Clinical
Summary
This
page
is
part
of
the
Continuous
Integration
Build
of
FHIR
Specification
(v4.0.1:
R4
-
Mixed
Normative
and
STU
)
in
it's
permanent
home
(it
will
always
(will
be
available
incorrect/inconsistent
at
this
URL).
The
current
version
which
supercedes
this
version
is
5.0.0
.
For
a
full
list
of
available
versions,
see
times).
See
the
Directory
of
published
versions
.
Page
versions:
R5
R4B
R4
R3
R2
|
Responsible
Owner:
Patient
Care
Work
Group
|
|
Security Category : Patient | Compartments : Encounter , Group , Patient , Practitioner , RelatedPerson |
A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
Condition
is
one
of
the
event
resources
in
the
FHIR
workflow
specification.
This
resource
is
used
to
record
detailed
information
about
a
condition,
problem,
diagnosis,
or
other
event,
situation,
issue,
or
clinical
concept
that
has
risen
to
a
level
of
concern.
The
condition
could
be
a
point
in
time
diagnosis
in
context
of
an
encounter,
it
could
be
an
item
on
the
practitioner’s
Problem
List,
or
it
could
be
a
concern
that
doesn’t
exist
on
the
practitioner’s
Problem
List.
Often
times,
Oftentimes,
a
condition
is
about
a
clinician's
assessment
and
assertion
of
a
particular
aspect
of
a
patient's
state
of
health.
It
can
be
used
to
record
information
about
a
disease/illness
identified
from
application
of
clinical
reasoning
over
the
pathologic
and
pathophysiologic
findings
(diagnosis),
or
identification
of
health
issues/situations
that
a
practitioner
considers
harmful,
potentially
harmful
and
may
be
investigated
and
managed
(problem),
or
other
health
issue/situation
that
may
require
ongoing
monitoring
and/or
management
(health
issue/concern).
The condition resource may be used to record a certain health state of a patient which does not normally present a negative outcome, e.g. pregnancy. The condition resource may be used to record a condition following a procedure, such as the condition of Amputee-BKA following an amputation procedure.
While conditions are frequently a result of a clinician's assessment and assertion of a particular aspect of a patient's state of health, conditions can also be expressed by the patient, related person, or any care team member. A clinician may have a concern about a patient condition (e.g. anorexia) that the patient is not concerned about. Likewise, the patient may have a condition (e.g. hair loss) that does not rise to the level of importance such that it belongs on a practitioner’s Problem List.
For
example,
each
of
the
following
conditions
could
rise
to
the
level
of
importance
such
that
it
belongs
on
a
problem
or
concern
list
due
to
its
direct
or
indirect
impact
on
the
patient’s
health.
These
examples
may
also
be
represented
using
other
resources,
such
as
FamilyMemberHistory
,
Observation
,
or
Procedure
.
health:
These examples may also be represented using other resources, such as FamilyMemberHistory , Observation , RiskAssessment , or Procedure .
The condition resource may be referenced by other resources as "reasons" for an action (e.g. MedicationRequest , Procedure , ServiceRequest , etc.)
This resource is not typically used to record information about subjective and objective information that might lead to the recording of a Condition resource. Such signs and symptoms are typically captured using the Observation resource; although in some cases a persistent symptom, e.g. fever, headache may be captured as a condition before a definitive diagnosis can be discerned by a clinician. In an inpatient scenario, a nursing problem list may document symptoms (such as respiratory alteration) as conditions if they are the focus of care provision. It became a problem because the nurse (clinician) wants to manage it. By contrast, headache may be captured as an Observation when it contributes to the establishment of a meningitis Condition.
Use the Observation resource when a symptom is resolved without long term management, tracking, or when a symptom contributes to the establishment of a condition.
Use Condition when a symptom requires long term management, tracking, or is used as a proxy for a diagnosis or problem that is not yet determined.
Note that a Condition represents an instance of a condition, not the categorical patient state. This can be a subtle distinction for systemic conditions, but it is easier to see with conditions that can happen more than once, e.g. refuting one record of a wound does not mean that the patient does not have any other wounds, and resolving one case of otitis media does not rule out recurrence. An observation that the patient doesn't have any wounds means the patient doesn't have any wounds at that point in time.
When the diagnosis is related to an allergy or intolerance, the Condition and AllergyIntolerance resources can both be used. However, to be actionable for decision support, using Condition alone is not sufficient as the allergy or intolerance condition needs to be represented as an AllergyIntolerance .
