This
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FHIR
Specification
(v5.0.0:
(v5.0.0-draft-final:
Final
QA
Preview
for
R5
-
STU
see
ballot
notes
).
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the
The
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version
is
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.
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versions:
R5
R4B
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Work
Group
|
Maturity
Level
:
|
Trial
Use
|
Security Category : Patient |
Compartments
:
|
Detailed Descriptions for the elements in the Condition resource.
|
|
|||||||||||||
| Element Id | Condition | ||||||||||||
| Definition | A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. | ||||||||||||
| Short Display | Detailed information about conditions, problems or diagnoses | ||||||||||||
| Cardinality | 0..* | ||||||||||||
| Type |
|
||||||||||||
| Summary | false | ||||||||||||
| Invariants |
| ||||||||||||
| Condition.identifier | |||||||||||||
| Element Id | Condition.identifier | ||||||||||||
| Definition |
| ||||||||||||
| Short Display | External Ids for this condition | ||||||||||||
| Note | This is a business identifier, not a resource identifier (see discussion ) | ||||||||||||
| Cardinality | 0..* | ||||||||||||
| Type | Identifier | ||||||||||||
| Requirements | Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. | ||||||||||||
| Summary | true | ||||||||||||
| Comments | This is a business identifier, not a resource identifier (see discussion ). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. | ||||||||||||
| Condition.clinicalStatus | |||||||||||||
| Element Id | Condition.clinicalStatus | ||||||||||||
| Definition | The clinical status of the condition. | ||||||||||||
| Short Display | active | recurrence | relapse | inactive | remission | resolved | unknown | ||||||||||||
| Cardinality | 1..1 | ||||||||||||
| Terminology Binding |
Condition
Clinical
Status
Codes
(
| ||||||||||||
| Type | CodeableConcept | ||||||||||||
| Is Modifier | true (Reason: This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.) | ||||||||||||
| Summary | true | ||||||||||||
| Comments | The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. clinicalStatus is required since it is a modifier element. For conditions that are problems list items, the clinicalStatus should not be unknown. For conditions that are not problem list items, the clinicalStatus may be unknown. For example, conditions derived from a claim are point in time, so those conditions may have a clinicalStatus of unknown | ||||||||||||
| Invariants |
| ||||||||||||
| Condition.verificationStatus | |||||||||||||
| Element Id | Condition.verificationStatus | ||||||||||||
| Definition | The verification status to support the clinical status of the condition. The verification status pertains to the condition, itself, not to any specific condition attribute. | ||||||||||||
| Short Display | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Terminology Binding | Condition Verification Status ( Required ) | ||||||||||||
| Type | CodeableConcept | ||||||||||||
| Is Modifier | true (Reason: This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.) | ||||||||||||
| Summary | true | ||||||||||||
| Comments | verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. |
||||||||||||
| Condition.category | |||||||||||||
| Element Id | Condition.category | ||||||||||||
| Definition |
A category assigned to the condition. | ||||||||||||
| Short Display | problem-list-item | encounter-diagnosis | ||||||||||||
| Cardinality | 0..* | ||||||||||||
| Terminology Binding | Condition Category Codes ( Preferred ) | ||||||||||||
| Type | CodeableConcept | ||||||||||||
| Summary | false | ||||||||||||
| Comments | The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. | ||||||||||||
| Invariants |
| ||||||||||||
| Condition.severity | |||||||||||||
| Element Id | Condition.severity | ||||||||||||
| Definition | A subjective assessment of the severity of the condition as evaluated by the clinician. | ||||||||||||
| Short Display | Subjective severity of condition | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Terminology Binding | Condition/Diagnosis Severity ( Preferred ) | ||||||||||||
| Type | CodeableConcept | ||||||||||||
| Summary | false | ||||||||||||
| Comments | Coding of the severity with a terminology is preferred, where possible. | ||||||||||||
| Condition.code | |||||||||||||
| Element Id | Condition.code | ||||||||||||
| Definition | Identification of the condition, problem or diagnosis. | ||||||||||||
| Short Display | Identification of the condition, problem or diagnosis | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Terminology Binding | Condition/Problem/Diagnosis Codes ( Example ) | ||||||||||||
| Type | CodeableConcept | ||||||||||||
| Requirements | 0..1 to account for primarily narrative only resources. | ||||||||||||
| Alternate Names | type | ||||||||||||
| Summary | true | ||||||||||||
| Condition.bodySite | |||||||||||||
| Element Id | Condition.bodySite | ||||||||||||
| Definition | The anatomical location where this condition manifests itself. | ||||||||||||
| Short Display | Anatomical location, if relevant | ||||||||||||
| Cardinality | 0..* | ||||||||||||
| Terminology Binding | SNOMED CT Body Structures ( Example ) | ||||||||||||
| Type | CodeableConcept | ||||||||||||
| Summary | true | ||||||||||||
| Comments |
Only
used
if
not
implicit
in
code
found
in
Condition.code.
