DSTU2 STU 3 Candidate
This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . For a full list of available versions, see the Directory of published versions . Page versions: . Page versions: R5 R4B R4 R3 R2

4.3 Resource Condition - Content Resource Condition - Content

Use to record detailed information about conditions, problems or diagnoses recognized by a clinician. There are many uses including: recording a diagnosis during an encounter; populating a problem list or a summary statement, such as a discharge summary.
Patient Care Patient Care Work Group Work Group Maturity Level : 2 Maturity Level : 2 Compartments : : Encounter , , Patient , , Practitioner

Use to record detailed information about conditions, problems or diagnoses recognized by a clinician. There are many uses including: recording a diagnosis during an encounter; populating a problem list or a summary statement, such as a discharge summary.

4.3.1 Scope and Usage Scope and Usage Used to record detailed information pertinent to a clinician's assessment and assertion of a particular aspect of a person's state of health. Examples of condition include problems, diagnoses, concerns, issues. There are many uses of condition which include: recording a problem, diagnosis, health concern or health issue during an encounter the use of such information to populate a problem list of a summary statement such as a discharge summary This resource is used to record detailed information about a clinician's assessment and assertion of a particular aspect of a patient's state of health. It is intended for use 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 require ongoing monitoring and/or management (health issue/concern), or identification of health issues/situations considered harmful, potentially harmful and required to be investigated and managed (problems). The condition resource may also be used to record certain health state of a patient which does not normally present negative outcome (until complications are predicted or detected), e.g. pregnancy. Examples of complications of pregnancy include: hyperemesis gravidarum, preeclampsia, eclampsia - which are captured as problems/diagnoses.

Used to record detailed information pertinent to a clinician's assessment and assertion of a particular aspect of a person's state of health. Examples of condition include problems, diagnoses, concerns, issues. There are many uses of condition which include:

  • recording a problem, diagnosis, health concern or health issue during an encounter
  • the use of such information to populate a problem list of a summary statement such as a discharge summary

This resource is used to record detailed information about a clinician's assessment and assertion of a particular aspect of a patient's state of health. It is intended for use 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 require ongoing monitoring and/or management (health issue/concern), or identification of health issues/situations considered harmful, potentially harmful and required to be investigated and managed (problems).

The condition resource may also be used to record certain health state of a patient which does not normally present negative outcome (until complications are predicted or detected), e.g. pregnancy. Examples of complications of pregnancy include: hyperemesis gravidarum, preeclampsia, eclampsia - which are captured as problems/diagnoses.

4.3.2 Boundaries and Relationships Boundaries and Relationships The condition resource may be referenced by other resources as "reasons" for an action (e.g.

The condition resource may be referenced by other resources as "reasons" for an action (e.g. MedicationOrder , , Procedure , , DiagnosticOrder , etc.) This resource is not to be used to record information about subjective and objective information that might lead to the recording of a Condition. Such signs and symptoms that are typically captured using the , etc.)

This resource is not to be used to record information about subjective and objective information that might lead to the recording of a Condition. Such signs and symptoms that 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. The condition resource also specifically excludes 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.

The condition resource also specifically excludes AllergyIntoelrance as those are handled with their own resource. This resource is referenced by as those are handled with their own resource.

This resource is referenced by CarePlan , , ClinicalImpression , , DiagnosticOrder , , Encounter , , EpisodeOfCare , , Goal , , MedicationOrder , , MedicationStatement , , Procedure , , ProcedureRequest , , Protocol , RiskAssessment and and VisionPrescription

