FHIR Release 3 (STU) R4 Ballot #1 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.0.2: STU 3). (v3.3.0: R4 Ballot 2). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

9.2 Resource Condition - Content

Patient Care Work Group Maturity Level : 3   Trial Use Compartments : Encounter , Patient , Practitioner , RelatedPerson

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

9.2.1 Scope and Usage

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, 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 .

  • Unemployed
  • Without transportation (or other barriers)
  • Susceptibility to falls
  • Exposure to communicable disease
  • Family History of cardiovascular disease
  • Fear of cancer
  • Cardiac pacemaker
  • Amputee-BKA
  • Risk of Zika virus following travel to a country
  • Former smoker
  • Travel to a country planned (that warrants immunizations)
  • Motor Vehicle Accident
  • Patient has had coronary bypass graft

9.2.2 Boundaries and Relationships

The condition resource may be referenced by other resources as "reasons" "reasons" for an action (e.g. MedicationRequest , Procedure , ProcedureRequest 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.

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.

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 to be actionable for decision support .

This resource is referenced by AdverseEvent , Appointment , CarePlan , CareTeam , Claim , ClinicalImpression , Communication , CommunicationRequest , DeviceRequest , DeviceUseStatement , EligibilityRequest , Encounter , EpisodeOfCare , ExplanationOfBenefit , FamilyMemberHistory , Goal , GuidanceResponse , ImagingStudy , Immunization , MedicationAdministration , MedicationRequest , MedicationStatement , Procedure , ProcedureRequest RequestGroup , ReferralRequest ResearchStudy , RiskAssessment , ServiceRequest , SupplyRequest and VisionPrescription

9.2.3 Resource Content

Structure

abatementBoolean
Name Flags Card. Type Description & Constraints doco
. . Condition I TU DomainResource Detailed information about conditions, problems or diagnoses
+ Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
+ If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
+ Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier External Ids for this condition
. . . clinicalStatus ?! Σ I 0..1 code active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
Condition Clinical Status Codes ( Required )
. . . verificationStatus ?! Σ I 0..1 code unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknown
ConditionVerificationStatus ( Required )
. . . category 0..* CodeableConcept problem-list-item | encounter-diagnosis
Condition Category Codes ( Example )
. . . severity 0..1 CodeableConcept Subjective severity of condition
Condition/Diagnosis Severity ( Preferred )
. . . code Σ 0..1 CodeableConcept Identification of the condition, problem or diagnosis
Condition/Problem/Diagnosis Codes ( Example )
. . . bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
SNOMED CT Body Structures ( Example )
. . . subject Σ 1..1 Reference ( Patient | Group ) Who has the condition?
. . . context Σ 0..1 Reference ( Encounter | EpisodeOfCare ) Encounter or episode when condition first asserted
. . . 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] I 0..1 If/when When in resolution/remission
. . . . abatementDateTime dateTime
. . . . abatementAge Age boolean Age
. . . . abatementPeriod Period
. . . . abatementRange Range
. . . . abatementString string
. . . assertedDate Σ 0..1 dateTime Date record was believed accurate
. . . recorder Σ 0..1 Reference ( Practitioner | Patient | RelatedPerson ) Who recorded the condition
... asserter Σ 0..1 Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson ) Person who asserts this condition
. . . stage I 0..1 0..* BackboneElement Stage/grade, usually assessed formally
+ Stage SHALL have summary or assessment
. . . . summary I 0..1 CodeableConcept Simple summary (disease specific)
Condition Stage ( Example )
. . . . assessment I 0..* Reference ( ClinicalImpression | DiagnosticReport | Observation ) Formal record of assessment
. . . . type 0..1 CodeableConcept Kind of staging
Condition Stage Type ( Example )
. . . evidence I 0..* BackboneElement Supporting evidence
+ evidence SHALL have code or details
. . . . code Σ I 0..* CodeableConcept Manifestation/symptom
Manifestation and Symptom Codes ( Example )
. . . . detail Σ I 0..* Reference ( Any ) Supporting information found elsewhere
. . . note 0..* Annotation Additional information about the Condition

doco Documentation for this format

UML Diagram ( Legend )

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

XML Template 

<

<Condition xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <
 <

 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <clinicalStatus value="[code]"/><!-- ?? 0..1 active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved -->
 <verificationStatus value="[code]"/><!-- ?? 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error -->

