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. 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.

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).

Need to allow connection to a wider workflow. Need to allow connection to a wider workflow.

Indicates the patient who the condition record is associated with. The clinical status of the condition.

Encounter during which the condition was first asserted. The verification status to support the clinical status of the condition.

Individual who is making the condition statement. A category assigned to the condition.

The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.

A date, when the Condition statement was documented. A subjective assessment of the severity of the condition as evaluated by the clinician.

The Date Recorded represents the date when this particular Condition record was created in the EHR, not the date of the most recent update in terms of when severity, abatement, etc. were specified.  The date of the last record modification can be retrieved from the resource metadata. Coding of the severity with a terminology is preferred, where possible.

Identification of the condition, problem or diagnosis. Identification of the condition, problem or diagnosis.

A category assigned to the condition. The anatomical location where this condition manifests itself.

The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. May be a summary code, or a reference to a very precise definition of the location, or both.

The clinical status of the condition. Indicates the patient or group who the condition record is associated with.

Group is typically used for veterinary or public health use cases.

The verification status to support the clinical status of the condition. Encounter during which the condition was first asserted.

This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".

A subjective assessment of the severity of the condition as evaluated by the clinician. Estimated or actual date or date-time the condition began, in the opinion of the clinician.

Coding of the severity with a terminology is preferred, where possible. Age is generally used when the patient reports an age at which the Condition began to occur.

Estimated or actual date or date-time the condition began, in the opinion of the clinician. 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.

Age is generally used when the patient reports an age at which the Condition began to occur. There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid.

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. A date, when the Condition statement was documented.

The Date Recorded represents the date when this particular Condition record was created in the EHR, not the date of the most recent update in terms of when severity, abatement, etc. were specified.  The date of the last record modification can be retrieved from the resource metadata.

Individual who is making the condition statement.

Clinical stage or grade of a condition. May include formal severity assessments. Clinical stage or grade of a condition. May include formal severity assessments.

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.

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.

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.

The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.

A manifestation or symptom that led to the recording of this condition. A manifestation or symptom that led to the recording of this condition.

Links to other relevant information, including pathology reports. Links to other relevant information, including pathology reports.

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.