4.3.3 Resource Content Resource Content

Structure

Name Flags Card. Type Description & Constraints Description & Constraints doco
. . Condition Σ DomainResource Detailed information about conditions, problems or diagnoses Detailed information about conditions, problems or diagnoses
. . . identifier Σ 0..* Identifier External Ids for this condition External Ids for this condition
. . . patient Σ 1..1 Reference ( Patient ) Who has the condition? Who has the condition?
. . . encounter Σ 0..1 Reference ( Encounter ) Encounter when condition first asserted Encounter when condition first asserted
. . . asserter Σ 0..1 Reference ( Practitioner | | Patient ) Person who asserts this condition Person who asserts this condition
. . . dateRecorded Σ 0..1 date When first entered When first entered
. . . code Σ 1..1 CodeableConcept Identification of the condition, problem or diagnosis Identification of the condition, problem or diagnosis
Condition/Problem/Diagnosis Codes ( Condition/Problem/Diagnosis Codes ( Example )
. . . category Σ 0..1 CodeableConcept complaint | symptom | finding | diagnosis complaint | symptom | finding | diagnosis
Condition Category Codes ( Condition Category Codes ( Preferred )
. . . clinicalStatus ?! ?! Σ 0..1 code active | relapse | remission | resolved active | relapse | remission | resolved
Condition Clinical Status Codes ( Condition Clinical Status Codes ( Preferred )
. . . verificationStatus ?! ?! Σ 1..1 code provisional | differential | confirmed | refuted | entered-in-error | unknown provisional | differential | confirmed | refuted | entered-in-error | unknown
ConditionVerificationStatus ( ( Required )
. . . severity Σ 0..1 CodeableConcept Subjective severity of condition Subjective severity of condition
Condition/Diagnosis Severity ( Condition/Diagnosis Severity ( Preferred )
. . . onset[x] Σ 0..1 Estimated or actual date, date-time, or age Estimated or actual date, date-time, or age
. . . . onsetDateTime dateTime
. . . onsetQuantity . onsetQuantity Age
. . . . onsetPeriod Period
. . . . onsetRange Range
. . . . onsetString string
. . . abatement[x] Σ 0..1 If/when in resolution/remission If/when in resolution/remission
. . . . abatementDateTime dateTime
. . . abatementQuantity . abatementQuantity Age
. . . . abatementBoolean boolean
. . . . abatementPeriod Period
. . . . abatementRange Range
. . . . abatementString string
. . . stage Σ Σ I 0..1 BackboneElement Stage/grade, usually assessed formally Stage/grade, usually assessed formally
Stage SHALL have summary or assessment Stage SHALL have summary or assessment
. . . . summary Σ Σ I 0..1 CodeableConcept Simple summary (disease specific) Simple summary (disease specific)
Condition Stage ( Condition Stage ( Example )
. . . . assessment Σ Σ I 0..* Reference ( ClinicalImpression | | DiagnosticReport | | Observation ) Formal record of assessment Formal record of assessment
. . . evidence Σ Σ I 0..* BackboneElement Supporting evidence Supporting evidence
evidence SHALL have code or details evidence SHALL have code or details
. . . . code Σ Σ I 0..1 CodeableConcept Manifestation/symptom
Manifestation and Symptom Codes ( Manifestation and Symptom Codes ( Example )
. . . . detail Σ Σ I 0..* Reference ( Any ) Supporting information found elsewhere Supporting information found elsewhere
. . . bodySite Σ 0..* CodeableConcept Anatomical location, if relevant Anatomical location, if relevant
SNOMED CT Body Structures ( SNOMED CT Body Structures ( Example )
. . . notes Σ 0..1 string Additional information about the Condition Additional information about the Condition

