1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2

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Encounter Disposition 1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2

This element records the intended or actual disposition for the patient (e.g., admit, discharge home after treatment, et cetera).

Uses

See Templates using Encounter Disposition

Specification

Encounter Disposition Example

<act classCode='ACT' moodCode='INT|EVN'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2'/> <id root='' extension=''/> <code code='' displayName='' codeSystem='' codeSystemName='' /> <text><reference value='#xxx'/></text> <statusCode code='normal|completed'/> <effectiveTime value=''/> <performer typeCode='PRF'> <assignedEntity> <id root='' extension=''/> <addr></addr> <telecom value='' use=''/> <assignedPerson> <name></name> </assignedPerson> </assignedEntity> </performer> <participant typeCode='RCV'> <time value=''/> <participantRole classCode='ROL'> <id root='' extension=''/> <addr></addr> <telecom value='' use=''/> <playingEntity> <name></name> </playingEntity> </participantRole> </participant> <entryRelationship typeCode='COMP'> <act classCode='ACT'> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/> : </act> </entryRelationship> </act>

<act classCode='ACT' moodCode='INT|EVN'>

The disposition is recorded in an act element, to describe the disposition action taken during the encounter¹ . In intent mood (moodCode='INT'), this records the expected disposition of the patient. In event mood (moodCode='EVN'), this records the actual disposition.

1	The HL7 RIM allows this portion of the encounter to be recorded in the dischargeDispositionCode RIM Attribute of the Encounter class, but the Encounter class is constrained within CDA. To record the disposition act therefore requires the use of the Act class.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.2'/>

The templateId indicates that this <encounter> entry conforms to the constraints of this content module.

<id root=' ' extension=' '/>

This required element shall contain an identifier.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' ' />

This required element indicates the disposition of the patient. The code shall come from a coding system that is able to record common patient dispositions (e.g., Discharged, Transferred, Admitted). The "Administrative Procedure" concept (14734007) of SNOMED CT contains several code values that cover a wide variety of dispositions routinely recorded. Other vocabularies that are commonly in use to describe discharge disposition codes are DEEDS (See section 8.02), and in the US, the Uniform National Billing Code.

<text><reference value='#xxx'/></text>

The <text> element shall contain a reference to the narrative text describing the disposition of the patient. <statusCode code='normal|completed'/> When the disposition act has occurred (moodCode='EVN'), the statusCode element shall be present, and shall contain the value 'completed'. When the disposition act is intended (moodCode='EVN') the statusCode element shall contain the value 'normal'.

<effectiveTime><low value=' '/><high value=' '/><effectiveTime/>

When the disposition has occurred, this element shall be sent, and indicates the effective time for the disposition process. This element may be sent to record when the disposition act is intended to occur. The <low> element records the time at which the disposition process was started. The <high> value records the time at which the disposition process was completed.

<performer typeCode='PRF'>

The <performer> element provides information about the person that performs the discharge, admission or transfer of the patient. When the disposition is in intent mood, this element describes any expectations with respect to the performer, and is optional. When the disposition is in event mood, this element is required.

<assignedEntity>

The <assignedEntity> element identifies the performer of the disposition.

<id root=' ' extension=' '/>

The <id> element shall be sent when the disponsition has occurred, and identifies the performer of the act.

<addr></addr>

The <addr> element may be sent to provide a contact postal address for the performer of the disposition.

<telecom value=' ' use=' '/>

The <telecom> element may be sent to provide a contact postal address for the performer of the disposition.

<assignedPerson><name/></assignedPerson>

The <assignedPerson> element shall be sent to identify the person who performed the disposition of the patient.

<participant typeCode='RCV'>
 
 <participantRole classCode='ROL'>
  <id root=' ' extension=' '/>
  <addr></addr>
  <telecom value=' ' use=' '/>
  <playingEntity><name/></playingEntity>

This element identifies the person or organization that is receiving the patient.

<entryRelationship typeCode='COMP'>
 <act classCode='ACT'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.4.1'/>

If the disposition of the patient requires transport to another location, this information shall be recorded in a subordinate act that conforms to the Transport template described above.