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9.2 Resource Condition - Content

Patient Care Work GroupMaturity Level: 3 Trial UseCompartments: 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.

  • Unemployed
  • Without transportation (or other barriers)
  • Susceptibility to falls
  • Exposure to communicable disease
  • Family History of cardiovascular disease
  • Fear of cancer
  • Cardiac pacemaker
  • Amputee-BKA
  • Risk of Zika virus following travel to a country
  • Former smoker
  • Travel to a country planned (that warrants immunizations)
  • Motor Vehicle Accident
  • Patient has had coronary bypass graft

The condition resource may be referenced by other resources as "reasons" for an action (e.g. MedicationRequest, Procedure, ProcedureRequest, 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.

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, using Condition alone is not sufficient as the allergy or intolerance 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, Encounter, EpisodeOfCare, ExplanationOfBenefit, FamilyMemberHistory, Goal, MedicationAdministration, MedicationRequest, MedicationStatement, Procedure, ProcedureRequest, RiskAssessment and VisionPrescription

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition IDomainResourceDetailed information about conditions, problems or diagnoses
+ If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
+ Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!ΣI0..1codeactive | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
Condition Clinical Status Codes (Required)
... verificationStatus ?!ΣI0..1codeunconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknown
ConditionVerificationStatus (Required)
... category 0..*CodeableConceptproblem-list-item | encounter-diagnosis
Condition Category Codes (Example)
... severity 0..1CodeableConceptSubjective severity of condition
Condition/Diagnosis Severity (Preferred)
... code Σ0..1CodeableConceptIdentification of the condition, problem or diagnosis
Condition/Problem/Diagnosis Codes (Example)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
SNOMED CT Body Structures (Example)
... subject Σ1..1Reference(Patient | Group)Who has the condition?
... context Σ0..1Reference(Encounter | EpisodeOfCare)Encounter or episode when condition first asserted
... onset[x] Σ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] I0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... assertedDate Σ0..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(Practitioner | Patient | RelatedPerson)Person who asserts this condition
... stage I0..*BackboneElementStage/grade, usually assessed formally
+ Stage SHALL have summary or assessment
.... summary I0..1CodeableConceptSimple summary (disease specific)
Condition Stage (Example)
.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Condition Stage Type (Example)
... evidence I0..*BackboneElementSupporting evidence
+ evidence SHALL have code or details
.... code ΣI0..*CodeableConceptManifestation/symptom
Manifestation and Symptom Codes (Example)
.... detail ΣI0..*Reference(Any)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

UML Diagram (Legend)

Condition (DomainResource)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)identifier : Identifier [0..*]The clinical status of the condition (this element modifies the meaning of other elements)clinicalStatus : code [0..1] The clinical status of the condition or diagnosis. (Strength=Required)Condition Clinical Status ! The verification status to support the clinical status of the condition (this element modifies the meaning of other elements)verificationStatus : code [0..1] The verification status to support or decline the clinical status of the condition or diagnosis. (Strength=Required)ConditionVerificationStatus! A category assigned to the conditioncategory : CodeableConcept [0..*] A category assigned to the condition. (Strength=Example)Condition Category ?? A subjective assessment of the severity of the condition as evaluated by the clinicianseverity : CodeableConcept [0..1] A subjective assessment of the severity of the condition as evaluated by the clinician. (Strength=Preferred)Condition/Diagnosis Severity? Identification of the condition, problem or diagnosiscode : CodeableConcept [0..1] Identification of the condition or diagnosis. (Strength=Example)Condition/Problem/Diagnosis ?? The anatomical location where this condition manifests itselfbodySite : CodeableConcept [0..*] Codes describing anatomical locations. May include laterality. (Strength=Example)SNOMED CT Body Structures?? Indicates the patient or group who the condition record is associated withsubject : Reference [1..1] Patient|Group Encounter during which the condition was first assertedcontext : Reference [0..1] Encounter|EpisodeOfCare Estimated or actual date or date-time the condition began, in the opinion of the clinicianonset[x] : Type [0..1] dateTime|Age|Period|Range|string 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 abateabatement[x] : Type [0..1] dateTime|Age|Period|Range|string The date on which the existance of the Condition was first asserted or acknowledgedassertedDate : dateTime [0..1]Individual who is making the condition statementasserter : Reference [0..1] Practitioner|Patient|RelatedPerson Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosisnote : Annotation [0..*]StageA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specificsummary : CodeableConcept [0..1] Codes describing condition stages (e.g. Cancer stages). (Strength=Example)Condition Stage?? Reference to a formal record of the evidence on which the staging assessment is basedassessment : Reference [0..*] ClinicalImpression|DiagnosticReport| Observation The kind of staging, such as pathological or clinical stagingtype : CodeableConcept [0..1] Codes describing the kind of condition staging (e.g. clinical or pathological). (Strength=Example)Condition Stage Type?? EvidenceA manifestation or symptom that led to the recording of this conditioncode : CodeableConcept [0..*] Codes that describe the manifestation or symptoms of a condition. (Strength=Example)Manifestation and Symptom ?? Links to other relevant information, including pathology reportsdetail : Reference [0..*] Any Clinical stage or grade of a condition. May include formal severity assessmentsstage[0..*]Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmedevidence[0..*]