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

Condition ( ( DomainResource ) This records identifiers associated with this condition that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation) This records identifiers associated with this condition that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation) identifier : : Identifier [0..*] [0..*] Indicates the patient who the condition record is associated with Indicates the patient who the condition record is associated with patient : : Reference [1..1] « [1..1] « Patient » » Encounter during which the condition was first asserted Encounter during which the condition was first asserted encounter : : Reference [0..1] « [0..1] « Encounter » » Individual who is making the condition statement Individual who is making the condition statement asserter : : Reference [0..1] « [0..1] « Practitioner | Patient » » A date, when the Condition statement was documented A date, when the Condition statement was documented dateRecorded : : date [0..1] [0..1] Identification of the condition, problem or diagnosis Identification of the condition, problem or diagnosis code : : CodeableConcept [1..1] « [1..1] « Identification of the condition or diagnosis. (Strength=Example) Identification of the condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis ?? » Condition/Problem/Diagnosis ?? » A category assigned to the condition A category assigned to the condition category : : CodeableConcept [0..1] « [0..1] « A category assigned to the condition. (Strength=Preferred) A category assigned to the condition. (Strength=Preferred) Condition Category ? » Condition Category ? » The clinical status of the condition (this element modifies the meaning of other elements) The clinical status of the condition (this element modifies the meaning of other elements) clinicalStatus : : code [0..1] « [0..1] « The clinical status of the condition or diagnosis. (Strength=Preferred) The clinical status of the condition or diagnosis. (Strength=Preferred) Condition Clinical Status ? » Condition Clinical Status ? » The verification status to support the clinical status of the condition (this element modifies the meaning of other elements) The verification status to support the clinical status of the condition (this element modifies the meaning of other elements) verificationStatus : : code [1..1] « [1..1] « The verification status to support or decline the clinical status of the condition or diagnosis. (Strength=Required) The verification status to support or decline the clinical status of the condition or diagnosis. (Strength=Required) ConditionVerificationStatus ! » ! » A subjective assessment of the severity of the condition as evaluated by the clinician A subjective assessment of the severity of the condition as evaluated by the clinician severity : : CodeableConcept [0..1] « [0..1] « A subjective assessment of the severity of the condition as evaluated by the clinician. (Strength=Preferred) A subjective assessment of the severity of the condition as evaluated by the clinician. (Strength=Preferred) Condition/Diagnosis Severity Condition/Diagnosis Severity ? » ? » Estimated or actual date or date-time the condition began, in the opinion of the clinician Estimated or actual date or date-time the condition began, in the opinion of the clinician onset[x] : : Type [0..1] « [0..1] « dateTime | Quantity ( Age )| Period | Range | string » » The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate abatement[x] : : Type [0..1] « [0..1] « dateTime | Quantity ( Age )| boolean | Period | Range | string » » The anatomical location where this condition manifests itself The anatomical location where this condition manifests itself bodySite : : CodeableConcept [0..*] « [0..*] « Codes describing anatomical locations. May include laterality. (Strength=Example) Codes describing anatomical locations. May include laterality. (Strength=Example) SNOMED CT Body Structures SNOMED CT Body Structures ?? » ?? » Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis notes : : string [0..1] [0..1] Stage A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific summary : : CodeableConcept [0..1] « [0..1] « Codes describing condition stages (e.g. Cancer stages). (Strength=Example) Codes describing condition stages (e.g. Cancer stages). (Strength=Example) Condition Stage Condition Stage ?? » ?? » Reference to a formal record of the evidence on which the staging assessment is based Reference to a formal record of the evidence on which the staging assessment is based assessment : : Reference [0..*] « [0..*] « ClinicalImpression | DiagnosticReport | Observation » » Evidence A manifestation or symptom that led to the recording of this condition A manifestation or symptom that led to the recording of this condition code : : CodeableConcept [0..1] « [0..1] « Codes that describe the manifestation or symptoms of a condition. (Strength=Example) Codes that describe the manifestation or symptoms of a condition. (Strength=Example) Manifestation and Symptom ?? » Manifestation and Symptom ?? » Links to other relevant information, including pathology reports Links to other relevant information, including pathology reports detail : : Reference [0..*] « [0..*] « Any » » Clinical stage or grade of a condition. May include formal severity assessments Clinical stage or grade of a condition. May include formal severity assessments stage [0..1] Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed evidence [0..*]

