Use to record detailed information about conditions, problems A clinical condition, problem, diagnosis, or diagnoses recognized by a clinician. There are many uses including: recording a diagnosis during an encounter; populating a problem list other event, situation, issue, or clinical concept that has risen to a summary statement, such as a discharge summary. level of concern.

This records identifiers associated with this condition that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

Need to allow connection to a wider workflow.

Indicates the patient who The clinical status of the condition record is associated with. condition.

This element is labeled as a modifier because the status contains codes that mark the condition as not currently valid or of concern.

Encounter during which The verification status to support the condition was first asserted. clinical status of the condition.

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 is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.

A date, when category assigned to the Condition statement was documented. condition.

The Date Recorded represents the date when this particular Condition record was created in the EHR, categorization is often highly contextual and may appear poorly differentiated or not the date of the most recent update very useful in terms of when severity, abatement, etc. were specified.  The date of the last record modification can be retrieved from the resource metadata. other contexts.

Identification A subjective assessment of the condition, problem or diagnosis. severity of the condition as evaluated by the clinician.

Coding of the severity with a terminology is preferred, where possible.

A category assigned to Identification of the condition. condition, problem or diagnosis.

0..1 to account for primarily narrative only resources.

The clinical status of the condition. anatomical location where this condition manifests itself.

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 . May be a summary code, or a reference to a very precise definition of the location, or both.

The verification status to support Indicates the clinical status of patient or group who the condition. condition record is associated with.

Group is typically used for veterinary or public health use cases.

A subjective assessment of the severity of Encounter during which the condition as evaluated by the clinician. was first asserted.

Coding of This record indicates the severity with a terminology encounter this particular record is preferred, where possible. 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".

Estimated or actual date or date-time the condition began, in the opinion of the clinician.

Age is generally used when the patient reports an age at which the Condition began to occur.

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" - Conditions are never really resolved, but they can abate.

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.

Clinical stage The date on which the existance of the Condition was first asserted or grade acknowledged.

The assertedDate represents the date when this particular Condition record was created in the EHR, not the date of a condition. May include formal severity assessments. the most recent update in terms of when severity, abatement, etc. were specified.  The date of the last record modification can be retrieved from the resource metadata.

Individual who is making the condition statement.

Clinical stage or grade of a condition. May include formal severity assessments.

A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.

Reference to a formal record of the evidence on which the staging assessment is based.

Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed.

The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.

A manifestation or symptom that led to the recording of this condition.

Links to other relevant information, including pathology reports.

Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.