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The Encounter section details any encounters information relevant to the patient's current health status or historical health history. Encounters are interactions between a patient and a practitioner who is responsible for diagnosing, evaluating or treating the patient. Encounters can occur in any location and may include visits, appointments, or phone or email interactions. There is a separate Entry section for each encounter.

This topic details the data elements that must be present in the Encounter section of a Continuity of Care Document (CCD) for it to be processed in the Clinical:EncounterCcda data space (hosted in Data Engine).

(R) - Required elements for the Encounter section and its sub-sections to be processed correctly in the Clinical:EncounterCcda data space.

(O) - Optional elements that are processed if provided in correct format.

Required (R) elements that are children of an Optional (O) element are only required for the immediate parent element to be processed.

Encounters Section Details

Encounter Section Template ID 

component/section/templateId

Specifies which CCDA R2.1 template is being used to determine the requirements, format and structure of the information this subsection.

...
<component>
	<section>
		...
		<templateId root=”2.16.840.1.113883.10.20.22.2.22.1”/>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
EncountertemplateIdrootMust be 2.16.840.1.113883.10.20.22.2.22 OR 2.16.840.1.113883.10.20.22.2.22.1

The unique identifier for the CCDA R2.1 template that defines the requirements, format and structure for the entire Encounter section in Continuity of Care Documents (CCDs).

Encounter Section Code

component/section/code

Identifies that this section contains encounter information.

...
<component>
	<section>
		...
		<templateId root=”2.16.840.1.113883.10.20.22.2.22.1”/>
		<code code=”46240-8” codeSystem=”2.16.840.1.113883.6.1”/> 
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
EncountercodecodeMust be 46240-8
codeSystemMust be 2.16.840.1.113883.6.1Identifies the Logical Observation Identifiers Names and Codes (LOINC) coding system used to translate the identifier provided in the code attribute.

Encounter Section Author

component/section/author

Indicates the author of the section. Refer to Assigned Author Element for more details on what information can be available for the author section.  

...
<component>
	<section>
		...
		<templateId root=”2.16.840.1.113883.10.20.22.2.22.1”/>
		<code code=”46240-8” codeSystem=”2.16.840.1.113883.6.1”/>
		<author>
			<assignedAuthor>
				...
			</assignedAuthor>
		</author>
		...
	</section>
</component>
...

Encounter Section Confidentiality Code

component/section/confidentialityCode

Indicates the level of security that should be applied to this Encounter section. The level of security that should be applied is typically driven by the guidelines of the system that generated the CCD.

...
<component>
	<section>
		...
		<templateId root=”2.16.840.1.113883.10.20.22.2.22.1”/>
		<code code=”46240-8” codeSystem=”2.16.840.1.113883.6.1”/>
		<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter
confidentialityCode
codeMust include an alphanumeric string of any length. The HL7-supported confidentiality coding system is typically used, where security levels are indicated as:
  • U - unrestricted
  • L - low
  • N - normal
  • - moderate
  • R - restricted
  • V - very restricted

If a nullFlavor attribute is set with a value of OTH or UNK, then the coded values from the translation sub-element of the Encounter Section Confidentiality Code element will be used instead.

codeSystemMust include an alphanumeric string of any length, typically in the following format: 2.16.840.1.113883.X.XX.X. The HL7-supported confidentiality coding system is indicated by 2.16.840.1.113883.5.25A numerical string that specifies which system will be used to translate the identifier provided in the code attribute.

Encounter Activity

component/section/entry/encounter

Indicates an interaction between a patient and clinician. Interactions may include in-person encounters, telephone conversations, and email exchanges.

...
<component>
	<section>
		...
		<templateId root=”2.16.840.1.113883.10.20.22.2.22.1”/>
		<code code=”46240-8” codeSystem=”2.16.840.1.113883.6.1”/>
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN">
				...
			</encounter>
		</entry>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter ActivityencounterclassCodeMust be ENC

Specifies the general nature of the entry, which in this case is an encounter (ENC).

moodCodeMust be EVNIndicates that this entry is an event (EVN) that actually happens, has happened or is an ongoing act, or was documented from a past act.