XML Template XML Template 

<Condition xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <patient><!-- 1..1 Reference(Patient) Who has the condition? --></patient>
 <encounter><!-- 0..1 Reference(Encounter) Encounter when condition first asserted --></encounter>
 <asserter><!-- 0..1 Reference(Practitioner|Patient) Person who asserts this condition --></asserter>
 <dateRecorded value="[date]"/><!-- 0..1 When first entered -->
 <code><!-- 1..1 CodeableConcept Identification of the condition, problem or diagnosis --></code>
 <category><!-- 0..1 CodeableConcept complaint | symptom | finding | diagnosis --></category>
 <clinicalStatus value="[code]"/><!-- 0..1 active | relapse | remission | resolved -->
 <verificationStatus value="[code]"/><!-- 1..1 provisional | differential | confirmed | refuted | entered-in-error | unknown -->
 <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity>
 <onset[x]><!-- 0..1 dateTime|Quantity(Age)|Period|Range|string Estimated or actual date,  date-time, or age --></onset[x]>
 <abatement[x]><!-- 0..1 dateTime|Quantity(Age)|boolean|Period|Range|string If/when in resolution/remission --></abatement[x]>
 <stage>  <!-- 0..1 Stage/grade, usually assessed formally -->
  <summary><!-- ?? 0..1 CodeableConcept Simple summary (disease specific) --></summary>
  <assessment><!-- ?? 0..* Reference(ClinicalImpression|DiagnosticReport|Observation) Formal record of assessment --></assessment>
 </stage>
 <evidence>  <!-- 0..* Supporting evidence -->
  <code><!-- ?? 0..1 CodeableConcept Manifestation/symptom --></code>
  <detail><!-- ?? 0..* Reference(Any) Supporting information found elsewhere --></detail>
 </evidence>
 <bodySite><!-- 0..* CodeableConcept Anatomical location, if relevant --></bodySite>
 <notes value="[string]"/><!-- 0..1 Additional information about the Condition -->
</Condition>

JSON Template JSON Template 

{doco
  "resourceType" : "Condition",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this condition
  "patient" : { Reference(Patient) }, // R!  Who has the condition?
  "encounter" : { Reference(Encounter) }, // Encounter when condition first asserted
  "asserter" : { Reference(Practitioner|Patient) }, // Person who asserts this condition
  "dateRecorded" : "<date>", // When first entered
  "code" : { CodeableConcept }, // R!  Identification of the condition, problem or diagnosis
  "category" : { CodeableConcept }, // complaint | symptom | finding | diagnosis
  "clinicalStatus" : "<code>", // active | relapse | remission | resolved
  "verificationStatus" : "<code>", // R!  provisional | differential | confirmed | refuted | entered-in-error | unknown
  "severity" : { CodeableConcept }, // Subjective severity of condition
  // onset[x]: Estimated or actual date,  date-time, or age. One of these 5:
  "onsetDateTime" : "<dateTime>",
  "onsetQuantity" : { Quantity(Age) },
  "onsetPeriod" : { Period },
  "onsetRange" : { Range },
  "onsetString" : "<string>",
  // abatement[x]: If/when in resolution/remission. One of these 6:
  "abatementDateTime" : "<dateTime>",
  "abatementQuantity" : { Quantity(Age) },
  "abatementBoolean" : <boolean>,
  "abatementPeriod" : { Period },
  "abatementRange" : { Range },
  "abatementString" : "<string>",
  "stage" : { // Stage/grade, usually assessed formally
    "summary" : { CodeableConcept }, // C? Simple summary (disease specific)
    "assessment" : [{ Reference(ClinicalImpression|DiagnosticReport|Observation) }] // C? Formal record of assessment
  },
  "evidence" : [{ // Supporting evidence
    "code" : { CodeableConcept }, // C? Manifestation/symptom
    "detail" : [{ Reference(Any) }] // C? Supporting information found elsewhere
  }],
  "bodySite" : [{ CodeableConcept }], // Anatomical location, if relevant
  "notes" : "<string>" // Additional information about the Condition
}

