This
page
is
part
of
the
FHIR
Specification
(v3.0.2:
(v4.0.1:
R4
-
Mixed
Normative
and
STU
3).
)
in
it's
permanent
home
(it
will
always
be
available
at
this
URL).
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
R4
R3
R2
Patient
Care
Work
Group
|
Maturity Level : 3 | Trial Use | Security Category : Patient | 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.
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 .
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. By contrast, headache may be captured as an Observation when it contributes to the establishment of a meningitis Condition.
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
,
Contract
,
CoverageEligibilityRequest
,
DeviceRequest
,
DeviceUseStatement
,
Encounter
,
EpisodeOfCare
,
ExplanationOfBenefit
,
FamilyMemberHistory
,
Goal
,
GuidanceResponse
,
ImagingStudy
,
Immunization
,
MedicationAdministration
,
MedicationRequest
,
MedicationStatement
,
Procedure
,
ProcedureRequest
,
ReferralRequest
RequestGroup
,
RiskAssessment
,
ServiceRequest
and
VisionPrescription
SupplyRequest
Structure
| Name | Flags | Card. | Type |
Description
&
Constraints
|
|---|---|---|---|---|
|
I TU | DomainResource |
Detailed
information
about
conditions,
problems
or
diagnoses
+ Guideline: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item + Rule: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission + Rule: Condition.clinicalStatus SHALL NOT be present if Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension |
|
|
Σ | 0..* | Identifier |
External
Ids
for
this
condition
|
|
?! Σ I | 0..1 |
|
active
|
recurrence
|
relapse
|
inactive
|
remission
|
resolved
Condition Clinical Status Codes ( Required ) |
|
?! Σ I | 0..1 |
|
unconfirmed
|
provisional
|
differential
|
confirmed
|
refuted
|
entered-in-error
ConditionVerificationStatus ( Required ) |
|
0..* | CodeableConcept |
problem-list-item
|
encounter-diagnosis
Condition Category Codes ( |
|
|
0..1 | CodeableConcept |
Subjective
severity
of
condition
Condition/Diagnosis Severity ( Preferred ) |
|
|
Σ | 0..1 | CodeableConcept |
Identification
of
the
condition,
problem
or
diagnosis
Condition/Problem/Diagnosis Codes ( Example ) |
|
Σ | 0..* | CodeableConcept |
Anatomical
location,
if
relevant
SNOMED CT Body Structures ( Example ) |
|
Σ | 1..1 | Reference ( Patient | Group ) | Who has the condition? |
|
Σ | 0..1 |
Reference
(
Encounter
|
Encounter
|
|
Σ | 0..1 | Estimated or actual date, date-time, or age | |
|
dateTime | |||
|
Age | |||
|
Period | |||
|
Range | |||
|
string | |||
|
I | 0..1 |
|
|
|
dateTime | |||
|
|
|
||
|
Period | |||
|
Range | |||
|
string | |||
|
Σ | 0..1 | dateTime |
Date
record
was
|
![]() ![]() | Σ | 0..1 | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson ) | Who recorded the condition |
|
Σ | 0..1 | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson ) | Person who asserts this condition |
|
I | 0..* | BackboneElement |
Stage/grade,
usually
assessed
formally
+ Rule: Stage SHALL have summary or assessment |
|
I | 0..1 | CodeableConcept |
Simple
summary
(disease
specific)
Condition Stage ( Example ) |
|
I | 0..* | Reference ( ClinicalImpression | DiagnosticReport | Observation ) |
Formal
record
of
assessment
|
| 0..1 | CodeableConcept |
Kind
of
staging
Condition Stage Type ( Example ) | |
|
I | 0..* | BackboneElement |
Supporting
evidence
+ Rule: evidence SHALL have code or details |
|
Σ I | 0..* | CodeableConcept |
Manifestation/symptom
Manifestation and Symptom Codes ( Example ) |
|
Σ I | 0..* | Reference ( Any ) |
Supporting
information
found
elsewhere
|
|
0..* | Annotation |
Additional
information
about
the
Condition
|
|
Documentation
for
this
format
|
||||
UML Diagram ( Legend )
XML Template
<<Condition xmlns="http://hl7.org/fhir"><!-- 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><!--0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved --></clinicalStatus> <verificationStatus><!--
0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error --></verificationStatus> <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><encounter><!-- 0..1 Reference(Encounter) Encounter created as part of --></encounter> <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]> <recordedDate value="[dateTime]"/><!-- 0..1 Date record was first recorded --> <recorder><!-- 0..1 Reference(Practitioner|PractitionerRole|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
{
"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" : { CodeableConcept }, // C? active | recurrence | relapse | inactive | remission | resolved
"verificationStatus" : { CodeableConcept }, // 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?
