Clinical Resources

Encounters

Overview

The Encounters page captures details about patient interactions with healthcare providers, including office visits, hospital admissions, telehealth sessions, and specialty consultations. Tracking encounters is essential for documenting care, supporting billing, and enabling clinical decision-making across the patient’s care continuum.

Clinical Data in Source Documents

Encounter information is often recorded in sections such as Progress Notes, Visit Summaries, Admission/Discharge Notes, or Telehealth Reports. The data may appear as:

• Unstructured narrative text describing the reason for visit, visit type, and provider specialty.
• Tables or structured sections indicating admission and discharge dates, encounter type, and facility information.
• Embedded metadata in C-CDAs containing standardized fields for date of service, encounter type, and identifiers.

Due to variability in source documents, encounter data can be fragmented across multiple sections, requiring careful extraction to ensure completeness.

JSON Output

The platform extracts encounter information into a standardized JSON structure, capturing key details of the patient visit:

• Encounter ID: Unique identifier for the encounter within the organization.
• Start Page / End Page: Document pages where the encounter is recorded.
• Note Type: Type of clinical note associated with the encounter (e.g., progress note, discharge summary).
• Date of Service: Date when the encounter occurred.
• Admission / Discharge Dates: Applicable for inpatient visits to track duration of stay.
• Telehealth Encounter: Boolean indicating how the visit was conducted. true means a telehealth (virtual) visit; false means an in-person, face to face visit.
• Visit Type: Classification of the encounter, such as in-person (face to face), telehealth, outpatient, or inpatient.
• Facility Name: Name of the healthcare facility where the encounter took place.
• Specialty: Provider or service specialty involved in the encounter.
• Reason for Visit: Clinical rationale or follow-up description for the patient visit.

This structured format enables consistent record-keeping, facilitates analytics, and allows encounters to be integrated into broader EHR workflows.

{
  "encounter_id": 4,
  "start_page": 4,
  "end_page": 4,
  "note_type": "progress note",
  "dos": "January 19, 2022",
  "admission_date": "01/10/2022",
  "discharge_date": "01/20/2022",
  "telehealth_encounter": false,
  "visit_type": "inpatient",
  "providers": [
    {
      "name": "Mary M. Johnson MD",
      "page_number": 4
    }
  ],
  "signed_provider": [
    {
      "name": "Mary M. Johnson MD",
      "page_number": 4
    }
  ],
  "facility_name": "Pulmonary Health Hospital",
  "specialty": "Pulmonology",
  "reason_for_visit": "Admitted for severe lung infection"
}

FHIR Output

Extracted encounter data is mapped to the FHIR Encounter resource for interoperability. Key mappings include:

• Encounter ID → Encounter.identifier.value – Uniquely identifies the encounter within the organization.
• Status → Encounter.status – Indicates the completion status of the encounter (e.g., completed).
• Visit Type / Class → Encounter.class.code – Categorizes the encounter as outpatient, inpatient, or other types.
• Note Type / Specialty → Encounter.type.text – Captures the documentation type and clinical specialty.
• Date of Service / Admission / Discharge → Encounter.period.start / period.end – Provides temporal context for the encounter.
• Patient Reference → Encounter.subject – Links the encounter to the associated patient.
• Provider / Participant → Encounter.participant.actor – Associates the encounter with attending clinicians or care team members.
• Reason for Visit → Encounter.reasonCode.text – Documents the clinical rationale for the encounter.
• Telehealth / Virtual Services → Encounter.virtualService.channelType.text – Indicates virtual participation, including session metadata.
• Facility / Location → Encounter.location.location.display – Captures the site or clinic of the encounter.

This mapping ensures that encounter data is accurately represented, standardized, and interoperable, supporting clinical workflows, reporting, and analytics across healthcare systems.

{
  "fullUrl": "urn:uuid:1dd92df1-17c3-4a55-9b3d-409d422f2c9e",
  "resource": {
    "resourceType": "Encounter",
    "status": "completed",
    "subject": {
      "reference": "Patient/b17aaab1-311c-4d98-9c93-030277d0aeb0"
    },
    "identifier": [
      {
        "value": "4"
      }
    ],
    "class": [
      {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code": "IMP",
            "display": "inpatient"
          }
        ]
      }
    ],
    "type": [
      {
        "text": "progress note"
      },
      {
        "text": "Pulmonology"
      }
    ],
    "actualPeriod": {
      "start": "2022-01-10",
      "end": "2022-01-20"
    },
    "participant": [
      {
        "type": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                "code": "ATND",
                "display": "attender"
              }
            ]
          }
        ],
        "actor": {
          "reference": "Practitioner/9a1de72f-33fd-47d9-a0b9-b34d26985db8",
          "display": "Mary M. Johnson MD"
        }
      },
      {
        "type": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                "code": "ATND",
                "display": "attender"
              }
            ]
          }
        ],
        "actor": {
          "reference": "Practitioner/67530fa1-9886-414f-9e4b-20ae3bd9f7b9",
          "display": "Mary M. Johnson MD"
        }
      }
    ],
    "reason": [
      {
        "value": [
          {
            "concept": {
              "text": "Admitted for severe lung infection"
            }
          }
        ]
      }
    ],
    "serviceProvider": {
      "reference": "Organization/c92ed345-4a6d-40ae-a7e8-9e89daf919a3"
    },
    "location": [
      {
        "location": {
          "display": "Pulmonary Health Hospital"
        }
      }
    ],
    "id": "1dd92df1-17c3-4a55-9b3d-409d422f2c9e"
  }
}