Structure

Name Flags Card. Type Description & Constraints Description & Constraints doco
. . Condition Σ DomainResource Detailed information about conditions, problems or diagnoses Detailed information about conditions, problems or diagnoses
. . . identifier Σ 0..* Identifier External Ids for this condition External Ids for this condition
. . . patient Σ 1..1 Reference ( Patient ) Who has the condition? Who has the condition?
. . . encounter Σ 0..1 Reference ( Encounter ) Encounter when condition first asserted Encounter when condition first asserted
. . . asserter Σ 0..1 Reference ( Practitioner | | Patient ) Person who asserts this condition Person who asserts this condition
. . . dateRecorded Σ 0..1 date When first entered When first entered
. . . code Σ 1..1 CodeableConcept Identification of the condition, problem or diagnosis Identification of the condition, problem or diagnosis
Condition/Problem/Diagnosis Codes ( Condition/Problem/Diagnosis Codes ( Example )
. . . category Σ 0..1 CodeableConcept complaint | symptom | finding | diagnosis complaint | symptom | finding | diagnosis
Condition Category Codes ( Condition Category Codes ( Preferred )
. . . clinicalStatus ?! ?! Σ 0..1 code active | relapse | remission | resolved active | relapse | remission | resolved
Condition Clinical Status Codes ( Condition Clinical Status Codes ( Preferred )
. . . verificationStatus ?! ?! Σ 1..1 code provisional | differential | confirmed | refuted | entered-in-error | unknown provisional | differential | confirmed | refuted | entered-in-error | unknown
ConditionVerificationStatus ( ( Required )
. . . severity Σ 0..1 CodeableConcept Subjective severity of condition Subjective severity of condition
Condition/Diagnosis Severity ( Condition/Diagnosis Severity ( Preferred )
. . . onset[x] Σ 0..1 Estimated or actual date, date-time, or age Estimated or actual date, date-time, or age
. . . . onsetDateTime dateTime
. . . onsetQuantity . onsetQuantity Age
. . . . onsetPeriod Period
. . . . onsetRange Range
. . . . onsetString string
. . . abatement[x] Σ 0..1 If/when in resolution/remission If/when in resolution/remission
. . . . abatementDateTime dateTime
. . . abatementQuantity . abatementQuantity Age
. . . . abatementBoolean boolean
. . . . abatementPeriod Period
. . . . abatementRange Range
. . . . abatementString string
. . . stage Σ Σ I 0..1 BackboneElement Stage/grade, usually assessed formally Stage/grade, usually assessed formally
Stage SHALL have summary or assessment Stage SHALL have summary or assessment
. . . . summary Σ Σ I 0..1 CodeableConcept Simple summary (disease specific) Simple summary (disease specific)
Condition Stage ( Condition Stage ( Example )
. . . . assessment Σ Σ I 0..* Reference ( ClinicalImpression | | DiagnosticReport | | Observation ) Formal record of assessment Formal record of assessment
. . . evidence Σ Σ I 0..* BackboneElement Supporting evidence Supporting evidence
evidence SHALL have code or details evidence SHALL have code or details
. . . . code Σ Σ I 0..1 CodeableConcept Manifestation/symptom
Manifestation and Symptom Codes ( Manifestation and Symptom Codes ( Example )
. . . . detail Σ Σ I 0..* Reference ( Any ) Supporting information found elsewhere Supporting information found elsewhere
. . . bodySite Σ 0..* CodeableConcept Anatomical location, if relevant Anatomical location, if relevant
SNOMED CT Body Structures ( SNOMED CT Body Structures ( Example )
. . . notes Σ 0..1 string Additional information about the Condition Additional information about the Condition