If
the
use
case
requires
attributes
from
the
BodyStructure
resource
(e.g.
to
identify
and
track
separately)
then
use
the
standard
extension
http://hl7.org/fhir/StructureDefinition/bodySite
.
May
be
a
summary
code,
or
a
reference
to
a
very
precise
definition
of
|
||||||||||||
| Condition.subject | |||||||||||||
| Element Id | Condition.subject | ||||||||||||
| Definition |
| ||||||||||||
| Short Display |
Who
has
| ||||||||||||
| Cardinality | 1..1 | ||||||||||||
| Type | Reference ( Patient | Group ) | ||||||||||||
| Requirements | Group is typically used for veterinary or public health use cases. | ||||||||||||
| Alternate Names | patient | ||||||||||||
| Summary | true | ||||||||||||
| Condition.encounter | |||||||||||||
| Element Id | Condition.encounter | ||||||||||||
| Definition |
The
Encounter
during
which
this
Condition
was
created
or
to
| ||||||||||||
| Short Display | The Encounter during which this Condition was created | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Type | Reference ( Encounter ) | ||||||||||||
| Summary | true | ||||||||||||
| Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. 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". | ||||||||||||
| Condition.onset[x] | |||||||||||||
| Element Id | Condition.onset[x] | ||||||||||||
| Definition | Estimated or actual date or date-time the condition began, in the opinion of the clinician. | ||||||||||||
| Short Display | Estimated or actual date, date-time, or age | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Type | dateTime | Age | Period | Range | string | ||||||||||||
| [x] Note | See Choice of Datatypes for further information about how to use [x] | ||||||||||||
| Summary | true | ||||||||||||
| Comments |
Age
is
generally
used
when
the
patient
reports
an
age
at
which
the
Condition
began
to
occur.
Period
is
generally
used
to
convey
an
imprecise
onset
that
occurred
within
the
| ||||||||||||
| Condition.abatement[x] | |||||||||||||
| Element Id | Condition.abatement[x] | ||||||||||||
| Definition |
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"
-
Some
conditions,
such
as
chronic
conditions,
are
never
really
resolved,
but
they
| ||||||||||||
| Short Display | When in resolution/remission | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Type | dateTime | Age | Period | Range | string | ||||||||||||
| [x] Note | See Choice of Datatypes for further information about how to use [x] | ||||||||||||
| Summary | false | ||||||||||||
| Comments |
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.
When
abatementString
exists,
it
implies
the
condition
is
abated.