Structure
| Name | Flags | Card. | Type |
Description
&
Constraints
Filter:
|
|---|---|---|---|---|
Condition
|
|
DomainResource |
Detailed
information
about
conditions,
problems
or
diagnoses
+ + Rule: Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension |
|
identifier
|
Σ | 0..* | Identifier |
External
Ids
for
this
condition
|
|
clinicalStatus
|
?!
Σ
|
1..1 | CodeableConcept |
active
|
recurrence
|
relapse
|
inactive
|
remission
|
resolved
|
unknown
Binding: Condition Clinical Status Codes ( Required ) |
|
verificationStatus
|
?!
Σ
|
0..1 | CodeableConcept |
unconfirmed
|
provisional
|
differential
|
confirmed
|
refuted
|
entered-in-error
|
|
category
|
0..* | CodeableConcept |
problem-list-item
|
encounter-diagnosis
Binding: Condition Category Codes ( |
|
|
severity
|
0..1 | CodeableConcept |
Subjective
severity
of
condition
Binding: Condition/Diagnosis Severity ( Preferred ) |
|
|
code
|
Σ | 0..1 | CodeableConcept |
Identification
of
the
condition,
problem
or
diagnosis
Binding: Condition/Problem/Diagnosis Codes ( Example ) |
|
bodySite
|
Σ C | 0..* | CodeableConcept |
Anatomical
location,
if
relevant
Binding: SNOMED CT Body Structures ( Example ) |
|
C
|
0..1 | Reference ( BodyStructure ) |
Anatomical
body
structure
|
|
subject
|
Σ | 1..1 | Reference ( Patient | Group ) |
Who
has
the
condition?
|
|
encounter
|
Σ | 0..1 | Reference ( Encounter ) |
The
Encounter
during
which
this
Condition
was
created
|
onset[x]
|
Σ | 0..1 |
Estimated
or
actual
date,
date-time,
or
age
|
|
onsetDateTime
|
dateTime | |||
|
onsetAge
|
Age | |||
|
onsetPeriod
|
Period | |||
|
onsetRange
|
Range | |||
onsetString
|
string | |||
|
abatement[x]
|
|
0..1 |
When
in
resolution/remission
|
|
|
abatementDateTime
|
dateTime | |||
|
abatementAge
|
Age | |||
|
abatementPeriod
|
Period | |||
|
abatementRange
|
Range | |||
|
abatementString
|
string | |||
|
recordedDate
|
Σ | 0..1 | dateTime |
Date
|
|
recorder
|
Σ | 0..1 | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson | Group ) |
Who
recorded
the
condition
|
|
asserter
|
Σ | 0..1 | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Group ) |
Person
|
stage
|
|
0..* | BackboneElement |
Stage/grade,
usually
assessed
formally
+ Rule: Stage SHALL have summary or assessment |
|
summary
|
|
0..1 | CodeableConcept |
Simple
summary
(disease
specific)
Binding: Condition Stage ( Example ) |
|
assessment
|
|
0..* |
Reference
(
|
Formal
record
of
assessment
|
|
type
|
0..1 | CodeableConcept |
Kind
of
staging
Binding: Condition Stage Type ( Example ) |
|
|
evidence
|
Σ
|
0..* |
|
Supporting
evidence
for
the
condition
|
|
note
|
0..* | Annotation |
Additional
information
about
the
Condition
|
|
|
Documentation
for
this
format
|
||||
See the Extensions for this resource
UML Diagram ( Legend )
XML Template
<Condition xmlns="http://hl7.org/fhir"><!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
<</clinicalStatus> <</verificationStatus><clinicalStatus><!-- I 1..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved | unknown --></clinicalStatus> <verificationStatus><!-- 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error --></verificationStatus> <category><!-- 0..* CodeableConcept problem-list-item | encounter-diagnosis --></category> <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity> <code><!-- 0..1 CodeableConcept Identification of the condition, problem or diagnosis --></code><</bodySite> <</subject> <</encounter> <</onset[x]> <</abatement[x]> < <|<bodySite><!-- I 0..* CodeableConcept Anatomical location, if relevant --></bodySite> <bodyStructure><!-- I 0..1 Reference(BodyStructure) Anatomical body structure --></bodyStructure> <subject><!-- 1..1 Reference(Group|Patient) Who has the condition? --></subject> <encounter><!-- 0..1 Reference(Encounter) The Encounter during which this Condition was created --></encounter> <onset[x]><!-- 0..1 dateTime|Age|Period|Range|string Estimated or actual date, date-time, or age --></onset[x]> <abatement[x]><!