 <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><!-- 0..* CodeableConcept Anatomical location, if relevant --></bodySite>
 <subject><!-- 1..1 Reference(Patient|Group) Who has the condition? --></subject>
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter or episode when condition first asserted --></context>
 <onset[x]><!-- 0..1 dateTime|Age|Period|Range|string Estimated or actual date,  date-time, or age --></onset[x]>
 <</abatement[x]>
 <
 <</asserter>
 <

 <abatement[x]><!-- ?? 0..1 dateTime|Age|Period|Range|string When in resolution/remission --></abatement[x]>
 <assertedDate value="[dateTime]"/><!-- 0..1 Date record was believed accurate -->
 <recorder><!-- 0..1 Reference(Practitioner|Patient|RelatedPerson) Who recorded the condition --></recorder>
 <asserter><!-- 0..1 Reference(Practitioner|PractitionerRole|Patient|
   RelatedPerson) Person who asserts this condition --></asserter>

 <stage>  <!-- 0..* 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>
  <type><!-- 0..1 CodeableConcept Kind of staging --></type>

 </stage>
 <

 <evidence>  <!-- 0..* Supporting evidence -->

  <code><!-- ?? 0..* CodeableConcept Manifestation/symptom --></code>
  <detail><!-- ?? 0..* Reference(Any) Supporting information found elsewhere --></detail>
 </evidence>
 <note><!-- 0..* Annotation Additional information about the Condition --></note>
</Condition>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "Condition",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // External Ids for this condition
  "clinicalStatus" : "<code>", // C? active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  "verificationStatus" : "<code>", // C? 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 }], // Anatomical location, if relevant
  "subject" : { Reference(Patient|Group) }, // R!  Who has the condition?
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter or episode when condition first asserted

  // 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>",
  "assertedDate" : "<dateTime>", // Date record was believed accurate
  "recorder" : { Reference(Practitioner|Patient|RelatedPerson) }, // Who recorded the condition
  "asserter" : { Reference(Practitioner|PractitionerRole|Patient|
   RelatedPerson) }, // Person who asserts this condition

  "stage" : [{ // Stage/grade, usually assessed formally
    "summary" : { CodeableConcept }, // C? Simple summary (disease specific)
    "assessment" : [{ Reference(ClinicalImpression|DiagnosticReport|Observation) }], // C? Formal record of assessment
    "type" : { CodeableConcept } // Kind of staging

  }],
  "

  "evidence" : [{ // Supporting evidence
    "code" : [{ CodeableConcept }], // C? Manifestation/symptom
    "detail" : [{ Reference(Any) }] // C? Supporting information found elsewhere
  }],
  "note" : [{ Annotation }] // Additional information about the Condition

}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:Condition;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:
  fhir:

  fhir:Condition.identifier [ Identifier ], ... ; # 0..* External Ids for this condition
  fhir:Condition.clinicalStatus [ code ]; # 0..1 active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  fhir:Condition.verificationStatus [ code ]; # 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error

  fhir:Condition.category [ CodeableConcept ], ... ; # 0..* problem-list-item | encounter-diagnosis
  fhir:Condition.severity [ CodeableConcept ]; # 0..1 Subjective severity of condition
  fhir:Condition.code [ CodeableConcept ]; # 0..1 Identification of the condition, problem or diagnosis
  fhir:Condition.bodySite [ CodeableConcept ], ... ; # 0..* Anatomical location, if relevant
  fhir:Condition.subject [ Reference(Patient|Group) ]; # 1..1 Who has the condition?
  fhir:Condition.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Encounter or episode when condition first asserted
  # Condition.onset[x] : 0..1 Estimated or actual date,  date-time, or age. One of these 5
    fhir:Condition.onsetDateTime [ dateTime ]
    fhir:Condition.onsetAge [ Age ]
    fhir:Condition.onsetPeriod [ Period ]
    fhir:Condition.onsetRange [ Range ]
    fhir:Condition.onsetString [ string ]
  # . One of these 6

