Detailed
Descriptions
for
the
elements
in
the
Condition
resource.
|
Condition
|
|
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.
|
Control
Cardinality
|
1..1
0..*
|
|
Type
|
DomainResource
|
|
Invariants
|
|
Defined
on
this
element
|
con-3
:
|
Guideline
|
Condition.clinicalStatus
SHALL
be
present
if
verificationStatus
is
not
entered-in-error
(
expression
and
category
is
problem-list-item
|
:
verificationStatus='entered-in-error'
clinicalStatus.exists()
or
clinicalStatus.exists(),
xpath:
f:verificationStatus/@value='entered-in-error'
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status'
and
code
=
'entered-in-error').exists()
or
exists(f:clinicalStatus))
category.select($this='problem-list-item').empty()
This
is
(only)
a
best
practice
guideline
because:
Most
systems
will
expect
a
clinicalStatus
to
be
valued
for
problem-list-items
that
are
managed
over
time,
but
might
not
need
a
clinicalStatus
for
point
in
time
encounter-diagnosis.
|
con-4
:
|
Rule
|
If
condition
is
abated,
then
clinicalStatus
must
be
either
inactive,
resolved,
or
remission
(
expression
|
:
abatement.empty()
or
(abatement
as
boolean).not()
or
clinicalStatus='resolved'
clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical'
and
(code='resolved'
or
clinicalStatus='remission'
code='remission'
or
clinicalStatus='inactive',
xpath:
not(exists(*[starts-with(local-name(.),
'abatement')]))
code='inactive')).exists()
| |
con-5
|
Rule
|
Condition.clinicalStatus
SHALL
NOT
be
present
if
verification
Status
is
entered-in-error
|
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status'
and
code='entered-in-error').empty()
or
f:clinicalStatus/@value=('resolved',
'remission',
'inactive'))
clinicalStatus.empty()
|
|
|
Condition.identifier
|
|
Element
Id
|
Condition.identifier
|
|
Definition
|
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.
|
|
Note
|
This
is
a
business
identifer,
identifier,
not
a
resource
identifier
(see
discussion
)
|
Control
Cardinality
|
0..*
|
|
Type
|
Identifier
|
|
Requirements
|
Need
to
allow
connection
to
Allows
identification
of
the
condition
as
it
is
known
by
various
participating
systems
and
in
a
wider
workflow.
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.
|
Control
Cardinality
|
0..1
|
|
Terminology
Binding
|
Condition
Clinical
Status
Codes
(
Required
)
|
|
Type
|
code
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
|
This
element
The
data
type
is
labeled
as
a
modifier
CodeableConcept
because
the
status
contains
codes
clinicalStatus
has
some
clinical
judgment
involved,
such
that
mark
there
might
need
to
be
more
specificity
than
the
condition
as
not
currently
valid
or
of
concern.
required
FHIR
value
set
allows.
For
example,
a
SNOMED
coding
might
allow
for
additional
specificity.
|
|
Invariants
|
|
Affect
this
element
|
con-3
:
|
Guideline
|
Condition.clinicalStatus
SHALL
be
present
if
verificationStatus
is
not
entered-in-error
(
expression
and
category
is
problem-list-item
|
:
verificationStatus='entered-in-error'
clinicalStatus.exists()
or
clinicalStatus.exists(),
xpath:
f:verificationStatus/@value='entered-in-error'
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status'
and
code
=
'entered-in-error').exists()
or
exists(f:clinicalStatus))
category.select($this='problem-list-item').empty()
This
is
(only)
a
best
practice
guideline
because:
Most
systems
will
expect
a
clinicalStatus
to
be
valued
for
problem-list-items
that
are
managed
over
time,
but
might
not
need
a
clinicalStatus
for
point
in
time
encounter-diagnosis.
|
con-4
:
|
Rule
|
If
condition
is
abated,
then
clinicalStatus
must
be
either
inactive,
resolved,
or
remission
(
expression
|
:
abatement.empty()
or
(abatement
as
boolean).not()
or
clinicalStatus='resolved'
clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical'
and
(code='resolved'
or
clinicalStatus='remission'
code='remission'
or
clinicalStatus='inactive',
xpath:
not(exists(*[starts-with(local-name(.),
'abatement')]))
code='inactive')).exists()
| |
con-5
|
Rule
|
Condition.clinicalStatus
SHALL
NOT
be
present
if
verification
Status
is
entered-in-error
|
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status'
and
code='entered-in-error').empty()
or
f:clinicalStatus/@value=('resolved',
'remission',
'inactive'))
clinicalStatus.empty()
|
|
|
Condition.verificationStatus
|
|
Element
Id
|
Condition.verificationStatus
|
|
Definition
|
The
verification
status
to
support
the
clinical
status
of
the
condition.
|
Control
Cardinality
|
0..1
|
|
Terminology
Binding
|
ConditionVerificationStatus
(
Required
)
|
|
Type
|
code
CodeableConcept
|
|
Is
Modifier
|
true
Default
Value
unknown
(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.