XML Template

<Condition xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <clinicalStatus value="[code]"/><!-- ?? 0..1 active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved -->
 <verificationStatus value="[code]"/><!-- ?? 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknown -->
 <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><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter or episode when condition first asserted --></context>
 <onset[x]><!-- 0..1 dateTime|Age|Period|Range|string Estimated or actual date,  date-time, or age --></onset[x]>
 <abatement[x]><!-- ?? 0..1 dateTime|Age|Period|Range|string When in resolution/remission --></abatement[x]>
 <assertedDate value="[dateTime]"/><!-- 0..1 Date record was believed accurate -->
 <asserter><!-- 0..1 Reference(Practitioner|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

{doco
  "resourceType" : "Condition",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this condition
  "clinicalStatus" : "<code>", // C? active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  "verificationStatus" : "<code>", // C? unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknown
  "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?
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter or episode when condition first asserted
  // 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>",
  "assertedDate" : "<dateTime>", // Date record was believed accurate
  "asserter" : { Reference(Practitioner|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/> .doco


[ 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:Condition.identifier [ Identifier ], ... ; # 0..* External Ids for this condition
  fhir:Condition.clinicalStatus [ code ]; # 0..1 active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  fhir:Condition.verificationStatus [ code ]; # 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknown
  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:Condition.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Encounter or episode when condition first asserted
  # 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 ]
  # Condition.abatement[x] : 0..1 When in resolution/remission. One of these 5
    fhir:Condition.abatementDateTime [ dateTime ]
    fhir:Condition.abatementAge [ Age ]
    fhir:Condition.abatementPeriod [ Period ]
    fhir:Condition.abatementRange [ Range ]
    fhir:Condition.abatementString [ string ]
  fhir:Condition.assertedDate [ dateTime ]; # 0..1 Date record was believed accurate
  fhir:Condition.asserter [ Reference(Practitioner|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: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

Condition
Condition.clinicalStatus
  • Add Binding http://hl7.org/fhir/ValueSet/condition-clinical (required)
Condition.verificationStatus
  • Min Cardinality changed from 1 to 0
  • Default Value "unknown" added
Condition.category
  • Max Cardinality changed from 1 to *
Condition.code
  • Min Cardinality changed from 1 to 0
Condition.subject
  • Renamed from patient to subject
  • Add Reference(Group)
Condition.context
  • Renamed from encounter to context
  • Add Reference(EpisodeOfCare)
Condition.onset[x]
  • Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Add Age
Condition.abatement[x]
  • Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Remove boolean, Add Age
Condition.assertedDate
  • Renamed from dateRecorded to assertedDate
  • Type changed from date to dateTime
Condition.asserter
  • Add Reference(RelatedPerson)
Condition.stage
  • Max Cardinality changed from 1 to *
Condition.stage.type
  • Added Element
Condition.evidence.code
  • Max Cardinality changed from 1 to *
Condition.note
  • Renamed from notes to note
  • Max Cardinality changed from 1 to *
  • Type changed from string to Annotation

See the Full Difference for further information

This analysis is available as XML or JSON.