  # Condition.abatement[x] : 0..1 When in resolution/remission. One of these 5

    fhir:Condition.abatementDateTime [ dateTime ]
    fhir:Condition.abatementAge [ Age ]
    fhir: ]

    fhir:Condition.abatementPeriod [ Period ]
    fhir:Condition.abatementRange [ Range ]
    fhir:Condition.abatementString [ string ]
  fhir:
  fhir:
  fhir:

  fhir:Condition.assertedDate [ dateTime ]; # 0..1 Date record was believed accurate
  fhir:Condition.recorder [ Reference(Practitioner|Patient|RelatedPerson) ]; # 0..1 Who recorded the condition
  fhir:Condition.asserter [ Reference(Practitioner|PractitionerRole|Patient|RelatedPerson) ]; # 0..1 Person who asserts this condition
  fhir:Condition.stage [ # 0..* Stage/grade, usually assessed formally

    fhir:Condition.stage.summary [ CodeableConcept ]; # 0..1 Simple summary (disease specific)
    fhir:Condition.stage.assessment [ Reference(ClinicalImpression|DiagnosticReport|Observation) ], ... ; # 0..* Formal record of assessment
  ];
  fhir:

    fhir:Condition.stage.type [ CodeableConcept ]; # 0..1 Kind of staging
  ], ...;
  fhir:Condition.evidence [ # 0..* Supporting evidence

    fhir:Condition.evidence.code [ CodeableConcept ], ... ; # 0..* Manifestation/symptom
    fhir:Condition.evidence.detail [ Reference(Any) ], ... ; # 0..* Supporting information found elsewhere
  ], ...;
  fhir:Condition.note [ Annotation ], ... ; # 0..* Additional information about the Condition
]

Changes since DSTU2 R3

Condition.clinicalStatus
Condition Add Binding http://hl7.org/fhir/ValueSet/condition-clinical (required)
Condition.verificationStatus
  • Min Cardinality changed from 1 to 0 Default Value "unknown" added Condition.category Max Cardinality changed from 1 to * Condition.code Min Cardinality changed from 1 to 0 Condition.subject Renamed from patient to subject Add Reference(Group) Condition.context Renamed from encounter to context Add Reference(EpisodeOfCare) "unknown" removed
Condition.onset[x] Condition.abatement[x]
  • Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Add Age boolean
Condition.abatement[x] Condition.recorder
  • Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Add Age Added Element
Condition.assertedDate Condition.asserter
  • Renamed from dateRecorded to assertedDate Type changed from date Reference(Practitioner|Patient|RelatedPerson) to dateTime Condition.asserter Add Reference(RelatedPerson) Reference(Practitioner|PractitionerRole|Patient|RelatedPerson)
Condition.evidence.code Condition.stage
  • Max Cardinality changed from 1 to *
Condition.note Condition.stage.type
  • Renamed from notes to note Max Cardinality changed from 1 to * Type changed from string to Annotation Added Element

See the Full Difference for further information

This analysis is available as XML or JSON .

See R2 <--> R3 Conversion Maps (status = 14 tests that all execute ok. 11 fail round-trip testing and 14 r3 resources are invalid (14 errors). ). Note: these have note yet been updated to be R3 to R4

Structure

abatementBoolean
Name Flags Card. Type Description & Constraints doco
. . Condition I TU DomainResource Detailed information about conditions, problems or diagnoses
+ Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
+ If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
+ Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier External Ids for this condition
. . . clinicalStatus ?! Σ I 0..1 code active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
Condition Clinical Status Codes ( Required )
. . . verificationStatus ?! Σ I 0..1 code unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknown
ConditionVerificationStatus ( Required )
. . . category 0..* CodeableConcept problem-list-item | encounter-diagnosis
Condition Category Codes ( Example )
. . . severity 0..1 CodeableConcept Subjective severity of condition
Condition/Diagnosis Severity ( Preferred )
. . . code Σ 0..1 CodeableConcept Identification of the condition, problem or diagnosis
Condition/Problem/Diagnosis Codes ( Example )
. . . bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
SNOMED CT Body Structures ( Example )
. . . subject Σ 1..1 Reference ( Patient | Group ) Who has the condition?
. . . context Σ 0..1 Reference ( Encounter | EpisodeOfCare ) Encounter or episode when condition first asserted
. . . 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] I 0..1 If/when When in resolution/remission
. . . . abatementDateTime dateTime
. . . . abatementAge Age boolean Age
. . . . abatementPeriod Period
. . . . abatementRange Range
. . . . abatementString string
. . . assertedDate Σ 0..1 dateTime Date record was believed accurate
. . . recorder Σ 0..1 Reference ( Practitioner | Patient | RelatedPerson ) Who recorded the condition
... asserter Σ 0..1 Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson ) Person who asserts this condition
. . . stage I 0..1 0..* BackboneElement Stage/grade, usually assessed formally
+ Stage SHALL have summary or assessment
. . . . summary I 0..1 CodeableConcept Simple summary (disease specific)
Condition Stage ( Example )
. . . . assessment I 0..* Reference ( ClinicalImpression | DiagnosticReport | Observation ) Formal record of assessment
. . . . type 0..1 CodeableConcept Kind of staging
Condition Stage Type ( Example )
. . . evidence I 0..* BackboneElement Supporting evidence
+ evidence SHALL have code or details
. . . . code Σ I 0..* CodeableConcept Manifestation/symptom
Manifestation and Symptom Codes ( Example )
. . . . detail Σ I 0..* Reference ( Any ) Supporting information found elsewhere
. . . note 0..* Annotation Additional information about the Condition