This
element
The
data
type
is
labeled
as
a
modifier
CodeableConcept
because
the
status
contains
the
code
refuted
and
entered-in-error
verificationStatus
has
some
clinical
judgment
involved,
such
that
mark
there
might
need
to
be
more
specificity
than
the
Condition
as
not
currently
valid.
required
FHIR
value
set
allows.
For
example,
a
SNOMED
coding
might
allow
for
additional
specificity.
|
|
Invariants
|
|
Affect
this
element
|
con-3
:
|
Guideline
|
Condition.clinicalStatus
SHALL
be
present
if
verificationStatus
is
not
entered-in-error
(
expression
and
category
is
problem-list-item
|
:
verificationStatus='entered-in-error'
clinicalStatus.exists()
or
clinicalStatus.exists(),
xpath:
f:verificationStatus/@value='entered-in-error'
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status'
and
code
=
'entered-in-error').exists()
or
exists(f:clinicalStatus))
category.select($this='problem-list-item').empty()
This
is
(only)
a
best
practice
guideline
because:
Most
systems
will
expect
a
clinicalStatus
to
be
valued
for
problem-list-items
that
are
managed
over
time,
but
might
not
need
a
clinicalStatus
for
point
in
time
encounter-diagnosis.
| |
con-5
|
Rule
|
Condition.clinicalStatus
SHALL
NOT
be
present
if
verification
Status
is
entered-in-error
|
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status'
and
code='entered-in-error').empty()
or
clinicalStatus.empty()
|
|
|
Condition.category
|
|
Element
Id
|
Condition.category
|
|
Definition
|
A
category
assigned
to
the
condition.
|
Control
Cardinality
|
0..*
|
|
Terminology
Binding
|
Condition
Category
Codes
(
Example
Extensible
)
|
|
Type
|
CodeableConcept
|
|
Comments
|
The
categorization
is
often
highly
contextual
and
may
appear
poorly
differentiated
or
not
very
useful
in
other
contexts.
|
|
Condition.severity
|
|
Element
Id
|
Condition.severity
|
|
Definition
|
A
subjective
assessment
of
the
severity
of
the
condition
as
evaluated
by
the
clinician.
|
Control
Cardinality
|
0..1
|
|
Terminology
Binding
|
Condition/Diagnosis
Severity
(
Preferred
)
|
|
Type
|
CodeableConcept
|
|
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.
|
Control
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.
|
Control
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
BodySite
resource
(e.g.
to
identify
and
track
separately)
then
use
the
standard
extension
body-site-instance
bodySite
.
May
be
a
summary
code,
or
a
reference
to
a
very
precise
definition
of
the
location,
or
both.
|
|
Condition.subject
|
|
Element
Id
|
Condition.subject
|
|
Definition
|
Indicates
the
patient
or
group
who
the
condition
record
is
associated
with.
|
Control
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.context
Condition.encounter
|
|
Element
Id
|
Condition.encounter
|
|
Definition
|
The
Encounter
during
which
the
condition
this
Condition
was
first
asserted.
created
or
to
which
the
creation
of
this
record
is
tightly
associated.
|
Control
Cardinality
|
0..1
|
|
Type
|
Reference
(
Encounter
|
EpisodeOfCare
)
|
Alternate
Names
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"
"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".
"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.
|
Control
Cardinality
|
0..1
|
|
Type
|
dateTime
|
Age
|
Period
|
Range
|
string
|
|
[x]
Note
|
See
Choice
of
Data
Types
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.
|
|
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"
"abatement"
because
of
the
many
overloaded
connotations
associated
with
"remission"
"remission"
or
"resolution"
"resolution"
-
Conditions
are
never
really
resolved,
but
they
can
abate.
|
Control
Cardinality
|
0..1
|
|
Type
|
dateTime
|
Age
|
boolean
|
Period
|
Range
|
string
|
|
[x]
Note
|
See
Choice
of
Data
Types
for
further
information
about
how
to
use
[x]
|
|
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.
|
|
Invariants
|
|
Affect
this
element
|
con-4
:
|
Rule
|
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'
clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical'
and
(code='resolved'
or
clinicalStatus='inactive',
xpath:
not(exists(*[starts-with(local-name(.),
'abatement')]))
code='remission'
or
f:clinicalStatus/@value=('resolved',
'remission',
'inactive'))
code='inactive')).exists()
|
|
Condition.assertedDate
Condition.recordedDate
|
|
Element
Id
|
Condition.recordedDate
|
|
Definition
|
The
date
on
which
the
existance
of
the
recordedDate
represents
when
this
particular
Condition
record
was
first
asserted
or
acknowledged.
created
in
the
system,
which
is
often
a
system-generated
date.
|
Control
Cardinality
|
0..1
|
|
Type
|
dateTime
|
|
Summary
|
true
|
|
Condition.recorder
|
Comments
Element
Id
|
Condition.recorder
|
|
Definition
|
The
assertedDate
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
Individual
who
recorded
the
last
record
modification
can
be
retrieved
from
the
resource
metadata.
