Current Build
Patient Care Work GroupMaturity Level: 3 Trial Use Compartments: Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the Condition resource.

Condition
Definition

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

Control1..1
InvariantsDefined on this element
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error (expression : verificationStatus='entered-in-error' or clinicalStatus.exists(), xpath: f:verificationStatus/@value='entered-in-error' or exists(f:clinicalStatus))
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (expression : abatement.empty() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive', xpath: not(exists(*[starts-with(local-name(.), 'abatement')])) or f:clinicalStatus/@value=('resolved', 'remission', 'inactive'))
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error (expression : verificationStatus!='entered-in-error' or clinicalStatus.empty(), xpath: f:verificationStatus/@value!='entered-in-error' or not(exists(f:clinicalStatus)))
Condition.identifier
Definition

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).

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Need to allow connection to a wider workflow.

Summarytrue
Condition.clinicalStatus
Definition

The clinical status of the condition.

Control0..1
Terminology BindingCondition Clinical Status Codes (Required)
Typecode
Is Modifiertrue (Reason: Not known why this is labelled a modifier)
Summarytrue
Comments

This element is labeled as a modifier because the status contains codes that mark the condition as not currently valid or of concern.
It is possible that the well-controlled or poorly-controlled clinical status could alternatively be conveyed via a pre-coordinated Condition.code.

InvariantsAffect this element
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error (expression : verificationStatus='entered-in-error' or clinicalStatus.exists(), xpath: f:verificationStatus/@value='entered-in-error' or exists(f:clinicalStatus))
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (expression : abatement.empty() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive', xpath: not(exists(*[starts-with(local-name(.), 'abatement')])) or f:clinicalStatus/@value=('resolved', 'remission', 'inactive'))
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error (expression : verificationStatus!='entered-in-error' or clinicalStatus.empty(), xpath: f:verificationStatus/@value!='entered-in-error' or not(exists(f:clinicalStatus)))
Condition.verificationStatus
Definition

The verification status to support the clinical status of the condition.

Control0..1
Terminology BindingConditionVerificationStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Default Valueunknown
Summarytrue
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 is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.

InvariantsAffect this element
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error (expression : verificationStatus='entered-in-error' or clinicalStatus.exists(), xpath: f:verificationStatus/@value='entered-in-error' or exists(f:clinicalStatus))
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error (expression : verificationStatus!='entered-in-error' or clinicalStatus.empty(), xpath: f:verificationStatus/@value!='entered-in-error' or not(exists(f:clinicalStatus)))
Condition.category
Definition

A category assigned to the condition.

Control0..*
Terminology BindingCondition Category Codes (Example)
TypeCodeableConcept
Comments

The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.

Condition.severity
Definition

A subjective assessment of the severity of the condition as evaluated by the clinician.

Control0..1
Terminology BindingCondition/Diagnosis Severity (Preferred)
TypeCodeableConcept
Comments

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

Condition.code
Definition

Identification of the condition, problem or diagnosis.

Control0..1
Terminology BindingCondition/Problem/Diagnosis Codes (Example)
TypeCodeableConcept
Requirements

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

Alternate Namestype
Summarytrue
Condition.bodySite
Definition

The anatomical location where this condition manifests itself.

Control0..*
Terminology BindingSNOMED CT Body Structures (Example)
TypeCodeableConcept
Summarytrue
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-structure. May be a summary code, or a reference to a very precise definition of the location, or both.

Condition.subject
Definition

Indicates the patient or group who the condition record is associated with.

Control1..1
TypeReference(Patient | Group)
Requirements

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

Alternate Namespatient
Summarytrue
Condition.context
Definition

Encounter during which the condition was first asserted.

Control0..1
TypeReference(Encounter | EpisodeOfCare)
Alternate Namesencounter
Summarytrue
Comments

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]
Definition

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

Control0..1
TypedateTime|Age|Period|Range|string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Comments

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

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

Control0..1
TypedateTime|Age|Period|Range|string
[x] NoteSee 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.

InvariantsAffect this element
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (expression : abatement.empty() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive', xpath: not(exists(*[starts-with(local-name(.), 'abatement')])) or f:clinicalStatus/@value=('resolved', 'remission', 'inactive'))
Condition.assertedDate
Definition

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

Control0..1
TypedateTime
Summarytrue
Comments

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 the last record modification can be retrieved from the resource metadata.

Condition.recorder
Definition

Individual who recorded the record and takes responsibility for its content.

Control0..1
TypeReference(Practitioner | Patient | RelatedPerson)
Summarytrue
Condition.asserter
Definition

Individual who is making the condition statement.

Control0..1
TypeReference(Practitioner | PractitionerRole | Patient | RelatedPerson)
Summarytrue
Condition.stage
Definition

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

Control0..*
InvariantsDefined on this element
con-1: Stage SHALL have summary or assessment (expression : summary.exists() or assessment.exists(), xpath: exists(f:summary) or exists(f:assessment))
Condition.stage.summary
Definition

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

Control0..1
Terminology BindingCondition Stage (Example)
TypeCodeableConcept
InvariantsAffect this element
con-1: Stage SHALL have summary or assessment (expression : summary.exists() or assessment.exists(), xpath: exists(f:summary) or exists(f:assessment))
Condition.stage.assessment
Definition

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

Control0..*
TypeReference(ClinicalImpression | DiagnosticReport | Observation)
InvariantsAffect this element
con-1: Stage SHALL have summary or assessment (expression : summary.exists() or assessment.exists(), xpath: exists(f:summary) or exists(f:assessment))
Condition.stage.type
Definition

The kind of staging, such as pathological or clinical staging.

Control0..1
Terminology BindingCondition Stage Type (Example)
TypeCodeableConcept
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.

Control0..*
Comments

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

InvariantsDefined on this element
con-2: evidence SHALL have code or details (expression : code.exists() or detail.exists(), xpath: exists(f:code) or exists(f:detail))
Condition.evidence.code
Definition

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

Control0..*
Terminology BindingManifestation and Symptom Codes (Example)
TypeCodeableConcept
Summarytrue
InvariantsAffect this element
con-2: evidence SHALL have code or details (expression : code.exists() or detail.exists(), xpath: exists(f:code) or exists(f:detail))
Condition.evidence.detail
Definition

Links to other relevant information, including pathology reports.

Control0..*
TypeReference(Any)
Summarytrue
InvariantsAffect this element
con-2: evidence SHALL have code or details (expression : code.exists() or detail.exists(), xpath: exists(f:code) or exists(f:detail))
Condition.note
Definition

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

Control0..*
TypeAnnotation