EncounterReason

Documents the clinical or administrative reason for a healthcare encounter including chief complaints, admission reasons, and health concerns. Supports standardized medical coding or free-text descriptions with priority ranking for comprehensive encounter documentation.

Overview

EncounterReason captures why a patient is being seen. This includes the chief complaint in the patient's words, the formal coded reason, or underlying health concerns being addressed. Multiple reasons can be documented with ranking to identify primary versus secondary reasons. Reasons can be coded (ICD-10, SNOMED-CT) for reporting or expressed as free text.

Key Concepts

Reason Use Types

The use field categorizes how the reason relates to the visit:

Use	Description	When Documented
`chief-complaint`	Primary symptom/concern	At registration
`admission-reason`	Formal admission reason	At admission
`reason-for-visit`	General visit reason	Outpatient visits
`health-concern`	Underlying condition	Preventive care

Chief Complaint

The patient's primary presenting concern:

Documented in patient's own words when possible
First thing addressed in clinical documentation
Drives initial assessment and triage
Example: "Chest pain for 2 hours"

Coded Reasons

The code field uses Coding:

ICD-10 codes for billing and statistics
SNOMED-CT for clinical precision
CPT for procedural visits
Enables population health analytics

Free-Text Reasons

The text field provides narrative:

Patient's description in their words
Additional context beyond codes
Nuances not captured in coding
Example: "Sharp pain that started after lifting boxes"

Priority Ranking

The rank field orders multiple reasons:

Rank 1 = Primary reason for visit
Rank 2+ = Secondary reasons
Affects DRG assignment for inpatients
Guides documentation priority

Onset Timing

The onsetDateTime field captures:

When symptoms first appeared
Duration of the presenting problem
Distinguishes acute from chronic
Important for clinical context

Use Cases

Emergency Triage

When patient arrives in ED:

Document chief complaint with use: "chief-complaint"
Record patient's description in text
Note symptom onset time
Set as rank 1
Code after initial assessment

Scheduled Visit

For routine appointments:

Document with use: "reason-for-visit"
Code the visit type (follow-up, routine exam)
Include any specific concerns
Link to appointment reason
Support visit planning

Hospital Admission

When admitting patient:

Create reason with use: "admission-reason"
Code with appropriate ICD-10
Link to ED chief complaint if applicable
Rank admission diagnoses
Support DRG assignment

Preventive Care

For wellness visits:

Use use: "health-concern" for chronic conditions
Document preventive care intent
List conditions being monitored
Code for quality reporting
Track health maintenance

Multiple Reasons

When visit has several purposes:

Create EncounterReason for each
Assign rank by priority
Rank 1 is primary billing reason
Document all relevant concerns
Support comprehensive coding

Related Entities

Entity	Relationship	Description
Encounter	Belongs to	Parent encounter
Coding	References	Coded reason (ICD-10, SNOMED-CT)

Enums

use

Value	Description
`chief-complaint`	Primary symptom or concern in patient's words prompting the visit
`admission-reason`	Formal reason for hospital admission
`reason-for-visit`	General reason for outpatient or scheduled visit
`health-concern`	Underlying health condition being addressed or monitored

6 properties

Schema

Properties

Property	Type	Mode	Description	Required
encounter	Encounter	stored	Reference to the healthcare encounter for which this reason is documented, establishing the relationship between the reason and the specific patient visit or care episode Example: `"encounter_12345"`	Required
use	string	stored	Classification of the reason type indicating how this reason relates to the encounter, such as the patient's chief complaint, the formal admission reason, the stated reason for visit, or an underlying health concern being addressed Values: `chief-complaint, admission-reason, reason-for-visit, health-concern` Example: `"chief-complaint"`	Required
code	Coding	stored	Standardized coded representation of the encounter reason using medical terminology systems such as ICD-10, SNOMED CT, or CPT, enabling interoperability and structured clinical data exchange Example: `"coding_chest_pain_icd10"`	Optional
text	string	stored	Human-readable free-text description of the encounter reason in the patient's or provider's own words, used when coded values are unavailable or to provide additional context beyond the coded representation Example: `"Patient reports sharp chest pain radiating to left arm for past 2 hours"`	Optional
onsetDateTime	DateTime	stored	Date and time when the symptom, condition, or health concern that prompted this encounter first began or was first noticed by the patient, establishing the temporal context for the presenting issue Example: `"2024-03-15T14:30:00Z"`	Optional
rank	number	stored	Priority order of this reason among multiple reasons for the same encounter, with lower numbers indicating higher priority, used to identify the primary versus secondary or tertiary reasons for the visit Example: `1`	Optional

Examples

Example 1

{
  "@type": "EncounterReason",
  "encounter": "encounter_er_001",
  "use": "chief-complaint",
  "code": "coding_r074_chest_pain",
  "text": "Patient presents with acute chest pain radiating to left arm, associated with shortness of breath",
  "onsetDateTime": "2024-03-15T14:30:00Z",
  "rank": 1
}

Example 2

{
  "@type": "EncounterReason",
  "encounter": "encounter_clinic_002",
  "use": "reason-for-visit",
  "code": "coding_z09_followup",
  "text": "Scheduled 6-week follow-up appointment after cardiac catheterization procedure to assess recovery and medication adherence",
  "onsetDateTime": null,
  "rank": 1
}

Example 3

{
  "@type": "EncounterReason",
  "encounter": "encounter_preventive_003",
  "use": "health-concern",
  "code": "coding_z00_general_exam",
  "text": "Annual preventive care visit for health maintenance, cancer screening, and immunization review",
  "onsetDateTime": null,
  "rank": 1
}