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

Condition ( ( DomainResource ) This records identifiers associated with this condition that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation) This records identifiers associated with this condition that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation) identifier : : Identifier [0..*] [0..*] Indicates the patient who the condition record is associated with Indicates the patient who the condition record is associated with patient : : Reference [1..1] « [1..1] « Patient » » Encounter during which the condition was first asserted Encounter during which the condition was first asserted encounter : : Reference [0..1] « [0..1] « Encounter » » Individual who is making the condition statement Individual who is making the condition statement asserter : : Reference [0..1] « [0..1] « Practitioner | Patient » » A date, when the Condition statement was documented A date, when the Condition statement was documented dateRecorded : : date [0..1] [0..1] Identification of the condition, problem or diagnosis Identification of the condition, problem or diagnosis code : : CodeableConcept [1..1] « [1..1] « Identification of the condition or diagnosis. (Strength=Example) Identification of the condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis ?? » Condition/Problem/Diagnosis ?? » A category assigned to the condition A category assigned to the condition category : : CodeableConcept [0..1] « [0..1] « A category assigned to the condition. (Strength=Preferred) A category assigned to the condition. (Strength=Preferred) Condition Category ? » Condition Category ? » The clinical status of the condition (this element modifies the meaning of other elements) The clinical status of the condition (this element modifies the meaning of other elements) clinicalStatus : : code [0..1] « [0..1] « The clinical status of the condition or diagnosis. (Strength=Preferred) The clinical status of the condition or diagnosis. (Strength=Preferred) Condition Clinical Status ? » Condition Clinical Status ? » The verification status to support the clinical status of the condition (this element modifies the meaning of other elements) The verification status to support the clinical status of the condition (this element modifies the meaning of other elements) verificationStatus : : code [1..1] « [1..1] « The verification status to support or decline the clinical status of the condition or diagnosis. (Strength=Required) The verification status to support or decline the clinical status of the condition or diagnosis. (Strength=Required) ConditionVerificationStatus ! » ! » A subjective assessment of the severity of the condition as evaluated by the clinician A subjective assessment of the severity of the condition as evaluated by the clinician severity : : CodeableConcept [0..1] « [0..1] « A subjective assessment of the severity of the condition as evaluated by the clinician. (Strength=Preferred) A subjective assessment of the severity of the condition as evaluated by the clinician. (Strength=Preferred) Condition/Diagnosis Severity Condition/Diagnosis Severity ? » ? » Estimated or actual date or date-time the condition began, in the opinion of the clinician Estimated or actual date or date-time the condition began, in the opinion of the clinician onset[x] : : Type [0..1] « [0..1] « dateTime | Quantity ( Age )| Period | Range | string » » The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate abatement[x] : : Type [0..1] « [0..1] « dateTime | Quantity ( Age )| boolean | Period | Range | string » » The anatomical location where this condition manifests itself The anatomical location where this condition manifests itself bodySite : : CodeableConcept [0..*] « [0..*] « Codes describing anatomical locations. May include laterality. (Strength=Example) Codes describing anatomical locations. May include laterality. (Strength=Example) SNOMED CT Body Structures SNOMED CT Body Structures ?? » ?? » Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis notes : : string [0..1] [0..1] Stage A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific summary : : CodeableConcept [0..1] « [0..1] « Codes describing condition stages (e.g. Cancer stages). (Strength=Example) Codes describing condition stages (e.g. Cancer stages). (Strength=Example) Condition Stage Condition Stage ?? » ?? » Reference to a formal record of the evidence on which the staging assessment is based Reference to a formal record of the evidence on which the staging assessment is based assessment : : Reference [0..*] « [0..*] « ClinicalImpression | DiagnosticReport | Observation » » Evidence A manifestation or symptom that led to the recording of this condition A manifestation or symptom that led to the recording of this condition code : : CodeableConcept [0..1] « [0..1] « Codes that describe the manifestation or symptoms of a condition. (Strength=Example) Codes that describe the manifestation or symptoms of a condition. (Strength=Example) Manifestation and Symptom ?? » Manifestation and Symptom ?? » Links to other relevant information, including pathology reports Links to other relevant information, including pathology reports detail : : Reference [0..*] « [0..*] « Any » » Clinical stage or grade of a condition. May include formal severity assessments Clinical stage or grade of a condition. May include formal severity assessments stage [0..1] Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed evidence [0..*]