See R2 <--> R3 Conversion Maps (status = 14 tests that all execute ok. 11 fail round-trip testing and 14 r3 resources are invalid (14 errors).).

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition IDomainResourceDetailed information about conditions, problems or diagnoses
+ If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
+ Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!ΣI0..1codeactive | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
Condition Clinical Status Codes (Required)
... verificationStatus ?!ΣI0..1codeunconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknown
ConditionVerificationStatus (Required)
... category 0..*CodeableConceptproblem-list-item | encounter-diagnosis
Condition Category Codes (Example)
... severity 0..1CodeableConceptSubjective severity of condition
Condition/Diagnosis Severity (Preferred)
... code Σ0..1CodeableConceptIdentification of the condition, problem or diagnosis
Condition/Problem/Diagnosis Codes (Example)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
SNOMED CT Body Structures (Example)
... subject Σ1..1Reference(Patient | Group)Who has the condition?
... context Σ0..1Reference(Encounter | EpisodeOfCare)Encounter or episode when condition first asserted
... onset[x] Σ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] I0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... assertedDate Σ0..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(Practitioner | Patient | RelatedPerson)Person who asserts this condition
... stage I0..*BackboneElementStage/grade, usually assessed formally
+ Stage SHALL have summary or assessment
.... summary I0..1CodeableConceptSimple summary (disease specific)
Condition Stage (Example)
.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Condition Stage Type (Example)
... evidence I0..*BackboneElementSupporting evidence
+ evidence SHALL have code or details
.... code ΣI0..*CodeableConceptManifestation/symptom
Manifestation and Symptom Codes (Example)
.... detail ΣI0..*Reference(Any)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

UML Diagram (Legend)

Condition (DomainResource)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)identifier : Identifier [0..*]The clinical status of the condition (this element modifies the meaning of other elements)clinicalStatus : code [0..1] The clinical status of the condition or diagnosis. (Strength=Required)Condition Clinical Status ! The verification status to support the clinical status of the condition (this element modifies the meaning of other elements)verificationStatus : code [0..1] The verification status to support or decline the clinical status of the condition or diagnosis. (Strength=Required)ConditionVerificationStatus! A category assigned to the conditioncategory : CodeableConcept [0..*] A category assigned to the condition. (Strength=Example)Condition Category ?? A subjective assessment of the severity of the condition as evaluated by the clinicianseverity : CodeableConcept [0..1] A subjective assessment of the severity of the condition as evaluated by the clinician. (Strength=Preferred)Condition/Diagnosis Severity? Identification of the condition, problem or diagnosiscode : CodeableConcept [0..1] Identification of the condition or diagnosis. (Strength=Example)Condition/Problem/Diagnosis ?? The anatomical location where this condition manifests itselfbodySite : CodeableConcept [0..*] Codes describing anatomical locations. May include laterality. (Strength=Example)SNOMED CT Body Structures?? Indicates the patient or group who the condition record is associated withsubject : Reference [1..1] Patient|Group Encounter during which the condition was first assertedcontext : Reference [0..1] Encounter|EpisodeOfCare Estimated or actual date or date-time the condition began, in the opinion of the clinicianonset[x] : Type [0..1] dateTime|Age|Period|Range|string 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 abateabatement[x] : Type [0..1] dateTime|Age|Period|Range|string The date on which the existance of the Condition was first asserted or acknowledgedassertedDate : dateTime [0..1]Individual who is making the condition statementasserter : Reference [0..1] Practitioner|Patient|RelatedPerson Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosisnote : Annotation [0..*]StageA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specificsummary : CodeableConcept [0..1] Codes describing condition stages (e.g. Cancer stages). (Strength=Example)Condition Stage?? Reference to a formal record of the evidence on which the staging assessment is basedassessment : Reference [0..*] ClinicalImpression|DiagnosticReport| Observation The kind of staging, such as pathological or clinical stagingtype : CodeableConcept [0..1] Codes describing the kind of condition staging (e.g. clinical or pathological). (Strength=Example)Condition Stage Type?? EvidenceA manifestation or symptom that led to the recording of this conditioncode : CodeableConcept [0..*] Codes that describe the manifestation or symptoms of a condition. (Strength=Example)Manifestation and Symptom ?? Links to other relevant information, including pathology reportsdetail : Reference [0..*] Any Clinical stage or grade of a condition. May include formal severity assessmentsstage[0..*]Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmedevidence[0..*]