-- I 0..1 dateTime|Age|Period|Range|string When in resolution/remission --></abatement[x]> <recordedDate value="[dateTime]"/><!-- 0..1 Date condition was first recorded --> <recorder><!-- 0..1 Reference(Group|Patient|Practitioner|PractitionerRole| RelatedPerson) Who recorded the condition --></recorder><| </asserter> < <</summary> <</assessment><asserter><!-- 0..1 Reference(Device|Group|Patient|Practitioner|PractitionerRole| RelatedPerson) Person or device that asserts this condition --></asserter> <stage> <!-- 0..* Stage/grade, usually assessed formally --> <summary><!-- I 0..1 CodeableConcept Simple summary (disease specific) --></summary> <assessment><!-- I 0..* Reference(ClinicalAssessment|DiagnosticReport|Observation) Formal record of assessment --></assessment> <type><!-- 0..1 CodeableConcept Kind of staging --></type> </stage>< <</code> <</detail> </evidence><evidence><!-- 0..* CodeableReference(Any) Supporting evidence for the condition --></evidence> <note><!-- 0..* Annotation Additional information about the Condition --></note> </Condition>
JSON Template
{
"resourceType" : "Condition",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"identifier" : [{ Identifier }], // External Ids for this condition
"
"
"clinicalStatus" : { CodeableConcept }, // I R! active | recurrence | relapse | inactive | remission | resolved | unknown
"verificationStatus" : { CodeableConcept }, // unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
"category" : [{ CodeableConcept }], // problem-list-item | encounter-diagnosis
"severity" : { CodeableConcept }, // Subjective severity of condition
"code" : { CodeableConcept }, // Identification of the condition, problem or diagnosis
"
"
"
"bodySite" : [{ CodeableConcept }], // I Anatomical location, if relevant
"bodyStructure" : { Reference(BodyStructure) }, // I Anatomical body structure
"subject" : { Reference(Group|Patient) }, // R! Who has the condition?
"encounter" : { Reference(Encounter) }, // The Encounter during which this Condition was created
// onset[x]: Estimated or actual date, date-time, or age. One of these 5:
">",
" },
" },
" },
">",
"onsetDateTime" : "<dateTime>",
"onsetAge" : { Age },
"onsetPeriod" : { Period },
"onsetRange" : { Range },
"onsetString" : "<string>",
// abatement[x]: When in resolution/remission. One of these 5:
">",
" },
" },
" },
">",
"
"|
"abatementDateTime" : "<dateTime>",
"abatementAge" : { Age },
"abatementPeriod" : { Period },
"abatementRange" : { Range },
"abatementString" : "<string>",
"recordedDate" : "<dateTime>", // Date condition was first recorded
"recorder" : { Reference(Group|Patient|Practitioner|PractitionerRole|
RelatedPerson) }, // Who recorded the condition
"|
"
"
"
"asserter" : { Reference(Device|Group|Patient|Practitioner|PractitionerRole|
RelatedPerson) }, // Person or device that asserts this condition
"stage" : [{ // Stage/grade, usually assessed formally
"summary" : { CodeableConcept }, // I Simple summary (disease specific)
"assessment" : [{ Reference(ClinicalAssessment|DiagnosticReport|Observation) }], // I Formal record of assessment
"type" : { CodeableConcept } // Kind of staging
}],
"
"
"
}],
"evidence" : [{ CodeableReference(Any) }], // Supporting evidence for the condition
"note" : [{ Annotation }] // Additional information about the Condition
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .# from # from fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: # . One of these 5 fhir: ] fhir: ] fhir: ] fhir: ] fhir: ] # . One of these 5 fhir: ] fhir: ] fhir: ] fhir: ] fhir: ] fhir: fhir: fhir: fhir: fhir: fhir: fhir: ], ...; fhir: fhir: fhir: ], ...; fhir:# from Resource: fhir:id, fhir:meta, fhir:implicitRules, and fhir:language # from DomainResource: fhir:text, fhir:contained, fhir:extension, and fhir:modifierExtension fhir:identifier ( [ Identifier ] ... ) ; # 0..