"encounter" : { Reference(Encounter) }, // Encounter created as part of
// 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>",
"recordedDate" : "<dateTime>", // Date record was first recorded
"recorder" : { Reference(Practitioner|PractitionerRole|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/> .[ 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 [ CodeableConcept ]; # 0..1 active | recurrence | relapse | inactive | remission | resolved fhir:Condition.verificationStatus [ CodeableConcept ]; # 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:fhir:Condition.encounter [ Reference(Encounter) ]; # 0..1 Encounter created as part of # 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.recordedDate [ dateTime ]; # 0..1 Date record was first recorded fhir:Condition.recorder [ Reference(Practitioner|PractitionerRole|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 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Condition.abatement[x] |
|
|
|
|
| Condition.recorder |
|
| Condition.asserter |
|
|
|
|
|
|
|
| Condition.context |
|
See the Full Difference for further information
This analysis is available as XML or JSON .
See
R2
<-->
R3
<-->
R4
Conversion
Maps
(status
=
14
12
tests
that
all
execute
ok.
11
fail
All
tests
pass
round-trip
testing
and
14
1
r3
resources
are
invalid
(14
(0
errors).
).
)
Structure
| Name | Flags | Card. | Type |
Description
&
Constraints
|
|---|---|---|---|---|
|
I TU | DomainResource |
Detailed
information
about
conditions,
problems
or
diagnoses
+ Guideline: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item + Rule: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission + Rule: Condition.clinicalStatus SHALL NOT be present if Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension |
|
|
Σ | 0..* | Identifier |
External
Ids
for
this
condition
|
|
?! Σ I | 0..1 |
|
active
|
recurrence
|
relapse
|
inactive
|
remission
|
resolved
Condition Clinical Status Codes ( Required ) |
|
?! Σ I | 0..1 |
|
unconfirmed
|
provisional
|
differential
|
confirmed
|
refuted
|
entered-in-error
ConditionVerificationStatus ( Required ) |
|
0..* | CodeableConcept |
problem-list-item
|
encounter-diagnosis
Condition Category Codes ( |
|
|
0..1 | CodeableConcept |
Subjective
severity
of
condition
Condition/Diagnosis Severity ( Preferred ) |
|
|
Σ | 0..1 | CodeableConcept |
Identification
of
the
condition,
problem
or
diagnosis
Condition/Problem/Diagnosis Codes ( Example ) |
|
Σ | 0..* | CodeableConcept |
Anatomical
location,
if
relevant
SNOMED CT Body Structures ( Example ) |
|
Σ | 1..1 | Reference ( Patient | Group ) | Who has the condition? |
|
Σ | 0..1 |
Reference
(
Encounter
|
Encounter
|
|
Σ | 0..1 | Estimated or actual date, date-time, or age | |
|
dateTime | |||
|
Age | |||
|
Period | |||
|
Range | |||
|
string | |||
|
I | 0..1 |
|
|
|
dateTime | |||
|
|
|
||
|
Period | |||
|
Range | |||
|
string | |||
|
Σ | 0..1 | dateTime |
Date
record
was
|
![]() ![]() | Σ | 0..1 | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson ) | Who recorded the condition |
|
Σ | 0..1 | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson ) | Person who asserts this condition |
|
I | 0..* | BackboneElement |
Stage/grade,
usually
assessed
formally
+ Rule: Stage SHALL have summary or assessment |
|
I | 0..1 | CodeableConcept |
Simple
summary
(disease
specific)
Condition Stage ( Example ) |
|
I | 0..* | Reference ( ClinicalImpression | DiagnosticReport | Observation ) |
Formal
record
of
assessment
|
| 0..1 | CodeableConcept |
Kind
of
staging
Condition Stage Type ( Example ) | |
|
I | 0..* | BackboneElement |
Supporting
evidence
+ Rule: evidence SHALL have code or details |
|
Σ I | 0..* | CodeableConcept |
Manifestation/symptom
Manifestation and Symptom Codes ( Example ) |
|
Σ I | 0..* | Reference ( Any ) |
Supporting
information
found
elsewhere
|
|
0..* | Annotation |
Additional
information
about
the
Condition
|
|
Documentation
for
this
format
|
||||
XML Template
<<Condition xmlns="http://hl7.org/fhir"><!-- 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><!--0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved --></clinicalStatus> <verificationStatus><!--
0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error --></verificationStatus> <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><encounter><!-- 0..1 Reference(Encounter) Encounter created as part of --></encounter> <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]> <recordedDate value="[dateTime]"/><!-- 0..1 Date record was first recorded --> <recorder><!-- 0..1 Reference(Practitioner|PractitionerRole|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
{
"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" : { CodeableConcept }, // C? active | recurrence | relapse | inactive | remission | resolved
"verificationStatus" : { CodeableConcept }, // 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?