Encounter Activity Template ID

component/section/entry/encounter/templateId

Specifies which CCDA R2.1 template is being used to structure the encounter activity procedure sub-section. R2.1 templates define the requirements, format, and structure of a CCD section.

...
<component>
	<section>
		...
		<templateId root=”2.16.840.1.113883.10.20.22.2.22.1”/>
		<code code=”46240-8” codeSystem=”2.16.840.1.113883.6.1”/>
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN"> 
				<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			</encounter>
		</entry>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter ActivitytemplateIdrootMust be 2.16.840.1.113883.10.20.22.4.49

Uniquely identifies the encounter activity sub-section template.

Encounter Activity Code

component/section/entry/encounter/code

Indicates the specific type of encounter (e.g in-person visit, telephone or email conversation) 

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN"> 
				<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
				<code code="99241" codeSystem="2.16.840.1.113883.6.12"/>
				...
			</encounter> 
		</entry> 
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter Activitycodecode

Must be an alphanumerical string of any length. Could be one of the following:

  • 99201 - Office or other outpatient visit (problem focused)
  • 99203 - Office or other outpatient visit (detailed)
  • 19681004 - Nursing evaluation of patient and report (procedure)
  • 225929007 - Joint home visit (procedure)

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust be of the following format 2.16.840.1.1113883.X.XX.

Typically, encounter type is determined by one of the following code systems:

  • 2.16.840.1.113883.6.12 (CPT)
  • 2.16.840.1.113883.6.96 (SNOMED)

Identifies the coding system used to translate the identifier provided in the code attribute.

For accurate processing, it is expected to see code with code and codeSystem attributes, as documented. However, if a nullFlavor attribute is provided it will be stored. If the nullFlavor value is OTH or UNK, and a child Translation element is provided, that value is stored.

Encounter Activity Author

component/section/entry/encounter/code

Indicates information of the person documenting the encounter activity. Refer to Assigned Author Element for more details on what information can be available for the author section.  

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN"> 
				<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
				<author>
					<assignedAuthor>
						...
					</assignedAuthor>
				</author>
				...
			</encounter> 
		</entry> 
		...
	</section>
</component>
...

Service Delivery Location Code

component/section/entry/encounter/participant/participantRole/code

Indicates the type of healthcare service location where the encounter took place, for example, emergency ward, GP practice, outpatient clinic.

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
				...
				<participant typeCode="LOC">
					<participantRole classCode="SDLOC">
						<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
						<code code="GACH" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" displayName="General Acute Care Hospital"/>
					</participantRole>
				</participant>
				...
			</encounter>
		</entry>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter Activity
code
code

Must be an alphanumeric string of any length.

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystem

Must be of the following format 2.16.840.1.113883.X.XX.X.X

Identifies the coding system used to translate the identifier provided in the code attribute.

If a nullFlavor value is provided it will be stored. If the nullFlavor value is OTH or UNK, and a child Translation element is provided, that value is stored.

codeSystemNameCan be an alphanumerical string of any length.This attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any length.This attribute is optional. A human readable display name for the service delivery location.

Service Delivery Location Address

component/section/entry/encounter/participant/participantRole/addr

Indicates the address of the service location where the encounter took place.

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN">
				...
				<participant typeCode="LOC">
					<participantRole classCode="SDLOC">
						<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
						<code code="GACH" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" displayName="General Acute Care Hospital"/>
						<addr>
							<streetAddressLine>1009 Health Drive</streetAddressLine>
							<city>Portland</city>
							<state>OR</state>
							<postalCode>99123</postalCode>
							<country>US</country>
						</addr>
					</participantRole>
				</participant>
				...
			</encounter>
		</entry>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter Activity
addr
N/A

Can contain various address related child elements such as:

  • streetAdressLine
  • city
  • state
  • postalCode
  • country



Service Delivery Location Telecom

component/section/entry/encounter/participant/participantRole/telecom

Indicates the phone number of the healthcare service location where the encounter took place.

