BSeR: Bidirectional Services_eReferral - Local Development build (v2.0.0-connectathon). See the Directory of published versions
Official URL: http://hl7.org/fhir/us/bser/StructureDefinition/BSeR-Diagnosis | Version: 2.0.0-connectathon | |||
Active as of 2023-04-13 | Computable Name: BSeR_Diagnosis |
A health condition of the referral patient.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreConditionProblemsHealthConcernsProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | USCoreConditionProblemsHealthConcernsProfile | Detailed information about conditions, problems or diagnoses | |
category | 1..1 | CodeableConcept | Problem List Item Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: problem-list-item | |
onset[x] | 0..1 | Estimated or actual date, date-time, or age | ||
onsetDateTime | dateTime | |||
onsetAge | Age | |||
onsetString | string | |||
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | USCoreConditionProblemsHealthConcernsProfile | Detailed information about conditions, problems or diagnoses |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required) |
verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required) |
Slices for category | S | 1..1 | CodeableConcept | Problem List Item Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: problem-list-item | |
category:us-core | S | 1..* | CodeableConcept | problem-list-item | health-concern Binding: US Core Problem or Health Concern (required) |
category:sdoh | S | 0..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-tags | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: sdoh | |
code | SΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who has the condition? |
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |
onsetDateTime | dateTime | |||
onsetAge | Age | |||
onsetString | string | |||
abatement[x] | SC | 0..1 | When in resolution/remission | |
abatementDateTime | dateTime | |||
recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Condition.clinicalStatus | required | ConditionClinicalStatusCodes |
Condition.verificationStatus | required | ConditionVerificationStatus |
Condition.category | extensible | Pattern: problem-list-item |
Condition.category:us-core | required | USCoreProblemOrHealthConcern |
Condition.category:sdoh | extensible | Pattern: sdoh |
Condition.code | extensible | USCoreConditionCodes |
Id | Grade | Path(s) | Details | Requirements |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | USCoreConditionProblemsHealthConcernsProfile | Detailed information about conditions, problems or diagnoses | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required) | ||||
verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required) | ||||
Slices for category | S | 1..1 | CodeableConcept | Problem List Item Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: problem-list-item | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category:us-core | S | 1..* | CodeableConcept | problem-list-item | health-concern Binding: US Core Problem or Health Concern (required) | ||||
category:sdoh | S | 0..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-tags | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: sdoh | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | |||||
code | SΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient | ||||
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who has the condition? | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||
onsetDateTime | dateTime | |||||||
onsetAge | Age | |||||||
onsetString | string | |||||||
abatement[x] | SC | 0..1 | When in resolution/remission | |||||
abatementDateTime | dateTime S | |||||||
abatementAge | Age | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | ||||
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | ||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||
evidence | C | 0..* | BackboneElement | Supporting evidence | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||
detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||
note | 0..* | Annotation | Additional information about the Condition | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Condition.language | preferred | CommonLanguages
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodes | ||||
Condition.verificationStatus | required | ConditionVerificationStatus | ||||
Condition.category | extensible | Pattern: problem-list-item | ||||
Condition.category:us-core | required | USCoreProblemOrHealthConcern | ||||
Condition.category:sdoh | extensible | Pattern: sdoh | ||||
Condition.severity | preferred | Condition/DiagnosisSeverity | ||||
Condition.code | extensible | USCoreConditionCodes | ||||
Condition.bodySite | example | SNOMEDCTBodyStructures | ||||
Condition.stage.summary | example | ConditionStage | ||||
Condition.stage.type | example | ConditionStageType | ||||
Condition.evidence.code | example | ManifestationAndSymptomCodes |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USCoreConditionProblemsHealthConcernsProfile
Differential View
This structure is derived from USCoreConditionProblemsHealthConcernsProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | USCoreConditionProblemsHealthConcernsProfile | Detailed information about conditions, problems or diagnoses | |
category | 1..1 | CodeableConcept | Problem List Item Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: problem-list-item | |
onset[x] | 0..1 | Estimated or actual date, date-time, or age | ||
onsetDateTime | dateTime | |||
onsetAge | Age | |||
onsetString | string | |||
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | USCoreConditionProblemsHealthConcernsProfile | Detailed information about conditions, problems or diagnoses |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required) |
verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required) |
Slices for category | S | 1..1 | CodeableConcept | Problem List Item Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: problem-list-item | |
category:us-core | S | 1..* | CodeableConcept | problem-list-item | health-concern Binding: US Core Problem or Health Concern (required) |
category:sdoh | S | 0..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-tags | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: sdoh | |
code | SΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who has the condition? |
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |
onsetDateTime | dateTime | |||
onsetAge | Age | |||
onsetString | string | |||
abatement[x] | SC | 0..1 | When in resolution/remission | |
abatementDateTime | dateTime | |||
recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Condition.clinicalStatus | required | ConditionClinicalStatusCodes |
Condition.verificationStatus | required | ConditionVerificationStatus |
Condition.category | extensible | Pattern: problem-list-item |
Condition.category:us-core | required | USCoreProblemOrHealthConcern |
Condition.category:sdoh | extensible | Pattern: sdoh |
Condition.code | extensible | USCoreConditionCodes |
Id | Grade | Path(s) | Details | Requirements |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | USCoreConditionProblemsHealthConcernsProfile | Detailed information about conditions, problems or diagnoses | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required) | ||||
verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required) | ||||
Slices for category | S | 1..1 | CodeableConcept | Problem List Item Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: problem-list-item | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category:us-core | S | 1..* | CodeableConcept | problem-list-item | health-concern Binding: US Core Problem or Health Concern (required) | ||||
category:sdoh | S | 0..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-tags | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: sdoh | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | |||||
code | SΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient | ||||
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who has the condition? | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||
onsetDateTime | dateTime | |||||||
onsetAge | Age | |||||||
onsetString | string | |||||||
abatement[x] | SC | 0..1 | When in resolution/remission | |||||
abatementDateTime | dateTime S | |||||||
abatementAge | Age | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | ||||
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | ||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||
evidence | C | 0..* | BackboneElement | Supporting evidence | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||
detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||
note | 0..* | Annotation | Additional information about the Condition | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Condition.language | preferred | CommonLanguages
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodes | ||||
Condition.verificationStatus | required | ConditionVerificationStatus | ||||
Condition.category | extensible | Pattern: problem-list-item | ||||
Condition.category:us-core | required | USCoreProblemOrHealthConcern | ||||
Condition.category:sdoh | extensible | Pattern: sdoh | ||||
Condition.severity | preferred | Condition/DiagnosisSeverity | ||||
Condition.code | extensible | USCoreConditionCodes | ||||
Condition.bodySite | example | SNOMEDCTBodyStructures | ||||
Condition.stage.summary | example | ConditionStage | ||||
Condition.stage.type | example | ConditionStageType | ||||
Condition.evidence.code | example | ManifestationAndSymptomCodes |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USCoreConditionProblemsHealthConcernsProfile
Other representations of profile: CSV, Excel, Schematron