Specific Encounters

Inpatient Admission

Inpatient Admission represents a patient's hospital stay where at least one overnight stay is required for treatment, observation, or procedures.

Field	Type	Required	Description
visit_code	string	YES	Reference to visit the unique code
is_new	boolean		Field to distinguish new cases from follow-ups
code	string	YES	Unique identifier for the operation
symptoms	array of strings		Primary symptom or problem reported by the doctor (nullable)
ward	string	YES	Name of the ward or clinic, or sub-clinic
service_type	string	YES	Name of the service or purpose of inpatient (nullable)
started_at	datetime	YES	Date and time operation started
ended_at	datetime		Date and time the operation ended
encountered_by	string	YES	Name of the healthcare provider
title	string		Position, whether doctor or nurse, or else
created_at	datetime	YES	Record creation timestamp
updated_at	datetime	YES	Record the last update timestamp

Example

{  
  "inpatients": [  
    {  
      "visit_code": "V420650",  
      "code": "E317001",
      "symptoms": ["fever","red skin"],  
      "ward": "General IPD",  
      "service_type": "Internal Medicine",  
      "started_at": "2025-03-20T14:00:00.000+07:00",  
      "ended_at": "2025-03-23T10:00:00.000+07:00",
      "encountered_by": "Dr. Chhun Sovannarith",
      "title": "Doctor",  
      "created_at": "2025-03-20T14:00:00.000+07:00",  
      "updated_at": "2025-03-23T10:00:00.000+07:00"  
    }  
  ]  
}

Outpatient

Outpatient represents a patient visit for treatment or consultation without requiring overnight hospital stay.

Field	Type	Required	Description
visit_code	string	YES	Reference to visit the unique code
is_new	boolean		Field to distinguish new cases from follow-ups
code	string	YES	Unique identifier for the operation
symptoms	array of strings		Primary symptom or problem reported by the doctor (nullable)
ward	string	YES	Name of the ward or clinic, or sub-clinic
service_type	string	YES	Name of the service or purpose of outpatient (nullable)
started_at	datetime	YES	Date and time the operation started
ended_at	datetime		Date and time the operation ended
encountered_by	string	YES	Name of the healthcare provider
title	string		Position, whether doctor or nurse, or else
created_at	datetime	YES	Record creation timestamp
updated_at	datetime	YES	Record the last update timestamp

Example

{  
  "outpatients": [  
    {  
      "visit_code": "V420650",  
      "code": "E317000",
      "symptoms": ["fever","red skin"],  
      "ward": "General Outpatient",  
      "service_type": "General Medicine",  
      "started_at": "2025-03-17T09:35:00.000+07:00",  
      "ended_at": "2025-03-17T10:15:00.000+07:00",
      "encountered_by": "Dr. Chhun Sovannarith",
      "title": "Doctor",  
      "created_at": "2025-03-17T09:35:00.000+07:00",  
      "updated_at": "2025-03-17T10:15:00.000+07:00"  
    }  
  ]  
}

Emergency

Emergency represents a patient visit requiring immediate attention for acute or potentially life-threatening conditions.

Data Model

Field	Type	Required	Description
visit_code	string	YES	Reference to visit the unique code
is_new	boolean		Field to distinguish new cases from follow-ups
code	string	YES	Unique identifier for the operation
symptoms	array of strings		Primary symptom or problem reported by the doctor (nullable)
ward	string	YES	Name of the ward or clinic, or sub-clinic
service_type	string	YES	Name of the service type or purpose (nullable)
started_at	datetime	YES	Date and time the encounter started
ended_at	datetime		Date and time the encounter ended
emergency_note	text	YES	Detailed notes about the emergency (nullable)
encountered_by	string	YES	Name of the healthcare provider
title	string		Position, whether doctor or nurse, or else
created_at	datetime	YES	Record creation timestamp
updated_at	datetime	YES	Record the last update timestamp

Example

{  
  "emergencies": [  
    {  
      "visit_code": "V420650",  
      "code": "E317001",
      "ward": "Emergency",  
      "service_type": "Emergency Medicine",  
      "started_at": "2025-03-17T15:30:00.000+07:00",  
      "ended_at": "2025-03-17T17:45:00.000+07:00",
      "encountered_by": "Dr. Chhun Sovannarith",
      "title": "Doctor",  
      "emergency_notes": "Patient brought by family after motorcycle accident. GCS 14/15. No loss of consciousness. Skull X-ray negative for fracture. CT not available. Multiple abrasions on right side. No apparent fractures. Wound cleaning and dressing performed. Tetanus prophylaxis given.",  
      "created_at": "2025-03-17T15:30:00.000+07:00",  
      "updated_at": "2025-03-17T17:45:00.000+07:00"  
    }  
  ]  
}

Surgery

Surgery refers to medical procedures performed on a patient in an operating theatre to treat, repair, or diagnose a condition, usually under anesthesia.

