This
page
is
part
of
the
FHIR
Specification
(v4.0.1:
R4
(v5.0.0:
R5
-
Mixed
Normative
and
STU
)
).
This
is
the
current
published
version
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
R2
Patient
Care
Work
Group
|
Maturity
Level
:
|
Trial Use | Security Category : Patient | Compartments : Encounter , Patient , Practitioner , RelatedPerson |
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. |
||||||||||||
| Short Display | Detailed information about conditions, problems or diagnoses | ||||||||||||
| Cardinality | 0..* | ||||||||||||
| Type | DomainResource | ||||||||||||
| Summary | false | ||||||||||||
| Invariants |
|
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| Condition.identifier | |||||||||||||
| Element Id | Condition.identifier | ||||||||||||
| Definition |
Business identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server. |
||||||||||||
| 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. |
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| Condition.clinicalStatus | |||||||||||||
| Element Id | Condition.clinicalStatus | ||||||||||||
| Definition |
The clinical status of the condition. |
||||||||||||
| Short Display | active | recurrence | relapse | inactive | remission | resolved | unknown | ||||||||||||
| Cardinality |
|
||||||||||||
| Terminology Binding | Condition Clinical Status Codes ( Required ) | ||||||||||||
| 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 |
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| 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 |
|
||||||||||||
| 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
(
|
||||||||||||
| 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
|
||||||||||||
| Condition.subject | |||||||||||||
| Element Id | Condition.subject | ||||||||||||
| Definition |
Indicates the patient or group who the condition record is associated with. |
||||||||||||
| Short Display | Who has the condition? | ||||||||||||
| 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 which the creation of this record is tightly associated. |
||||||||||||
| 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
|
||||||||||||
| 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 time period. For example, Period is not intended to convey the transition period before the chronic bronchitis or COPD condition was diagnosed, but Period can be used to convey an imprecise diagnosis date. Range is generally used to convey an imprecise age range (e.g. 4 to 6 years old). Because a Condition.code can represent multiple levels of granularity and can be modified over time, the onset and abatement dates can have ambiguity whether those dates apply to the current Condition.code or an earlier representation of that Condition.code. For example, if the Condition.code was initially documented as severe asthma, then it is ambiguous whether the onset and abatement dates apply to asthma (overall in that subject's lifetime) or when asthma transitioned to become severe. |
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| 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"
-
|
||||||||||||
| Short Display | When in resolution/remission | ||||||||||||
| Cardinality | 0..1 | ||||||||||||
| Type | dateTime | Age | Period | Range | string | ||||||||||||
| [x] Note |
See
Choice
of
|
||||||||||||
| 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 Condition.code can represent multiple levels of granularity and can be modified over time, the onset and abatement dates can have ambiguity whether those dates apply to the current Condition.code or an earlier representation of that Condition.code. For example, if the Condition.code was initially documented as severe asthma, then it is ambiguous whether the onset and abatement dates apply to asthma (overall in that subject's lifetime) or when asthma transitioned to become severe. |
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| Invariants |
|
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| 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. | ||||||||||||
|
|
|||||||||||||
| Element Id |
|
||||||||||||
| Definition |
|
||||||||||||
| Short Display | Who or what participated in the activities related to the condition and how they were involved | ||||||||||||
| Cardinality |
|
||||||||||||
|
|
true | ||||||||||||
|
| |||||||||||||
| 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
|
||||||||||||
| Type | CodeableConcept | ||||||||||||
| Summary | true | ||||||||||||
|
|
|||||||||||||
| Element Id |
|
||||||||||||
| Definition |
|
||||||||||||
| Short Display | Who or what participated in the activities related to the condition | ||||||||||||
| Cardinality |
|
||||||||||||
| Type | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization | CareTeam ) | ||||||||||||
| Summary | true | ||||||||||||
| Condition.stage | |||||||||||||
| Element Id | Condition.stage | ||||||||||||
| Definition |
|
||||||||||||
| 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
|
||||||||||||
| 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. |
||||||||||||
|
|
Supporting
evidence
|
||||||||||||
| Cardinality | 0..* | ||||||||||||
| Terminology Binding |
|
||||||||||||
| Type |
|
||||||||||||
| Summary | true | ||||||||||||
|
|
If
the
condition
was
confirmed,
but
subsequently
refuted,
then
the
evidence
|
||||||||||||
| 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 | ||||||||||||