doco Documentation for this format

UML Diagram ( Legend )

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

XML Template 

<

<Condition xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <
 <

 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <clinicalStatus value="[code]"/><!-- ?? 0..1 active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved -->
 <verificationStatus value="[code]"/><!-- ?? 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error -->

 <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><!-- 0..* CodeableConcept Anatomical location, if relevant --></bodySite>
 <subject><!-- 1..1 Reference(Patient|Group) Who has the condition? --></subject>
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter or episode when condition first asserted --></context>
 <onset[x]><!-- 0..1 dateTime|Age|Period|Range|string Estimated or actual date,  date-time, or age --></onset[x]>
 <</abatement[x]>
 <
 <</asserter>
 <

 <abatement[x]><!-- ?? 0..1 dateTime|Age|Period|Range|string When in resolution/remission --></abatement[x]>
 <assertedDate value="[dateTime]"/><!-- 0..1 Date record was believed accurate -->
 <recorder><!-- 0..1 Reference(Practitioner|Patient|RelatedPerson) Who recorded the condition --></recorder>
 <asserter><!-- 0..1 Reference(Practitioner|PractitionerRole|Patient|
   RelatedPerson) Person who asserts this condition --></asserter>

 <stage>  <!-- 0..* 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>
  <type><!-- 0..1 CodeableConcept Kind of staging --></type>

 </stage>
 <

 <evidence>  <!-- 0..* Supporting evidence -->

  <code><!-- ?? 0..* CodeableConcept Manifestation/symptom --></code>
  <detail><!-- ?? 0..* Reference(Any) Supporting information found elsewhere --></detail>
 </evidence>
 <note><!-- 0..* Annotation Additional information about the Condition --></note>
</Condition>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "Condition",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // External Ids for this condition
  "clinicalStatus" : "<code>", // C? active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  "verificationStatus" : "<code>", // C? 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 }], // Anatomical location, if relevant
  "subject" : { Reference(Patient|Group) }, // R!  Who has the condition?
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter or episode when condition first asserted

  // 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>",
  "assertedDate" : "<dateTime>", // Date record was believed accurate
  "recorder" : { Reference(Practitioner|Patient|RelatedPerson) }, // Who recorded the condition
  "asserter" : { Reference(Practitioner|PractitionerRole|Patient|
   RelatedPerson) }, // Person who asserts this condition

  "stage" : [{ // Stage/grade, usually assessed formally
    "summary" : { CodeableConcept }, // C? Simple summary (disease specific)
    "assessment" : [{ Reference(ClinicalImpression|DiagnosticReport|Observation) }], // C? Formal record of assessment
    "type" : { CodeableConcept } // Kind of staging

  }],
  "

  "evidence" : [{ // Supporting evidence
    "code" : [{ CodeableConcept }], // C? Manifestation/symptom
    "detail" : [{ Reference(Any) }] // C? Supporting information found elsewhere
  }],
  "note" : [{ Annotation }] // Additional information about the Condition

}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:Condition;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:
  fhir:

  fhir:Condition.identifier [ Identifier ], ... ; # 0..* External Ids for this condition
  fhir:Condition.clinicalStatus [ code ]; # 0..1 active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  fhir:Condition.verificationStatus [ code ]; # 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error

  fhir:Condition.category [ CodeableConcept ], ... ; # 0..* problem-list-item | encounter-diagnosis
  fhir:Condition.severity [ CodeableConcept ]; # 0..1 Subjective severity of condition
  fhir:Condition.code [ CodeableConcept ]; # 0..1 Identification of the condition, problem or diagnosis
  fhir:Condition.bodySite [ CodeableConcept ], ... ; # 0..* Anatomical location, if relevant
  fhir:Condition.subject [ Reference(Patient|Group) ]; # 1..1 Who has the condition?
  fhir:Condition.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Encounter or episode when condition first asserted
  # Condition.onset[x] : 0..1 Estimated or actual date,  date-time, or age. One of these 5
    fhir:Condition.onsetDateTime [ dateTime ]
    fhir:Condition.onsetAge [ Age ]
    fhir:Condition.onsetPeriod [ Period ]
    fhir:Condition.onsetRange [ Range ]
    fhir:Condition.onsetString [ string ]
  # . One of these 6

