FHIR CI-Build

This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions icon

Patient Care icon Work GroupMaturity Level: 3 Trial UseSecurity Category: Patient Compartments: Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the Condition resource.

Condition
Element IdCondition
Definition

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

Short DisplayDetailed information about conditions, problems or diagnoses
Cardinality0..*
TypeDomainResource
Summaryfalse
Invariants
Defined on this element
con-2Warning If category is problems list item, the clinicalStatus should not be unknowncategory.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-category' and code='problem-list-item').exists() implies clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and code='unknown').exists().not()
con-3Rule If condition is abated, then clinicalStatus must be either inactive, resolved, or remission.abatement.exists() implies (clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='inactive' or code='resolved' or code='remission')).exists())
Condition.identifier
Element IdCondition.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 DisplayExternal Ids for this condition
NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Requirements

Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers.

Summarytrue
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 IdCondition.clinicalStatus
Definition

The clinical status of the condition.

Short Displayactive | recurrence | relapse | inactive | remission | resolved | unknown
Cardinality1..1
Terminology BindingCondition Clinical Status Codes (Required)
TypeCodeableConcept
Is Modifiertrue (Reason: This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.)
Summarytrue
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

Invariants
Affect this element
con-2Warning If category is problems list item, the clinicalStatus should not be unknowncategory.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-category' and code='problem-list-item').exists() implies clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and code='unknown').exists().not()
con-3Rule If condition is abated, then clinicalStatus must be either inactive, resolved, or remission.abatement.exists() implies (clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='inactive' or code='resolved' or code='remission')).exists())
Condition.verificationStatus
Element IdCondition.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 Displayunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Cardinality0..1
Terminology BindingConditionVerificationStatus (Required)
TypeCodeableConcept
Is Modifiertrue (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.)
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. 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 IdCondition.category
Definition

A category assigned to the condition.

Short Displayproblem-list-item | encounter-diagnosis
Cardinality0..*
Terminology BindingCondition Category Codes (Preferred)
TypeCodeableConcept
Summaryfalse
Comments

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

Invariants
Affect this element
con-2Warning If category is problems list item, the clinicalStatus should not be unknowncategory.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-category' and code='problem-list-item').exists() implies clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and code='unknown').exists().not()
Condition.severity
Element IdCondition.severity
Definition

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

Short DisplaySubjective severity of condition
Cardinality0..1
Terminology BindingCondition/Diagnosis Severity (Preferred)
TypeCodeableConcept
Summaryfalse
Comments

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

Condition.code
Element IdCondition.code
Definition

Identification of the condition, problem or diagnosis.

Short DisplayIdentification of the condition, problem or diagnosis
Cardinality0..1
Terminology BindingCondition/Problem/Diagnosis Codes (Example)
TypeCodeableConcept
Requirements

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

Alternate Namestype
Summarytrue
Condition.bodySite
Element IdCondition.bodySite
Definition

The anatomical location where this condition manifests itself.

Short DisplayAnatomical location, if relevant
Cardinality0..*
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 BodyStructure resource (e.g. to identify and track separately) then use the standard extension bodyStructure. May be a summary code, or a reference to a very precise definition of the location, or both.

Condition.subject
Element IdCondition.subject
Definition

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

Short DisplayWho has the condition?
Cardinality1..1
TypeReference(Patient | Group)
Requirements

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

Alternate Namespatient
Summarytrue
Condition.encounter
Element IdCondition.encounter
Definition

The Encounter during which this Condition was created or to which the creation of this record is tightly associated.

Short DisplayThe Encounter during which this Condition was created
Cardinality0..1
TypeReference(Encounter)
Summarytrue
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 IdCondition.onset[x]
Definition

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

Short DisplayEstimated or actual date, date-time, or age
Cardinality0..1
TypedateTime|Age|Period|Range|string
[x] NoteSee Choice of Datatypes 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. 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. 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.

Condition.abatement[x]
Element IdCondition.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" - Some conditions, such as chronic conditions, are never really resolved, but they can abate.

Short DisplayWhen in resolution/remission
Cardinality0..1
TypedateTime|Age|Period|Range|string
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Summaryfalse
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.

Invariants
Affect this element
con-3Rule If condition is abated, then clinicalStatus must be either inactive, resolved, or remission.abatement.exists() implies (clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='inactive' or code='resolved' or code='remission')).exists())
Condition.recordedDate
Element IdCondition.recordedDate
Definition

The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.

Short DisplayDate condition was first recorded
Cardinality0..1
TypedateTime
Summarytrue
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.

Condition.participant
Element IdCondition.participant
Definition

Indicates who or what participated in the activities related to the condition and how they were involved.

Short DisplayWho or what participated in the activities related to the condition and how they were involved
Cardinality0..*
Summarytrue
Condition.participant.function
Element IdCondition.participant.function
Definition

Distinguishes the type of involvement of the actor in the activities related to the condition.

Short DisplayType of involvement
Cardinality0..1
Terminology BindingParticipationRoleType (Extensible)
TypeCodeableConcept
Summarytrue
Condition.participant.actor
Element IdCondition.participant.actor
Definition

Indicates who or what participated in the activities related to the condition.

Short DisplayWho or what participated in the activities related to the condition
Cardinality1..1
TypeReference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization | CareTeam)
Summarytrue
Condition.stage
Element IdCondition.stage
Definition

A simple summary of the stage such as "Stage 3" or "Early Onset". The determination of the stage is disease-specific, such as cancer, retinopathy of prematurity, kidney diseases, Alzheimer's, or Parkinson disease.

Short DisplayStage/grade, usually assessed formally
Cardinality0..*
Summaryfalse
Invariants
Defined on this element
con-1Rule Stage SHALL have summary or assessmentsummary.exists() or assessment.exists()
Condition.stage.summary
Element IdCondition.stage.summary
Definition

A simple summary of the stage such as "Stage 3" or "Early Onset". The determination of the stage is disease-specific, such as cancer, retinopathy of prematurity, kidney diseases, Alzheimer's, or Parkinson disease.

Short DisplaySimple summary (disease specific)
Cardinality0..1
Terminology BindingCondition Stage (Example)
TypeCodeableConcept
Summaryfalse
Invariants
Affect this element
con-1Rule Stage SHALL have summary or assessmentsummary.exists() or assessment.exists()
Condition.stage.assessment
Element IdCondition.stage.assessment
Definition

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

Short DisplayFormal record of assessment
Cardinality0..*
TypeReference(ClinicalImpression | DiagnosticReport | Observation)
Summaryfalse
Invariants
Affect this element
con-1Rule Stage SHALL have summary or assessmentsummary.exists() or assessment.exists()
Condition.stage.type
Element IdCondition.stage.type
Definition

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

Short DisplayKind of staging
Cardinality0..1
Terminology BindingCondition Stage Type (Example)
TypeCodeableConcept
Summaryfalse
Condition.evidence
Element IdCondition.evidence
Definition

Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition.

Short DisplaySupporting evidence for the verification status
Cardinality0..*
Terminology BindingSNOMED CT Clinical Findings (Example)
TypeCodeableReference(Any)
Summarytrue
Comments

If the condition was confirmed, but subsequently refuted, then the evidence can be cumulative including all evidence over time. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. For example, if the Condition.code is pneumonia, then there could be an evidence list where Condition.evidence.concept = fever (CodeableConcept), Condition.evidence.concept = cough (CodeableConcept), and Condition.evidence.reference = bronchitis (reference to Condition).

Condition.note
Element IdCondition.note
Definition

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

Short DisplayAdditional information about the Condition
Cardinality0..*
TypeAnnotation
Summaryfalse