Data Model

Field	Type	Required	Description
visit_code	string	YES	Reference to visit the unique code
is_new	boolean		Field to distinguish new cases from follow-ups
encounter_code	string		Unique identifier for the encounter result in operation
code	string	YES	Unique identifier for the operation
symptoms	array of strings		Primary symptom or problem reported by the doctor (nullable)
theater_name	string	YES	Name of the operating theater
service_type	string	YES	Name of the operation
started_at	datetime	YES	Date and time the operation started
ended_at	datetime	YES	Date and time the operation ended
reason	string	YES	Reason for operating
anesthesia_type	string		Type of anesthesia used
procedure_notes	text	YES	Detailed notes about the procedure
complications	array of strings		Any complications during the operation
specimens	array of strings		Specimens collected during the operation
pre_operative_diagnosis	string		The clinical diagnosis made BEFORE surgery, based on symptoms, physical examination, and investigations
post_operative_diagnosis	string		The final diagnosis confirmed AFTER the surgery, based on what the surgeon actually found during the operation
blood_loss	string		Amount of blood loss during surgery (including unit)
surgeon_name	string	YES	Name of the surgeon
anesthetist_name	string		Name of the anesthetist
assistant_names	array of strings		Names of assistants
created_at	datetime	YES	Record creation timestamp
updated_at	datetime		Record the last update timestamp
details	object		Detail how the surgery was performed

Detail Model

Field	Type	Required	Description
position	string	YES	How the patient lies during surgery

Example

{  
  "surgeries": [{  
    "visit_code": "V420650",  
    "encounter_code": "E401001",  
    "code": "SUR20250401001",  
    "theater_name": "Operating Theater 2",  
    "service_type": "Laparoscopic Cholecystectomy",  
    "started_at": "2025-04-01T08:30:00.000+07:00",  
    "ended_at": "2025-04-01T10:15:00.000+07:00",  
    "reason": "Symptomatic gallstones with recurrent biliary colic",  
    "anesthesia_type": "General Endotracheal",  
    "procedure_notes": "Patient positioned supine. Pneumoperitoneum established with Veress needle. Four ports were placed. Gallbladder dissected from liver bed with hook cautery. Cystic duct and artery identified, clipped and divided. Gallbladder removed through umbilical port. Hemostasis confirmed. No bile leak. Ports removed under direct visualization. Wounds closed with 3-0 Vicryl and 4-0 Monocryl. Patient tolerated procedure well.",  
    "complications": [  
      "Mild bleeding from liver bed, controlled with electrocautery"  
    ],  
    "specimens": [  
      "Gallbladder with multiple stones",  
      "Cystic fluid sample"  
    ],
    "blood_loss": "5cl",  
    "surgeon_name": "Dr. Sok Vichet",  
    "anesthetist_name": "Dr. Meas Sokunthea",  
    "assistant_names": [  
      "Dr. Chhan Rathana", "Nurse Van Bopha"  
    ],  
    "created_at": "2025-04-01T08:30:00.000+07:00",  
    "updated_at": "2025-04-01T10:20:00.000+07:00"  
  }]  
}

Progress Notes

Progress Note documents a patient's ongoing assessment, treatment, and response during their care. It often uses the SOAP format.

Data Model

Field	Type	Required	Description
visit_code	string	YES	Reference to visit the unique code
encounter_code	string		Reference to the parent encounter code
code	string	YES	Unique identifier for the daily progress note
started_at	datetime	YES	Date and time assessment started
ended_at	datetime		Date and time assessment ended
encountered_by	string	YES	Name of the healthcare provider
title	string	YES	Position, whether doctor or nurse, or else
created_at	datetime	YES	Record creation timestamp
updated_at	datetime	YES	Record the last update timestamp

Example

{  
  "progress_notes": [  
    {  
      "visit_code": "VS20250317001",  
      "encounter_code": "E417001",  
      "code": "E317001",  
      "started_at": "2025-03-17T16:00:00.000+07:00",  
      "ended_at": "2025-03-17T16:15:00.000+07:00",  
      "encountered_by": "Dr. Chhun Sovannarith",
      "title": "Doctor",  
      "created_at": "2025-03-20T14:00:00.000+07:00",  
      "updated_at": "2025-03-23T10:00:00.000+07:00"  
    }  
  ]  
}