FHIR Release 3 (STU) 4

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

Detailed Descriptions for the elements in the Condition resource.

Alternate Names encounter
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 : verificationStatus='entered-in-error' :
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 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 : verificationStatus='entered-in-error' :
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 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 : verificationStatus='entered-in-error'
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 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 )
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