* External Ids for this condition fhir:clinicalStatus [ CodeableConcept ] ; # 1..1 I active | recurrence | relapse | inactive | remission | resolved | unknown fhir:verificationStatus [ CodeableConcept ] ; # 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error fhir:category ( [ CodeableConcept ] ... ) ; # 0..* problem-list-item | encounter-diagnosis fhir:severity [ CodeableConcept ] ; # 0..1 Subjective severity of condition fhir:code [ CodeableConcept ] ; # 0..1 Identification of the condition, problem or diagnosis fhir:bodySite ( [ CodeableConcept ] ... ) ; # 0..* I Anatomical location, if relevant fhir:bodyStructure [ Reference(BodyStructure) ] ; # 0..1 I Anatomical body structure fhir:subject [ Reference(Group|Patient) ] ; # 1..1 Who has the condition? fhir:encounter [ Reference(Encounter) ] ; # 0..1 The Encounter during which this Condition was created # onset[x] : 0..1 Estimated or actual date, date-time, or age. One of these 5 fhir:onset [ a fhir:DateTime ; dateTime ] fhir:onset [ a fhir:Age ; Age ] fhir:onset [ a fhir:Period ; Period ] fhir:onset [ a fhir:Range ; Range ] fhir:onset [ a fhir:String ; string ] # abatement[x] : 0..1 I When in resolution/remission. One of these 5 fhir:abatement [ a fhir:DateTime ; dateTime ] fhir:abatement [ a fhir:Age ; Age ] fhir:abatement [ a fhir:Period ; Period ] fhir:abatement [ a fhir:Range ; Range ] fhir:abatement [ a fhir:String ; string ] fhir:recordedDate [ dateTime ] ; # 0..1 Date condition was first recorded fhir:recorder [ Reference(Group|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Who recorded the condition fhir:asserter [ Reference(Device|Group|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Person or device that asserts this condition fhir:stage ( [ # 0..* Stage/grade, usually assessed formally fhir:summary [ CodeableConcept ] ; # 0..1 I Simple summary (disease specific) fhir:assessment ( [ Reference(ClinicalAssessment|DiagnosticReport|Observation) ] ... ) ; # 0..* I Formal record of assessment fhir:type [ CodeableConcept ] ; # 0..1 Kind of staging ] ... ) ; fhir:evidence ( [ CodeableReference(Any) ] ... ) ; # 0..* Supporting evidence for the condition fhir:note ( [ Annotation ] ... ) ; # 0..* Additional information about the Condition ]
Changes
since
R3
from
both
R4
and
R4B
| Condition | |
| Condition.clinicalStatus |
|
| Condition.verificationStatus |
|
| Condition.category |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
See the Full Difference for further information
This
analysis
is
available
for
R4
as
XML
or
JSON
.
See
R3
<-->
R4
Conversion
Maps
(status
=
12
tests
that
all
execute
ok.
All
tests
pass
round-trip
testing
and
1
r3
resources
are
invalid
(0
errors).
)
for
R4B
as
XML
or
JSON
.
Structure
| Name | Flags | Card. | Type |
Description
&
Constraints
Filter:
|
|---|---|---|---|---|
|
Condition
|
|
DomainResource |
Detailed
information
about
conditions,
problems
or
diagnoses
+ + Rule: Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension |
|
|
identifier
|
Σ | 0..* | Identifier |
External
Ids
for
this
condition
|
|
clinicalStatus
|
?!
Σ
|
1..1 | CodeableConcept |
active
|
recurrence
|
relapse
|
inactive
|
remission
|
resolved
|
unknown
Binding: Condition Clinical Status Codes ( Required ) |
|
verificationStatus
|
?!
Σ
|
0..1 | CodeableConcept |
unconfirmed
|
provisional
|
differential
|
confirmed
|
refuted
|
entered-in-error
|
|
category
|
0..* | CodeableConcept |
problem-list-item
|
encounter-diagnosis
Binding: Condition Category Codes ( |
|
|
severity
|
0..1 | CodeableConcept |
Subjective
severity
of
condition
Binding: Condition/Diagnosis Severity ( Preferred ) |
|
|
code
|
Σ | 0..1 | CodeableConcept |
Identification
of
the
condition,
problem
or
diagnosis
Binding: Condition/Problem/Diagnosis Codes ( Example ) |
|
bodySite
|
Σ C | 0..* | CodeableConcept |
Anatomical
location,
if
relevant
Binding: SNOMED CT Body Structures ( Example ) |
|
|
C
|
0..1 | Reference ( BodyStructure ) |
Anatomical
body
structure
|
|
subject
|
Σ | 1..1 | Reference ( Patient | Group ) |
Who
has
the
condition?