Because
a
| ||||||||||||
| Invariants |
| ||||||||||||
| Condition.recordedDate | |||||||||||||
| Element Id | Condition.recordedDate | ||||||||||||
| Definition | The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date. | ||||||||||||
| Short Display | Date condition was first recorded | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Type | dateTime | ||||||||||||
| Summary | true | ||||||||||||
| Comments | When onset date is unknown, recordedDate can be used to establish if the condition was present on or before a given date. If the recordedDate is known and provided by a sending system, it is preferred that the receiving system preserve that recordedDate value. If the recordedDate is not provided by the sending system, the receipt timestamp is sometimes used as the recordedDate. | ||||||||||||
| Condition.participant | |||||||||||||
| Element Id | Condition.participant | ||||||||||||
| Definition | Indicates who or what participated in the activities related to the condition and how they were involved. | ||||||||||||
| Short Display | Who or what participated in the activities related to the condition and how they were involved | ||||||||||||
| Cardinality | 0..* | ||||||||||||
| Summary | true | ||||||||||||
| Condition.participant.function | |||||||||||||
| Element Id | Condition.participant.function | ||||||||||||
| Definition | Distinguishes the type of involvement of the actor in the activities related to the condition. | ||||||||||||
| Short Display | Type of involvement | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Terminology Binding | Participation Role Type ( Extensible ) | ||||||||||||
| Type | CodeableConcept | ||||||||||||
| Summary | true | ||||||||||||
| Condition.participant.actor | |||||||||||||
| Element Id | Condition.participant.actor | ||||||||||||
| Definition | Indicates who or what participated in the activities related to the condition. |
||||||||||||
| Short Display | Who or what participated in the activities related to the condition | ||||||||||||
| Cardinality | 1..1 | ||||||||||||
| Type | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization | CareTeam ) | ||||||||||||
| Summary | true | ||||||||||||
| Condition.stage | |||||||||||||
| Element Id | Condition.stage | ||||||||||||
| Definition | A simple summary of the stage such as "Stage 3" or "Early Onset". The determination of the stage is disease-specific, such as cancer, retinopathy of prematurity, kidney diseases, Alzheimer's, or Parkinson disease. | ||||||||||||
| Short Display | Stage/grade, usually assessed formally | ||||||||||||
| Cardinality | 0..* | ||||||||||||
| Summary | false | ||||||||||||
| Invariants |
| ||||||||||||
| Condition.stage.summary | |||||||||||||
| Element Id | Condition.stage.summary | ||||||||||||
| Definition | A simple summary of the stage such as "Stage 3" or "Early Onset". The determination of the stage is disease-specific, such as cancer, retinopathy of prematurity, kidney diseases, Alzheimer's, or Parkinson disease. | ||||||||||||
| Short Display | Simple summary (disease specific) | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Terminology Binding | Condition Stage ( Example ) | ||||||||||||
| Type | CodeableConcept | ||||||||||||
| Summary | false | ||||||||||||
| Invariants |
| ||||||||||||
| Condition.stage.assessment | |||||||||||||
| Element Id | Condition.stage.assessment | ||||||||||||
| Definition | Reference to a formal record of the evidence on which the staging assessment is based. | ||||||||||||
| Short Display | Formal record of assessment | ||||||||||||
| Cardinality | 0..* | ||||||||||||
| Type | Reference ( ClinicalImpression | DiagnosticReport | Observation ) | ||||||||||||
| Summary | false | ||||||||||||
| Invariants |
| ||||||||||||
| Condition.stage.type | |||||||||||||
| Element Id | Condition.stage.type | ||||||||||||
| Definition | The kind of staging, such as pathological or clinical staging. | ||||||||||||
| Short Display | Kind of staging | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Terminology Binding | Condition Stage Type ( Example ) | ||||||||||||
| Type | CodeableConcept | ||||||||||||
| Summary | false | ||||||||||||
| Condition.evidence | |||||||||||||
| Element Id | Condition.evidence | ||||||||||||
| Definition | Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. | ||||||||||||
| Short Display | Supporting evidence for the verification status | ||||||||||||
| Cardinality | 0..* | ||||||||||||
| Terminology Binding | SNOMED CT Clinical Findings ( Example ) | ||||||||||||
| Type | CodeableReference ( Any ) | ||||||||||||
| Summary | true | ||||||||||||
| Comments | If the condition was confirmed, but subsequently refuted, then the evidence can be cumulative including all evidence over time. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. For example, if the Condition.code is pneumonia, then there could be an evidence list where Condition.evidence.concept = fever (CodeableConcept), Condition.evidence.concept = cough (CodeableConcept), and Condition.evidence.reference = bronchitis (reference to Condition). | ||||||||||||
| Condition.note | |||||||||||||
| Element Id | Condition.note | ||||||||||||
| Definition | Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. | ||||||||||||
| Short Display | Additional information about the Condition | ||||||||||||
| Cardinality | 0..* | ||||||||||||
| Type | Annotation | ||||||||||||
| Summary | false | ||||||||||||