XML Template

<Condition xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <clinicalStatus value="[code]"/><!-- ?? 0..1 active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved -->
 <verificationStatus value="[code]"/><!-- ?? 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknown -->
 <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><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter or episode when condition first asserted --></context>
 <onset[x]><!-- 0..1 dateTime|Age|Period|Range|string Estimated or actual date,  date-time, or age --></onset[x]>
 <abatement[x]><!-- ?? 0..1 dateTime|Age|Period|Range|string When in resolution/remission --></abatement[x]>
 <assertedDate value="[dateTime]"/><!-- 0..1 Date record was believed accurate -->
 <asserter><!-- 0..1 Reference(Practitioner|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

{doco
  "resourceType" : "Condition",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this condition
  "clinicalStatus" : "<code>", // C? active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  "verificationStatus" : "<code>", // C? unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknown
  "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?
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter or episode when condition first asserted
  // 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>",
  "assertedDate" : "<dateTime>", // Date record was believed accurate
  "asserter" : { Reference(Practitioner|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/> .doco


[ 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:Condition.identifier [ Identifier ], ... ; # 0..* External Ids for this condition
  fhir:Condition.clinicalStatus [ code ]; # 0..1 active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  fhir:Condition.verificationStatus [ code ]; # 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknown
  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:Condition.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Encounter or episode when condition first asserted
  # 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 ]
  # Condition.abatement[x] : 0..1 When in resolution/remission. One of these 5
    fhir:Condition.abatementDateTime [ dateTime ]
    fhir:Condition.abatementAge [ Age ]
    fhir:Condition.abatementPeriod [ Period ]
    fhir:Condition.abatementRange [ Range ]
    fhir:Condition.abatementString [ string ]
  fhir:Condition.assertedDate [ dateTime ]; # 0..1 Date record was believed accurate
  fhir:Condition.asserter [ Reference(Practitioner|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: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

Condition
Condition.clinicalStatus
  • Add Binding http://hl7.org/fhir/ValueSet/condition-clinical (required)
Condition.verificationStatus
  • Min Cardinality changed from 1 to 0
  • Default Value "unknown" added
Condition.category
  • Max Cardinality changed from 1 to *
Condition.code
  • Min Cardinality changed from 1 to 0
Condition.subject
  • Renamed from patient to subject
  • Add Reference(Group)
Condition.context
  • Renamed from encounter to context
  • Add Reference(EpisodeOfCare)
Condition.onset[x]
  • Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Add Age
Condition.abatement[x]
  • Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Remove boolean, Add Age
Condition.assertedDate
  • Renamed from dateRecorded to assertedDate
  • Type changed from date to dateTime
Condition.asserter
  • Add Reference(RelatedPerson)
Condition.stage
  • Max Cardinality changed from 1 to *
Condition.stage.type
  • Added Element
Condition.evidence.code
  • Max Cardinality changed from 1 to *
Condition.note
  • Renamed from notes to note
  • Max Cardinality changed from 1 to *
  • Type changed from string to Annotation

See the Full Difference for further information

This analysis is available as XML or JSON.

See R2 <--> R3 Conversion Maps (status = 14 tests that all execute ok. 11 fail round-trip testing and 14 r3 resources are invalid (14 errors).).