|
|
encounter
|
Σ | 0..1 | Reference ( Encounter ) |
The
Encounter
during
which
this
Condition
was
created
|
|
onset[x]
|
Σ | 0..1 |
Estimated
or
actual
date,
date-time,
or
age
|
|
|
onsetDateTime
|
dateTime | |||
|
onsetAge
|
Age | |||
|
onsetPeriod
|
Period | |||
|
onsetRange
|
Range | |||
|
onsetString
|
string | |||
|
abatement[x]
|
|
0..1 |
When
in
resolution/remission
|
|
|
abatementDateTime
|
dateTime | |||
|
abatementAge
|
Age | |||
|
abatementPeriod
|
Period | |||
|
abatementRange
|
Range | |||
|
abatementString
|
string | |||
|
recordedDate
|
Σ | 0..1 | dateTime |
Date
|
|
recorder
|
Σ | 0..1 | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson | Group ) |
Who
recorded
the
condition
|
|
asserter
|
Σ | 0..1 | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Group ) |
Person
|
|
stage
|
|
0..* | BackboneElement |
Stage/grade,
usually
assessed
formally
+ Rule: Stage SHALL have summary or assessment |
|
summary
|
|
0..1 | CodeableConcept |
Simple
summary
(disease
specific)
Binding: Condition Stage ( Example ) |
|
assessment
|
|
0..* |
Reference
(
|
Formal
record
of
assessment
|
|
type
|
0..1 | CodeableConcept |
Kind
of
staging
Binding: Condition Stage Type ( Example ) |
|
|
evidence
|
Σ
|
0..* |
|
Supporting
evidence
for
the
condition
|
|
note
|
0..* | Annotation |
Additional
information
about
the
Condition
|
|
|
Documentation
for
this
format
|
||||
See the Extensions for this resource
XML Template
<Condition xmlns="http://hl7.org/fhir"><</clinicalStatus> <</verificationStatus><clinicalStatus><!-- I 1..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved | unknown --></clinicalStatus> <verificationStatus><!-- 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error --></verificationStatus> <category><!-- 0..* CodeableConcept problem-list-item | encounter-diagnosis --></category> <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity> <code><!-- 0..1 CodeableConcept Identification of the condition, problem or diagnosis --></code><</bodySite> <</subject> <</encounter> <</onset[x]> <</abatement[x]> < <|<bodySite><!-- I 0..* CodeableConcept Anatomical location, if relevant --></bodySite> <bodyStructure><!-- I 0..1 Reference(BodyStructure) Anatomical body structure --></bodyStructure> <subject><!-- 1..1 Reference(Group|Patient) Who has the condition? --></subject> <encounter><!-- 0..1 Reference(Encounter) The Encounter during which this Condition was created --></encounter> <onset[x]><!-- 0..1 dateTime|Age|Period|Range|string Estimated or actual date, date-time, or age --></onset[x]> <abatement[x]><!-- I 0..1 dateTime|Age|Period|Range|string When in resolution/remission --></abatement[x]> <recordedDate value="[dateTime]"/><!-- 0..1 Date condition was first recorded --> <recorder><!-- 0..1 Reference(Group|Patient|Practitioner|PractitionerRole| RelatedPerson) Who recorded the condition --></recorder><| </asserter> < <</summary> <</assessment><asserter><!-- 0..1 Reference(Device|Group|Patient|Practitioner|PractitionerRole| RelatedPerson) Person or device that asserts this condition --></asserter> <stage> <!-- 0..* Stage/grade, usually assessed formally --> <summary><!-- I 0..1 CodeableConcept Simple summary (disease specific) --></summary> <assessment><!-- I 0..* Reference(ClinicalAssessment|DiagnosticReport|Observation) Formal record of assessment --></assessment> <type><!-- 0..1 CodeableConcept Kind of staging --></type> </stage>< <</code> <</detail> </evidence><evidence><!-- 0..* CodeableReference(Any) Supporting evidence for the condition --></evidence> <note><!-- 0..* Annotation Additional information about the Condition --></note> </Condition>
JSON Template
{
"resourceType" : "Condition",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"identifier" : [{ Identifier }], // External Ids for this condition
"
"
"clinicalStatus" : { CodeableConcept }, // I R! active | recurrence | relapse | inactive | remission | resolved | unknown
"verificationStatus" : { CodeableConcept }, // unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
"category" : [{ CodeableConcept }], // problem-list-item | encounter-diagnosis
"severity" : { CodeableConcept }, // Subjective severity of condition
"code" : { CodeableConcept }, // Identification of the condition, problem or diagnosis
"
"
"
"bodySite" : [{ CodeableConcept }], // I Anatomical location, if relevant
"bodyStructure" : { Reference(BodyStructure) }, // I Anatomical body structure
"subject" : { Reference(Group|Patient) }, // R! Who has the condition?