  # Condition.abatement[x] : 0..1 When in resolution/remission. One of these 5

    fhir:Condition.abatementDateTime [ dateTime ]
    fhir:Condition.abatementAge [ Age ]
    fhir: ]

    fhir:Condition.abatementPeriod [ Period ]
    fhir:Condition.abatementRange [ Range ]
    fhir:Condition.abatementString [ string ]
  fhir:
  fhir:
  fhir:

  fhir:Condition.assertedDate [ dateTime ]; # 0..1 Date record was believed accurate
  fhir:Condition.recorder [ Reference(Practitioner|Patient|RelatedPerson) ]; # 0..1 Who recorded the condition
  fhir:Condition.asserter [ Reference(Practitioner|PractitionerRole|Patient|RelatedPerson) ]; # 0..1 Person who asserts this condition
  fhir:Condition.stage [ # 0..* Stage/grade, usually assessed formally

    fhir:Condition.stage.summary [ CodeableConcept ]; # 0..1 Simple summary (disease specific)
    fhir:Condition.stage.assessment [ Reference(ClinicalImpression|DiagnosticReport|Observation) ], ... ; # 0..* Formal record of assessment
  ];
  fhir:

    fhir:Condition.stage.type [ CodeableConcept ]; # 0..1 Kind of staging
  ], ...;
  fhir:Condition.evidence [ # 0..* Supporting evidence

    fhir:Condition.evidence.code [ CodeableConcept ], ... ; # 0..* Manifestation/symptom
    fhir:Condition.evidence.detail [ Reference(Any) ], ... ; # 0..* Supporting information found elsewhere
  ], ...;
  fhir:Condition.note [ Annotation ], ... ; # 0..* Additional information about the Condition
]

Changes since DSTU2

Condition.clinicalStatus
Condition Add Binding http://hl7.org/fhir/ValueSet/condition-clinical (required)
Condition.verificationStatus
  • Min Cardinality changed from 1 to 0 Default Value "unknown" added Condition.category Max Cardinality changed from 1 to * Condition.code Min Cardinality changed from 1 to 0 Condition.subject Renamed from patient to subject Add Reference(Group) Condition.context Renamed from encounter to context Add Reference(EpisodeOfCare) "unknown" removed
Condition.onset[x] Condition.abatement[x]
  • Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Add Age boolean
Condition.abatement[x] Condition.recorder
  • Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Add Age Added Element
Condition.assertedDate Condition.asserter
  • Renamed from dateRecorded to assertedDate Type changed from date Reference(Practitioner|Patient|RelatedPerson) to dateTime Condition.asserter Add Reference(RelatedPerson) Reference(Practitioner|PractitionerRole|Patient|RelatedPerson)
Condition.evidence.code Condition.stage
  • Max Cardinality changed from 1 to *
Condition.note Condition.stage.type
  • Renamed from notes to note Max Cardinality changed from 1 to * Type changed from string to Annotation Added Element

See the Full Difference for further information

This analysis is available as XML or JSON .

See R2 <--> R3 Conversion Maps (status = 14 tests that all execute ok. 11 fail round-trip testing and 14 r3 resources are invalid (14 errors). ). Note: these have note yet been updated to be R3 to R4

 

Alternate definitions: Master Definition ( XML , + JSON ), , XML Schema / Schematron (for ) + JSON Schema , ShEx (for Turtle ) + see the extensions & the dependency analysis

9.2.3.1 Terminology Bindings

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

9.2.3.2 Constraints

  • con-1 : On Condition.stage: Stage SHALL have summary or assessment ( expression on Condition.stage: summary.exists() or assessment.exists() )
  • con-2 : On Condition.evidence: evidence SHALL have code or details ( expression on Condition.evidence: code.exists() or detail.exists() )
  • con-3 : Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error ( expression : verificationStatus='entered-in-error' or clinicalStatus.exists() )
  • con-4 : If condition is abated, then clinicalStatus must be either inactive, resolved, or remission ( expression : abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive' )
  • con-5 : Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error ( expression : verificationStatus!='entered-in-error' or clinicalStatus.empty() )