XML Template XML Template 

<Condition xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <patient><!-- 1..1 Reference(Patient) Who has the condition? --></patient>
 <encounter><!-- 0..1 Reference(Encounter) Encounter when condition first asserted --></encounter>
 <asserter><!-- 0..1 Reference(Practitioner|Patient) Person who asserts this condition --></asserter>
 <dateRecorded value="[date]"/><!-- 0..1 When first entered -->
 <code><!-- 1..1 CodeableConcept Identification of the condition, problem or diagnosis --></code>
 <category><!-- 0..1 CodeableConcept complaint | symptom | finding | diagnosis --></category>
 <clinicalStatus value="[code]"/><!-- 0..1 active | relapse | remission | resolved -->
 <verificationStatus value="[code]"/><!-- 1..1 provisional | differential | confirmed | refuted | entered-in-error | unknown -->
 <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity>
 <onset[x]><!-- 0..1 dateTime|Quantity(Age)|Period|Range|string Estimated or actual date,  date-time, or age --></onset[x]>
 <abatement[x]><!-- 0..1 dateTime|Quantity(Age)|boolean|Period|Range|string If/when in resolution/remission --></abatement[x]>
 <stage>  <!-- 0..1 Stage/grade, usually assessed formally -->
  <summary><!-- ?? 0..1 CodeableConcept Simple summary (disease specific) --></summary>
  <assessment><!-- ?? 0..* Reference(ClinicalImpression|DiagnosticReport|Observation) Formal record of assessment --></assessment>
 </stage>
 <evidence>  <!-- 0..* Supporting evidence -->
  <code><!-- ?? 0..1 CodeableConcept Manifestation/symptom --></code>
  <detail><!-- ?? 0..* Reference(Any) Supporting information found elsewhere --></detail>
 </evidence>
 <bodySite><!-- 0..* CodeableConcept Anatomical location, if relevant --></bodySite>
 <notes value="[string]"/><!-- 0..1 Additional information about the Condition -->
</Condition>

JSON Template JSON Template 

{doco
  "resourceType" : "Condition",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this condition
  "patient" : { Reference(Patient) }, // R!  Who has the condition?
  "encounter" : { Reference(Encounter) }, // Encounter when condition first asserted
  "asserter" : { Reference(Practitioner|Patient) }, // Person who asserts this condition
  "dateRecorded" : "<date>", // When first entered
  "code" : { CodeableConcept }, // R!  Identification of the condition, problem or diagnosis
  "category" : { CodeableConcept }, // complaint | symptom | finding | diagnosis
  "clinicalStatus" : "<code>", // active | relapse | remission | resolved
  "verificationStatus" : "<code>", // R!  provisional | differential | confirmed | refuted | entered-in-error | unknown
  "severity" : { CodeableConcept }, // Subjective severity of condition
  // onset[x]: Estimated or actual date,  date-time, or age. One of these 5:
  "onsetDateTime" : "<dateTime>",
  "onsetQuantity" : { Quantity(Age) },
  "onsetPeriod" : { Period },
  "onsetRange" : { Range },
  "onsetString" : "<string>",
  // abatement[x]: If/when in resolution/remission. One of these 6:
  "abatementDateTime" : "<dateTime>",
  "abatementQuantity" : { Quantity(Age) },
  "abatementBoolean" : <boolean>,
  "abatementPeriod" : { Period },
  "abatementRange" : { Range },
  "abatementString" : "<string>",
  "stage" : { // Stage/grade, usually assessed formally
    "summary" : { CodeableConcept }, // C? Simple summary (disease specific)
    "assessment" : [{ Reference(ClinicalImpression|DiagnosticReport|Observation) }] // C? Formal record of assessment
  },
  "evidence" : [{ // Supporting evidence
    "code" : { CodeableConcept }, // C? Manifestation/symptom
    "detail" : [{ Reference(Any) }] // C? Supporting information found elsewhere
  }],
  "bodySite" : [{ CodeableConcept }], // Anatomical location, if relevant
  "notes" : "<string>" // Additional information about the Condition
}

  Alternate definitions:

Alternate definitions: Schema / Schematron , Resource Profile ( , Resource Profile ( XML , , JSON ), ), Questionnaire