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN">
				...
				<participant typeCode="LOC">
					<participantRole classCode="SDLOC">
						<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
						<telecom value="09-123-6543" use="HP"/>
					</participantRole>
				</participant>
				...
			</encounter>
		</entry>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter Activity
telecom
value

Must be an alphanumeric string of any length.

Identifies the phone number of the healthcare service location.

use

Must include one of the following:

  • HP (Primary Home)
  • HV (Vacation Home)
  • WP (Workplace)
  • MC (Mobile Contact)

Identifies the type of phone number provided (for example, primary, vacation, work, mobile).

Service Delivery Location Playing Entity

component/section/entry/encounter/participant/participantRole/playingEntity

Indicates the healthcare service location where the encounter took place.

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN">
				...
				<participant typeCode="LOC">
					<participantRole classCode="SDLOC">
						<templateId root="2.16.840.1.113883.10.20.22.4.32"/>
						<playingEntity classCode="PLC">
							<name>Good Health Clinic</name>
						</playingEntity> 
					</participantRole>
				</participant>
				...
			</encounter>
		</entry>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter ActivityplayingEntityclassCodeMust be PLC
  • playingEntity
    • name
N/AMust contain an alphanumeric string of any length.Describes the name of the healthcare service location of the encounter.

Encounter Activity Effective Time

component/section/entry/encounter/effectiveTime

Indicates when the encounter activity (that is, an interaction between a clinician and patient) took place. Refer to  How Effective Time values are processed  for details on the different ways  effectiveTime  information can be processed.

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
				...
				<effectiveTime value="20000407"/>
				...
			</encounter>
		</entry>
		...
	</section>
</component>
...

Encounter Activity Discharge Disposition Code

component/section/entry/encounter/sdtc:dischargeDispositionCode

Indicates the current patient discharge status as it relates to this encounter.

...
<section>
	...
	<entry typeCode="DRIV">
		<encounter classCode="ENC" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			...
			<sdtc:dischargeDispositionCode code="04" codeSystem="2.16.840.1.113883.6.301.5">
				<originalText>04sdtc</originalText>
			</sdtc:dischargeDispositionCode>
			...
		</encounter>
	</entry>
	...
</section>
...
SubsectionElementAttributeValueNotes
Encounter Activity
sdtc:dischargeDispositionCode
codeMust be an alphanumeric string of any length.

Identifies the discharge status of the patient.

codeSystem

Must be 2.16.840.1.113883.6.301.5 OR 2.16.840.1.113883.12.112

Identifies the coding system used to translate the identifier provided in the code attribute.

Encounter Activity Performer

component/section/entry/encounter/performer

Indicates the clinician interacting with a patient in this specific encounter (for example, the site-specific alphanumerical ID for a community nurse visiting a patient at home). Refer to Performer Element for more details on what information can be available for the performer section. 

...
<section>
	...
	<entry typeCode="DRIV">
		<encounter classCode="ENC" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			...
			<performer>
                <assignedEntity>
                    ...
                </assignedEntity>
            </performer>
			...
		</encounter>
	</entry>
	...
</section>
...

Encounter Activity Indication

component/section/entry/encounter/entryRelationship/observation

Indicates the rationale for why the encounter activity occurred.

...
<section>
	...
	<entry typeCode="DRIV">
		<encounter classCode="ENC" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			...
			<entryRelationship typeCode="RSON">
				<observation classCode="OBS" moodCode="EVN">
					...
				</observation>
			</entryRelationship>
			...
		</encounter>
	</entry>
	...
</section>
...
SubsectionElementAttributeValueNotes
Encounter Activity Indication
entryRelationship
typeCode

Must be RSON

Indicates that this section contains the reason (RSON) for why the encounter activity occurred.

  • entryRelationship
    • observation
classCodeMust be OBSSpecifies the general nature of the entry, which in this case is an observation (OBS).
moodCodeMust be EVNIndicates that this entry is an event (EVN) that has happened or is an ongoing activity, or was documented from a past activity.

Encounter Activity Indication Value

component/section/entry/encounter/entryRelationship/observation/value

Indicates the rationale for why the encounter activity occurred.