and
takes
responsibility
for
its
content.
|
|
Cardinality
|
0..1
|
|
Type
|
Reference
(
Practitioner
|
PractitionerRole
|
Patient
|
RelatedPerson
)
|
|
Summary
|
true
|
|
Condition.asserter
|
|
Element
Id
|
Condition.asserter
|
|
Definition
|
Individual
who
is
making
the
condition
statement.
|
Control
Cardinality
|
0..1
|
|
Type
|
Reference
(
Practitioner
|
PractitionerRole
|
Patient
|
RelatedPerson
)
|
|
Summary
|
true
|
|
Condition.stage
|
|
Element
Id
|
Condition.stage
|
|
Definition
|
Clinical
stage
or
grade
of
a
condition.
May
include
formal
severity
assessments.
|
Control
Cardinality
|
0..1
0..*
|
|
Invariants
|
|
Defined
on
this
element
|
con-1
:
|
Rule
|
Stage
SHALL
have
summary
or
assessment
(
expression
|
:
summary.exists()
or
assessment.exists(),
xpath:
exists(f:summary)
or
exists(f:assessment))
assessment.exists()
|
|
|
Condition.stage.summary
|
|
Element
Id
|
Condition.stage.summary
|
|
Definition
|
A
simple
summary
of
the
stage
such
as
"Stage
3".
"Stage
3".
The
determination
of
the
stage
is
disease-specific.
|
Control
Cardinality
|
0..1
|
|
Terminology
Binding
|
Condition
Stage
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Invariants
|
|
Affect
this
element
|
con-1
:
|
Rule
|
Stage
SHALL
have
summary
or
assessment
(
expression
|
:
summary.exists()
or
assessment.exists(),
xpath:
exists(f:summary)
or
exists(f:assessment))
assessment.exists()
|
|
|
Condition.stage.assessment
|
|
Element
Id
|
Condition.stage.assessment
|
|
Definition
|
Reference
to
a
formal
record
of
the
evidence
on
which
the
staging
assessment
is
based.
|
Control
Cardinality
|
0..*
|
|
Type
|
Reference
(
ClinicalImpression
|
DiagnosticReport
|
Observation
)
|
|
Invariants
|
|
Affect
this
element
|
con-1
:
|
Rule
|
Stage
SHALL
have
summary
or
assessment
(
expression
|
:
summary.exists()
or
assessment.exists(),
xpath:
exists(f:summary)
assessment.exists()
| |
|
Condition.stage.type
|
|
Element
Id
|
Condition.stage.type
|
|
Definition
|
The
kind
of
staging,
such
as
pathological
or
exists(f:assessment))
clinical
staging.
|
|
Cardinality
|
0..1
|
|
Terminology
Binding
|
Condition
Stage
Type
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Condition.evidence
|
|
Element
Id
|
Condition.evidence
|
|
Definition
|
Supporting
Evidence
evidence
/
manifestations
that
are
the
basis
on
which
this
condition
is
suspected
of
the
Condition's
verification
status,
such
as
evidence
that
confirmed
or
confirmed.
refuted
the
condition.
|
Control
Cardinality
|
0..*
|
|
Comments
|
The
evidence
may
be
a
simple
list
of
coded
symptoms/manifestations,
or
references
to
observations
or
formal
assessments,
or
both.
|
|
Invariants
|
|
Defined
on
this
element
|
con-2
:
|
Rule
|
evidence
SHALL
have
code
or
details
(
expression
|
:
code.exists()
or
detail.exists(),
xpath:
exists(f:code)
or
exists(f:detail))
detail.exists()
|
|
|
Condition.evidence.code
|
|
Element
Id
|
Condition.evidence.code
|
|
Definition
|
A
manifestation
or
symptom
that
led
to
the
recording
of
this
condition.
|
Control
Cardinality
|
0..*
|
|
Terminology
Binding
|
Manifestation
and
Symptom
Codes
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Summary
|
true
|
|
Invariants
|
|
Affect
this
element
|
con-2
:
|
Rule
|
evidence
SHALL
have
code
or
details
(
expression
|
:
code.exists()
or
detail.exists(),
xpath:
exists(f:code)
or
exists(f:detail))
detail.exists()
|
|
|
Condition.evidence.detail
|
|
Element
Id
|
Condition.evidence.detail
|
|
Definition
|
Links
to
other
relevant
information,
including
pathology
reports.
|
Control
Cardinality
|
0..*
|
|
Type
|
Reference
(
Any
)
|
|
Summary
|
true
|
|
Invariants
|
|
Affect
this
element
|
con-2
:
|
Rule
|
evidence
SHALL
have
code
or
details
(
expression
|
:
code.exists()
or
detail.exists(),
xpath:
exists(f:code)
or
exists(f:detail))
detail.exists()
|
|
|
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.
|
Control
Cardinality
|
0..*
|
|
Type
|
Annotation
|