"encounter" : { Reference(Encounter) }, // The Encounter during which this Condition was created
// onset[x]: Estimated or actual date, date-time, or age. One of these 5:
">",
" },
" },
" },
">",
"onsetDateTime" : "<dateTime>",
"onsetAge" : { Age },
"onsetPeriod" : { Period },
"onsetRange" : { Range },
"onsetString" : "<string>",
// abatement[x]: When in resolution/remission. One of these 5:
">",
" },
" },
" },
">",
"
"|
"abatementDateTime" : "<dateTime>",
"abatementAge" : { Age },
"abatementPeriod" : { Period },
"abatementRange" : { Range },
"abatementString" : "<string>",
"recordedDate" : "<dateTime>", // Date condition was first recorded
"recorder" : { Reference(Group|Patient|Practitioner|PractitionerRole|
RelatedPerson) }, // Who recorded the condition
"|
"
"
"
"asserter" : { Reference(Device|Group|Patient|Practitioner|PractitionerRole|
RelatedPerson) }, // Person or device that asserts this condition
"stage" : [{ // Stage/grade, usually assessed formally
"summary" : { CodeableConcept }, // I Simple summary (disease specific)
"assessment" : [{ Reference(ClinicalAssessment|DiagnosticReport|Observation) }], // I Formal record of assessment
"type" : { CodeableConcept } // Kind of staging
}],
"
"
"
}],
"evidence" : [{ CodeableReference(Any) }], // Supporting evidence for the condition
"note" : [{ Annotation }] // Additional information about the Condition
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .# from # from fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: # . One of these 5 fhir: ] fhir: ] fhir: ] fhir: ] fhir: ] # . One of these 5 fhir: ] fhir: ] fhir: ] fhir: ] fhir: ] fhir: fhir: fhir: fhir: fhir: fhir: fhir: ], ...; fhir: fhir: fhir: ], ...; fhir:# from Resource: fhir:id, fhir:meta, fhir:implicitRules, and fhir:language # from DomainResource: fhir:text, fhir:contained, fhir:extension, and fhir:modifierExtension fhir:identifier ( [ Identifier ] ... ) ; # 0..* External Ids for this condition fhir:clinicalStatus [ CodeableConcept ] ; # 1..1 I active | recurrence | relapse | inactive | remission | resolved | unknown fhir:verificationStatus [ CodeableConcept ] ; # 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error fhir:category ( [ CodeableConcept ] ... ) ; # 0..* problem-list-item | encounter-diagnosis fhir:severity [ CodeableConcept ] ; # 0..1 Subjective severity of condition fhir:code [ CodeableConcept ] ; # 0..1 Identification of the condition, problem or diagnosis fhir:bodySite ( [ CodeableConcept ] ... ) ; # 0..* I Anatomical location, if relevant fhir:bodyStructure [ Reference(BodyStructure) ] ; # 0..1 I Anatomical body structure fhir:subject [ Reference(Group|Patient) ] ; # 1..1 Who has the condition? fhir:encounter [ Reference(Encounter) ] ; # 0..1 The Encounter during which this Condition was created # onset[x] : 0..1 Estimated or actual date, date-time, or age. One of these 5 fhir:onset [ a fhir:DateTime ; dateTime ] fhir:onset [ a fhir:Age ; Age ] fhir:onset [ a fhir:Period ; Period ] fhir:onset [ a fhir:Range ; Range ] fhir:onset [ a fhir:String ; string ] # abatement[x] : 0..1 I When in resolution/remission. One of these 5 fhir:abatement [ a fhir:DateTime ; dateTime ] fhir:abatement [ a fhir:Age ; Age ] fhir:abatement [ a fhir:Period ; Period ] fhir:abatement [ a fhir:Range ; Range ] fhir:abatement [ a fhir:String ; string ] fhir:recordedDate [ dateTime ] ; # 0..1 Date condition was first recorded fhir:recorder [ Reference(Group|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Who recorded the condition fhir:asserter [ Reference(Device|Group|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Person or device that asserts this condition fhir:stage ( [ # 0..* Stage/grade, usually assessed formally fhir:summary [ CodeableConcept ] ; # 0..1 I Simple summary (disease specific) fhir:assessment ( [ Reference(ClinicalAssessment|DiagnosticReport|Observation) ] ... ) ; # 0..* I Formal record of assessment fhir:type [ CodeableConcept ] ; # 0..1 Kind of staging ] ... ) ; fhir:evidence ( [ CodeableReference(Any) ] ... ) ; # 0..* Supporting evidence for the condition fhir:note ( [ Annotation ] ... ) ; # 0..* Additional information about the Condition ]