...
<section>
	...
	<entry typeCode="DRIV">
		<encounter classCode="ENC" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
			...
			<entryRelationship typeCode="RSON">
				<observation classCode="OBS" moodCode="EVN">
					<value xsi:type="CD" code="32398004" codeSystem="2.16.840.1.113883.6.96" displayName="Bronchitis"/>
				</observation>
			</entryRelationship>
			...
		</encounter>
	</entry>
	...
</section>
...
SubsectionElementAttributeValueNotes
Encounter Activity Indication
value
xsi:type

Must be CD


codeMust be an alphanumeric string of any length
codeSystemMust be of the following format 2.16.840.1.113883.X.XX.X.XIdentifies the coding system used to translate the identifier provided in the code attribute.
displayNameCan be an alphanumeric string of any lengthThis attribute is optional. A human readable display name for the encounter activity indication code.

Encounter Diagnosis

component/section/entry/encounter/entryRelationship/act

Indicates the relevant problems or diagnoses at the close of a visit or that need to be followed after the visit.

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
				...
				<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
						...
					</act>
				</entryRelationship>
			</encounter>
		</entry>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter Diagnosis
entryRelationship
typeCode

Must be REFR

Indicates that the information in this subsection relates to the parent encounter activity act. Contains a child observation element.

  • entryRelationship
    • act
classCodeMust be ACTSpecifies the general nature of the entry, which in this case is an activity (ACT).
moodCodeMust be EVNIndicates that this entry is an event (EVN) that has happened or is an ongoing activity, or was documented from a past activity.

Encounter Diagnosis Template ID

component/section/entry/encounter/entryRelationship/act/templateId

Specifies which CCDA R2.1 template is being used to structure the encounter diagnosis sub-section. R2.1 templates define the requirements, format, and structure of a CCD section.

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
				...
				<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
						<templateId root="2.16.840.1.113883.10.20.22.4.80"/>
					</act>
				</entryRelationship>
			</encounter>
		</entry>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter Diagnosis
templateId
root

Must be 2.16.840.1.113883.10.20.22.4.80.

Uniquely identifies the encounter diagnosis sub-section template.

Encounter Diagnosis Code

component/section/entry/encounter/entryRelationship/act/code

Identifies the particular type of problem or diagnosis made at the encounter.

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
				<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
						<templateId root="2.16.840.1.113883.10.20.22.4.80"/>
						<code code="29308-4" displayName="Encounter Diagnosis" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					</act>
				</entryRelationship>
			</encounter>
		</entry>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Encounter Diagnosis
code
code

Must be an alphanumeric string of any length.

Identifies the specific diagnosis in the coding system.

codeSystem

Must be of the following format 2.16.840.1.113883.X.XX.X.X

Identifies the coding system used to translate the identifier provided in the code attribute.

codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the encounter diagnosis code.

Problem Observation Relationship

component/section/entry/encounter/entryRelationship/act/entryRelationship

Indicates a discrete observation about a patient's problem.

Information about this section and its children elements are detailed in the Problem Observation section in GenericProblemCCDA: Data Preparation Checklist.

...
<component>
	<section>
		...
		<entry typeCode="DRIV">
			<encounter classCode="ENC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
				<entryRelationship typeCode="REFR">
					<act classCode="ACT" moodCode="EVN">
						<templateId root="2.16.840.1.113883.10.20.22.4.80"/>
						<entryRelationship typeCode="SUBJ">
							<observation classCode="OBS" moodCode="EVN">
								...
							</observation>
						</entryRelationship>
					</act>
				</entryRelationship>
			</encounter>
		</entry>
		...
	</section>
</component>
...
SubsectionElementAttributeValueNotes

Problem Observation

entryRelationship

typeCode

Must be SUBJ

Indicates that the information in this subsection relates to the observed problem (the 'Subject').

  • entryRelationship
    • observation
classCodeMust be OBSSpecifies the general nature of the entry, which in this case is an observation (OBS).
moodCodeMust be EVNIndicates that this entry is an event (EVN) that has happened or is an ongoing activity, or was documented from a past activity.


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