4.3.3.1 Terminology Bindings Terminology Bindings

Path Definition Type Reference
Condition.code Condition.code Identification of the condition or diagnosis. Identification of the condition or diagnosis. Example Condition/Problem/Diagnosis Codes Condition/Problem/Diagnosis Codes
Condition.category Condition.category A category assigned to the condition. A category assigned to the condition. Preferred Condition Category Codes Condition Category Codes
Condition.clinicalStatus Condition.clinicalStatus The clinical status of the condition or diagnosis. The clinical status of the condition or diagnosis. Preferred Condition Clinical Status Codes Condition Clinical Status Codes
Condition.verificationStatus Condition.verificationStatus The verification status to support or decline the clinical status of the condition or diagnosis. The verification status to support or decline the clinical status of the condition or diagnosis. Required ConditionVerificationStatus
Condition.severity Condition.severity A subjective assessment of the severity of the condition as evaluated by the clinician. A subjective assessment of the severity of the condition as evaluated by the clinician. Preferred Condition/Diagnosis Severity Condition/Diagnosis Severity
Condition.stage.summary Condition.stage.summary Codes describing condition stages (e.g. Cancer stages). Codes describing condition stages (e.g. Cancer stages). Example Condition Stage Condition Stage
Condition.evidence.code Condition.evidence.code Codes that describe the manifestation or symptoms of a condition. Codes that describe the manifestation or symptoms of a condition. Example Manifestation and Symptom Codes Manifestation and Symptom Codes
Condition.bodySite Condition.bodySite Codes describing anatomical locations. May include laterality. Codes describing anatomical locations. May include laterality. Example SNOMED CT Body Structures SNOMED CT Body Structures

4.3.3.2 Constraints Constraints

  • con-1 : On Condition.stage: Stage SHALL have summary or assessment (xpath on f:Condition/f:stage: exists(f:summary) or exists(f:assessment) : On Condition.stage: Stage SHALL have summary or assessment ( expression on Condition.stage: summary or assessment )
  • con-2 : On Condition.evidence: evidence SHALL have code or details (xpath on f:Condition/f:evidence: exists(f:code) or exists(f:detail) : On Condition.evidence: evidence SHALL have code or details ( expression on Condition.evidence: code or detail )

4.3.3.3 Use of Condition.code Use of Condition.code 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 of X" 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. 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.

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 of X" 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.

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.

4.3.3.4 Use of Condition.evidence Use of Condition.evidence The Condition.evidence provides the basis for whatever is present in Condition.code.

The Condition.evidence provides the basis for whatever is present in Condition.code.

4.3.3.5 Use of Condition.abatementRange Use of Condition.abatementRange A range is used to communicate age period of subject at time of abatement.

A range is used to communicate age period of subject at time of abatement.

4.3.3.6 Use of Condition.asserter Use of Condition.asserter 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.

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.

4.3.3.7 Use of Condition.clinicalStatus Use of Condition.clinicalStatus 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.

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.

4.3.4 Search Parameters Search Parameters Search parameters for this resource. The common parameters also apply. See

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services. for more information about searching in REST, messaging, and services.

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search
Name Type Description Paths
asserter reference Person who asserts this condition Person who asserts this condition Condition.asserter
( Patient , , Practitioner )
body-site token Anatomical location, if relevant Anatomical location, if relevant Condition.bodySite
category token The category of the condition The category of the condition Condition.category
clinicalstatus token The clinical status of the condition The clinical status of the condition Condition.clinicalStatus
code token Code for the condition Code for the condition Condition.code
date-recorded date A date, when the Condition statement was documented A date, when the Condition statement was documented Condition.dateRecorded
encounter reference Encounter when condition first asserted Encounter when condition first asserted Condition.encounter
( Encounter )
evidence token Manifestation/symptom Condition.evidence.code
identifier token A unique identifier of the condition record A unique identifier of the condition record Condition.identifier
onset date Date related onsets (dateTime and Period) Date related onsets (dateTime and Period) Condition.onset[x]
onset-info string Other onsets (boolean, age, range, string) Other onsets (boolean, age, range, string) Condition.onset[x]
patient reference Who has the condition? Who has the condition? Condition.patient
( Patient )
severity token The severity of the condition The severity of the condition Condition.severity
stage token Simple summary (disease specific) Simple summary (disease specific) Condition.stage.summary