Changes
since
Release
3
from
both
R4
and
R4B
| Condition | |
| Condition.clinicalStatus |
|
| Condition.verificationStatus |
|
| Condition.category |
|
|
|
|
|
|
|
|
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|
|
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|
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|
See the Full Difference for further information
This
analysis
is
available
for
R4
as
XML
or
JSON
.
See
R3
<-->
R4
Conversion
Maps
(status
=
12
tests
that
all
execute
ok.
All
tests
pass
round-trip
testing
and
1
r3
resources
are
invalid
(0
errors).
)
for
R4B
as
XML
or
JSON
.
See
the
Profiles
&
Extensions
and
the
alternate
Additional
definitions:
Master
Definition
XML
+
JSON
,
XML
Schema
/
Schematron
+
JSON
Schema
,
ShEx
(for
Turtle
)
+
see
the
extensions
,
the
spreadsheet
version
&
the
dependency
analysis
| Path |
|
Type |
|
|---|---|---|---|
| Condition.clinicalStatus |
|
Required |
Preferred value set for Condition Clinical Status. |
| Condition.verificationStatus | ConditionVerificationStatus | Required |
The
verification
status
to
support
or
decline
the
clinical
status
of
the
condition
or
diagnosis.
|
| Condition.category |
|
|
Preferred value set for Condition Categories. |
| Condition.severity |
|
Preferred |
Preferred value set for Condition/Diagnosis severity grading. |
| Condition.code |
|
Example |
Example value set for Condition/Problem/Diagnosis codes. |
| Condition.bodySite |
|
Example |
This
value
set
includes
all
codes
from
SNOMED
CT
|
| Condition.stage.summary |
|
Example |
Value set for stages of cancer and other conditions. |
| Condition.stage.type |
|
Example |
Example value set for the type of stages of cancer and other conditions |
| Condition.evidence |
|
Example |
This
value
set
includes
all
the
"Clinical
finding"
SNOMED
CT
|
|
|
Level | Location | Description | Expression |
con-1
|
Rule | Condition.stage | Stage SHALL have summary or assessment | summary.exists() or assessment.exists() |
|
con-3
|
Rule | (base) |
If
condition
is
abated,
then
clinicalStatus
must
be
either
inactive,
resolved,
or
|
|
con-4
|
Rule | (base) |
|
|
Many of the code systems used for coding conditions will provide codes that define not only the condition itself, but may also specify a particular stage, location, or causality as part of the code. This is particularly true if SNOMED CT is used for the condition, and especially if expressions are allowed.
The
Condition.code
may
also
include
such
concepts
as "history
as
"history
of
X"
and "good
and
"good
health",
where
it
is
useful
or
appropriate
to
make
such
assertions.
It
can
also
be
used
to
capture
"risk
of"
and
"fear
of",
in
addition
to
physical
conditions,
as
well
as
"no
known
problems"
or
"negated"
conditions
(e.g.,
"no
X"
or
"no
history
of
X"
-
see
the
following
section
for
"No
Known
Problems"
and
Negated
Conditions).
When the Condition.code specifies additional properties of the condition, the other properties are not given a value - instead, the value must be understood from the Condition.code.
Conditions/Problems Not Reviewed, Not Asked
When a sending system does not have any information about conditions/problems being reviewed or the statement is about conditions/problems not yet being asked, then the List resource should be used to indicate the List.emptyReason.code="notasked".