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron + JSON Schema, ShEx (for Turtle)

PathDefinitionTypeReference
Condition.clinicalStatus The clinical status of the condition or diagnosis.RequiredCondition Clinical Status Codes
Condition.verificationStatus The verification status to support or decline the clinical status of the condition or diagnosis.RequiredConditionVerificationStatus
Condition.category A category assigned to the condition.ExampleCondition Category Codes
Condition.severity A subjective assessment of the severity of the condition as evaluated by the clinician.PreferredCondition/Diagnosis Severity
Condition.code Identification of the condition or diagnosis.ExampleCondition/Problem/Diagnosis Codes
Condition.bodySite Codes describing anatomical locations. May include laterality.ExampleSNOMED CT Body Structures
Condition.stage.summary Codes describing condition stages (e.g. Cancer stages).ExampleCondition Stage
Condition.stage.type Codes describing the kind of condition staging (e.g. clinical or pathological).ExampleCondition Stage Type
Condition.evidence.code Codes that describe the manifestation or symptoms of a condition.ExampleManifestation and Symptom Codes

  • con-1: On Condition.stage: Stage SHALL have summary or assessment (expression on Condition.stage: summary.exists() or assessment.exists())
  • con-2: On Condition.evidence: evidence SHALL have code or details (expression on Condition.evidence: code.exists() or detail.exists())
  • con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error (expression : verificationStatus='entered-in-error' or clinicalStatus.exists())
  • 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')

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 of X" and "good health", where it is useful or appropriate to make such assertions. It can also be used to capture "risk of" and "fear of", in addition to physical conditions, as well as "no known problems" or "negated" conditions (e.g., "no X" or "no history of X" - see the following section for "No Known 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".

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 known 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 known problems" record and you add a "diabetes" condition record, then be sure that you remove the "no known problems" record.

STU Note: There are two primary ways of reporting "no known problems" in the current specification: using the CodeableConcept, as described above, or using the List resource with emptyReason. During the STU period, feedback is 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:

  • It is appropriate to capture a "refuted" Condition record if the patient or anyone else had reason to believe that a patient did have a condition for a period of time and subsequent evidence has demonstrated that belief was mistaken. In this case, a concrete statement acknowledging the belief as well as the refutation of it is useful.
  • It is common as part of checklists prior to admission, surgery, enrollment in trials, etc. to ask questions such as "are you pregnant", "do you have a history of hypertension", etc. This information should NOT be captured using the Condition resource but should instead be captured using QuestionnaireResponse or Observation. In this case, the combination of the question and answer would convey that a particular condition was not present.

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" 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.

NameTypeDescriptionExpressionIn Common
abatement-agequantityAbatement as age or age rangeCondition.abatement.as(Age) | Condition.abatement.as(Range) | Condition.abatement.as(Age)
abatement-datedateDate-related abatements (dateTime and period)Condition.abatement.as(dateTime) | Condition.abatement.as(Period)
abatement-stringstringAbatement as a stringCondition.abatement.as(string)
asserted-datedateDate record was believed accurateCondition.assertedDate
asserterreferencePerson who asserts this conditionCondition.asserter
(Practitioner, Patient, RelatedPerson)
body-sitetokenAnatomical location, if relevantCondition.bodySite
categorytokenThe category of the conditionCondition.category
clinical-statustokenThe clinical status of the conditionCondition.clinicalStatus
codetokenCode for the conditionCondition.code8 Resources
contextreferenceEncounter or episode when condition first assertedCondition.context
(EpisodeOfCare, Encounter)
encounterreferenceEncounter when condition first assertedCondition.context
(Encounter)
evidencetokenManifestation/symptomCondition.evidence.code
evidence-detailreferenceSupporting information found elsewhereCondition.evidence.detail
(Any)
identifiertokenA unique identifier of the condition recordCondition.identifier26 Resources
onset-agequantityOnsets as age or age rangeCondition.onset.as(Age) | Condition.onset.as(Range)
onset-datedateDate related onsets (dateTime and Period)Condition.onset.as(dateTime) | Condition.onset.as(Period)
onset-infostringOnsets as a stringCondition.onset.as(string)
patientreferenceWho has the condition?Condition.subject
(Patient)
30 Resources
severitytokenThe severity of the conditionCondition.severity
stagetokenSimple summary (disease specific)Condition.stage.summary
subjectreferenceWho has the condition?Condition.subject
(Group, Patient)
verification-statustokenunconfirmed | provisional | differential | confirmed | refuted | entered-in-error | unknownCondition.verificationStatus