisungsdiagnose | Behandlungsrelevante Diagnosen

Operationsdiagnose | Abteilung Hauptdiagnose | Todesursache | Infektionsschutzdiagnose +

OPTIONAL, Rangfolge der Diagnose

OPTIONAL. Referenz auf den Abrechnungsfall. Eine logische Referenz ist ausreichend zur Abbildung des Abrechnungskontextes.

OPTIONAL, Details zur Aufnahme und Entlassung

VERPFLICHTEND, Aufnahmeanlass. Preferred Binding auf http://fhir.de/ValueSet/dgkev/Aufnahmeanlass

OPTIONAL Daten zur Entlassung

OPTIONAL, Entlassungs-/Verlegungsgrund nach § 301 Abs. 3 SGB V

OPTIONAL, Details zum Kontaktort wie Zimmer, Bett, Station

SOLL, extensible Binding auf https://www.medizininformatik-initiative.de/fhir/core/modul-fall/ValueSet/location-physical-type

Von Patient oder Patientin während des Kontaktes belegtes Zimmer auf einer Station.

Von Patient oder Patientin während des Kontaktes belegter Bettenstellplatz.

Die Station, auf welcher der Patient oder die Patientin während des Kontaktes behandelt wurde.

OPTIONAL. Leistungserbringer, der für den Kontakt verantwortlich ist. Referenz auf eine Organisation

OPTIONAL. Abbildung der Hierarchie zwischen Kontaktebenen durch Referenz auf weitere Kontakte, wenn bspw. ein Versorgungsstellenkontakt Teil eines Abteilungskontaktes oder ein Abteilungskontakt Teil eines Einrichtungskontaktes ist.

An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

Angabe OPTIONAL, vom Server automatisch vergebene system-abhängige ID

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Angabe OPTIONAL zur Provenance und zum Profil

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

When the resource last changed - e.g. when the version changed.

This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.

A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.

In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.

This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

Security Labels from the Healthcare Privacy and Security Classification System.

Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

An Extension

OPTIONAL, Aufnahmegrund entsprechend Schlüssel 1 der Anlage 2 der Datenübermittlung nach § 301 Abs. 3 SGB V

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

OPTIONAL, Aufnahmegrund (1. und 2. Stelle), Datenübermittlung nach § 301 Abs. 3 SGB V.