Conditions/Problems Reviewed, None Identified
Systems may use the List.emptyReason when a statement is about the full scope of the list (i.e. the patient has no conditions/problems of any type). However, it may be preferred to use a code for "no known problems" (e.g., SNOMED CT: 160245001 |No current problems or disability (situation)|), so that all condition/problem data will be available and queryable from Condition resource instances.
Also note that care should be used when adding new Condition resources to a list to ensure that any negation statements that are voided by the addition of a new record are removed from the list. E.g. If the list contains a "no known problems" record and you add a "diabetes" condition record, then be sure that you remove the "no known problems" record.
Trial-Use Note:Note to Implementers: There are two primary ways of reporting "no known problems" in the current specification: using the CodeableConcept, as described above, or using the List resource with emptyReason. During the STU period, feedbackProvide feedback here
Patient Denies Condition
When the patient denies a condition, that can be annotated in the Condition.note element.
Generally, electronic records do not contain assertions of conditions that a patient does not have. There are however two exceptions:
The Condition.evidence provides the basis for whatever is present in Condition.code.
A
range
is
used
to
communicate
an
imprecise
age
period
of
the
subject
at
the
time
of
abatement.
If the data enterer is different from the asserter and needs to be known, this could be captured using a Provenance instance pointing to the Condition. For example, it is possible that a nurse records the condition on behalf of a physician. The physician is taking responsibility, despite the nurse entering it into the medical record.
The Condition.stage and Condition.clinicalStatus may have interdependencies. For example, some "stages" of cancer, etc. will be different for a remission than for the initial occurrence.
To represent the role of the diagnosis within an encounter, such as admission diagnosis or discharge diagnosis, use Encounter.diagnosis.role .
To represent the numeric ranking of the diagnosis within an encounter, such as primary, secondary, or tertiary, use Encounter.diagnosis.rank .
A
known
issue
exists
with
circular
references
between
Condition
and
ClinicalImpression,
ClinicalAssessment,
which
is
due
to
the
low
maturity
level
of
ClinicalImpression.
ClinicalAssessment.
The
Patient
Care
work
group
intends
to
address
this
issue
when
ClinicalImpression
ClinicalAssessment
is
considered
substantially
complete
and
ready
for
implementation.
Search parameters for this resource. See also the full list of search parameters for this resource , and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
| Name | Type | Description | Expression | In Common |
| abatement-age | quantity | Abatement as age or age range |
|
|
| abatement-date | date | Date-related abatements (dateTime and period) |
|
|
| abatement-string | string | Abatement as a string |
|
|
| asserter | reference |
Person
|
Condition.asserter
( Practitioner , Group , Device , Patient , PractitionerRole , RelatedPerson ) |
|
| body-site | token | Anatomical location, if relevant | Condition.bodySite | |
| category | token | The category of the condition | Condition.category | |
| clinical-status | token | The clinical status of the condition | Condition.clinicalStatus | |
| code | token | Code for the condition | Condition.code |
|
| encounter | reference |
The
Encounter
during
which
this
Condition
was
created
|
Condition.encounter
( Encounter ) |
29 Resources |
| evidence | token | Manifestation/symptom |
|
|
| evidence-detail | reference | Supporting information found elsewhere |
|
|
| identifier | token | A unique identifier of the condition record | Condition.identifier |
|
| onset-age | quantity | Onsets as age or age range |
|
|
| onset-date | date | Date related onsets (dateTime and Period) |
|
|
| onset-info | string | Onsets as a string |
|
|
| patient | reference | Who has the condition? |
Condition.subject.where(resolve()
is
Patient)
( Patient ) |
|
| recorded-date | date | Date record was first recorded | Condition.recordedDate | |
| severity | token | The severity of the condition | Condition.severity | |
| stage | token | Simple summary (disease specific) | Condition.stage.summary | |
| subject | reference | Who has the condition? |
Condition.subject
( Group , Patient ) |
|
| verification-status | token | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | Condition.verificationStatus |
FHIR
®©
HL7.org
2011+.
FHIR
Release
4
(Technical
Correction
#1)
(v4.0.1)
R6
hl7.fhir.core#6.0.0-ballot3
generated
on
Fri,
Nov
1,
2019
09:34+1100.
QA
Page
7,
2025
10:09+0000.
Links:
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|
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Contents
|
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|
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|
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|
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