9.2.3.3 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 as "history of X" and "good health", X" and "good health", where it is useful or appropriate to make such assertions. It can also be used to capture "risk of" "risk of" and "fear of", "fear of", in addition to physical conditions, as well as "no "no known problems" problems" or "negated" "negated" conditions (e.g., "no X" "no X" or "no "no history of X" X" - see the following section for "No "No Known Problems" 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.

9.2.3.4 "No "No Known Problems" Problems" and Negated Conditions

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". 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 "no known problems" 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 "no known problems" problems" record and you add a "diabetes" "diabetes" condition record, then be sure that you remove the "no "no known problems" problems" record.

STU Note: There are two primary ways of reporting "no "no known problems" problems" in the current specification: using the CodeableConcept, as described above, or using the List resource with emptyReason. During the STU period, feedback is sought regarding the preferred approach.

Provide feedback here .

Patient Denies Condition

When the patient denies a condition, that can be annotated in the Condition.note element.

9.2.3.5 Assertions of Condition Absence

Generally, electronic records do not contain assertions of conditions that a patient does not have. There are however two exceptions:

  • It is appropriate to capture a "refuted" "refuted" Condition record if the patient or anyone else had reason to believe that a patient did have a condition for a period of time and subsequent evidence has demonstrated that belief was mistaken. In this case, a concrete statement acknowledging the belief as well as the refutation of it is useful.
  • It is common as part of checklists prior to admission, surgery, enrollment in trials, etc. to ask questions such as "are "are you pregnant", "do pregnant", "do you have a history of hypertension", hypertension", etc. This information should NOT be captured using the Condition resource but should instead be captured using QuestionnaireResponse or Observation. In this case, the combination of the question and answer would convey that a particular condition was not present.

9.2.3.6 Use of Condition.evidence

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

9.2.3.7 Use of Condition.abatementRange

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

9.2.3.8 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.

9.2.3.9 Use of Condition.clinicalStatus

The Condition.stage and Condition.clinicalStatus may have interdependencies. For example, some "stages" "stages" of cancer, etc. will be different for a remission than for the initial occurrence.

9.2.3.10 Diagnosis Role and Rank within an Encounter

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 .

9.2.3.11 Known Issue

A known issue exists with circular references between Condition and ClinicalImpression, which is due to the low maturity level of ClinicalImpression. The Patient Care work group intends to address this issue when ClinicalImpression is considered substantially complete and ready for implementation.

9.2.4 Search Parameters

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

abatement-boolean
Name Type Description Expression In Common
abatement-age quantity Abatement as age or age range Condition.abatement.as(Age) | Condition.abatement.as(Range) | Condition.abatement.as(Age) token Abatement boolean (boolean is true or non-boolean values are present) Condition.abatement.as(boolean) | Condition.abatement.is(dateTime) | Condition.abatement.is(Age) | Condition.abatement.is(Period) | Condition.abatement.is(Range) | Condition.abatement.is(string)
abatement-date date Date-related abatements (dateTime and period) Condition.abatement.as(dateTime) | Condition.abatement.as(Period)
abatement-string string Abatement as a string Condition.abatement.as(string)
asserted-date date Date record was believed accurate Condition.assertedDate
asserter reference Person who asserts this condition Condition.asserter
( Practitioner , 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 8 Resources
context reference Encounter or episode when condition first asserted Condition.context
( EpisodeOfCare , Encounter )
encounter reference Encounter when condition first asserted Condition.context
( Encounter )
evidence token Manifestation/symptom Condition.evidence.code
evidence-detail reference Supporting information found elsewhere Condition.evidence.detail
(Any)
identifier token A unique identifier of the condition record Condition.identifier 26 Resources
onset-age quantity Onsets as age or age range Condition.onset.as(Age) | Condition.onset.as(Range)
onset-date date Date related onsets (dateTime and Period) Condition.onset.as(dateTime) | Condition.onset.as(Period)
onset-info string Onsets as a string Condition.onset.as(string)
patient reference Who has the condition? Condition.subject
( Patient ) 		31 29 Resources
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 | unknown Condition.verificationStatus