"encounter" : { Reference(Encounter) }, // Encounter created as part of
// 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>",
"recordedDate" : "<dateTime>", // Date record was first recorded
"recorder" : { Reference(Practitioner|PractitionerRole|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/> .[ 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 [ CodeableConcept ]; # 0..1 active | recurrence | relapse | inactive | remission | resolved fhir:Condition.verificationStatus [ CodeableConcept ]; # 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:fhir:Condition.encounter [ Reference(Encounter) ]; # 0..1 Encounter created as part of # 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.recordedDate [ dateTime ]; # 0..1 Date record was first recorded fhir:Condition.recorder [ Reference(Practitioner|PractitionerRole|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
Release
3
| Condition |
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| Condition.abatement[x] |
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| Condition.recorder |
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| Condition.asserter |
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| Condition.context |
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See the Full Difference for further information
This analysis is available as XML or JSON .
See
R2
<-->
R3
<-->
R4
Conversion
Maps
(status
=
14
12
tests
that
all
execute
ok.
11
fail
All
tests
pass
round-trip
testing
and
14
1
r3
resources
are
invalid
(14
(0
errors).
).
)
Alternate
See
the
Profiles
&
Extensions
and
the
alternate
definitions:
Master
Definition
(
XML
,
+
JSON
),
,
XML
Schema
/
Schematron
(for
)
+
JSON
Schema
,
ShEx
(for
Turtle
)
+
see
the
extensions
&
the
dependency
analysis
| Path | Definition | Type | Reference |
|---|---|---|---|
| Condition.clinicalStatus | The clinical status of the condition or diagnosis. | Required |
|
| 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. |
|
|
| Condition.severity | A subjective assessment of the severity of the condition as evaluated by the clinician. | Preferred |
|
| Condition.code | Identification of the condition or diagnosis. | Example |
|
| Condition.bodySite | Codes describing anatomical locations. May include laterality. | Example |
|
| Condition.stage.summary | Codes describing condition stages (e.g. Cancer stages). | Example |
|
| Condition.stage.type | Codes describing the kind of condition staging (e.g. clinical or pathological). | Example | ConditionStageType |
| Condition.evidence.code | Codes that describe the manifestation or symptoms of a condition. | Example |
|
| id | Level | Location | Description | Expression |
|
con-1
|
Rule | Condition.stage |
Stage
SHALL
have
summary
or
assessment
|
|
|
con-2
|
Rule | Condition.evidence |
evidence
SHALL
have
code
or
details
|
|
|
con-3
|
Guideline | (base) |
Condition.clinicalStatus
SHALL
be
present
if
verificationStatus
is
not
entered-in-error
|
This is (only) a best practice guideline because:
|
|
con-4
|
Rule | (base) |
If
condition
is
abated,
then
clinicalStatus
must
be
either
inactive,
resolved,
or
remission
|
|
| con-5 | Rule | (base) | 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
|
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.
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.
STUTrial-Use Note: There are two primary ways of reporting"no"no knownproblems"problems" in the current specification: using the CodeableConcept, as described above, or using the List resource with emptyReason. During the STU period, feedbackis 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.
Generally, electronic records do not contain assertions of conditions that a patient does not have. There are however two exceptions:
The Condition.evidence provides the basis for whatever is present in Condition.code.
A range is used to communicate age period of subject at time of abatement.
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.
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.
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 .
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.
Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
| Name | Type | Description | Expression | In Common |
| abatement-age | quantity | Abatement as age or age range |
Condition.abatement.as(Age)
|
Condition.abatement.as(Range)
|
|
| 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) |
|
| 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 |
|
|
|
reference |
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 |
|
| 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? |
( Patient ) |
|
| recorded-date | date | Date record was first recorded | Condition.recordedDate | |
| 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
|
Condition.verificationStatus |