Canadian Baseline
1.1.0 - CI Build
Canadian Baseline, published by HL7 Canada - FHIR Implementation Work Group. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-Canada/ca-baseline/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-condition | Version: 1.1.0 | |||
Draft as of 2020-07-21 | Computable Name: ConditionProfile |
Proposed constraints and extensions on the Condition Resource
This profile is seeking community and implementer feedback on whether further constraints on use of verificationStatus are needed.
VerificationStatus has been identified by members of our community as having clinical significance, though standardization around its use is still evolving in the international community (particularly in implementation guidance and value sets). We are currently seeking feedback from implementers on current utilization practices before further strengthening guidance on its use.
Feedback can be provided through the Simplifier issue log for this profile.. Proposed language for inclusion under our Best Practice/Should support section is also welcomed.
This profile constrains the Condition resource to record a list of problems associated with a patient. It identifies which elements, vocabularies and value sets to be present in the resource when using this profile.
This profile defines localization concepts for use in a Canadian context.
All elements or attributes defined in FHIR have cardinality as part of their definition - a minimum number of required appearances and a maximum number.
Most elements in FHIR specification have a minimum cardinality of 0, which means that they may be missing from a resource when it is exchanged between systems.
Required elements:
Some elements are labeled as MustSupport meaning that implementations that produce or consume resources SHALL provide "support" for the element in some meaningful way (see Must Support definition).
Following elements are marked as Must Support in the Canadian Condition profile to aid record matching in databases with many pediatric records.
Must Support elements:
Condition is intended for capturing and querying patient's current and historical problems.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Condition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | Condition | Condition Profile | |
clinicalStatus | ?!S | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved |
verificationStatus | ?! | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error |
code | S | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode (preferred): Codes for problems from the SNOMED CT Canadian edition value set |
Slices for coding | S | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:binding.valueSet |
coding:HealthConcernCode | 0..1 | Coding | CHI identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode (required): Represents the patient's relevant clinical problems, conditions, diagnoses, symptoms, findings and complaints, as interpreted by the provider. | |
coding:@default | 0..1 | Coding | Other identifications of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example) | |
subject | S | 1..1 | Reference(Patient Profile) | Who has the condition? |
encounter | 0..1 | Reference(Encounter Profile) | Encounter created as part of | |
onset[x] | S | 0..1 | dateTime, Age, Period, Range, string | Estimated or actual date, date-time, or age |
recorder | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Who recorded the condition | |
asserter | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Person who asserts this condition | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcodehttps://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode | |
Condition.code.coding:HealthConcernCode | required | https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncodehttps://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode | |
Condition.code.coding:@default | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | Condition | Condition Profile con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. |
verificationStatus | ?!ΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. |
code | SΣ | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode (preferred): Codes for problems from the SNOMED CT Canadian edition value set |
Slices for coding | SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:binding.valueSet |
coding:HealthConcernCode | Σ | 0..1 | Coding | CHI identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode (required): Represents the patient's relevant clinical problems, conditions, diagnoses, symptoms, findings and complaints, as interpreted by the provider. |
coding:@default | Σ | 0..1 | Coding | Other identifications of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example) |
subject | SΣ | 1..1 | Reference(Patient Profile) | Who has the condition? |
encounter | Σ | 0..1 | Reference(Encounter Profile) | Encounter created as part of |
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |
onsetDateTime | dateTime | |||
onsetAge | Age | |||
onsetPeriod | Period | |||
onsetRange | Range | |||
onsetString | string | |||
recorder | Σ | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Who recorded the condition |
asserter | Σ | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Person who asserts this condition |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | |
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | |
Condition.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcodehttps://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode | |
Condition.code.coding:HealthConcernCode | required | https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncodehttps://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode | |
Condition.code.coding:@default | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | Condition | Condition Profile con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||
verificationStatus | ?!ΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | ||||
category | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. | |||||
severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | |||||
code | SΣ | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode (preferred): Codes for problems from the SNOMED CT Canadian edition value set | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:binding.valueSet | ||||
coding:HealthConcernCode | Σ | 0..1 | Coding | CHI identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode (required): Represents the patient's relevant clinical problems, conditions, diagnoses, symptoms, findings and complaints, as interpreted by the provider. | ||||
coding:@default | Σ | 0..1 | Coding | Other identifications of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example) | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
subject | SΣ | 1..1 | Reference(Patient Profile) | Who has the condition? | ||||
encounter | Σ | 0..1 | Reference(Encounter Profile) | Encounter created as part of | ||||
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||
onsetDateTime | dateTime | |||||||
onsetAge | Age | |||||||
onsetPeriod | Period | |||||||
onsetRange | Range | |||||||
onsetString | string | |||||||
abatement[x] | C | 0..1 | When in resolution/remission | |||||
abatementDateTime | dateTime | |||||||
abatementAge | Age | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
recordedDate | Σ | 0..1 | dateTime | Date record was first recorded | ||||
recorder | Σ | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Who recorded the condition | ||||
asserter | Σ | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Person who asserts this condition | ||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||
evidence | C | 0..* | BackboneElement | Supporting evidence con-2: evidence SHALL have code or details | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||
detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||
note | 0..* | Annotation | Additional information about the Condition | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | preferred | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcodehttps://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode | ||||
Condition.code.coding:HealthConcernCode | required | https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncodehttps://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode | ||||
Condition.code.coding:@default | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.stage.summary | example | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | example | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | example | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Condition
Summary
Must-Support: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Condition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | Condition | Condition Profile | |
clinicalStatus | ?!S | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved |
verificationStatus | ?! | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error |
code | S | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode (preferred): Codes for problems from the SNOMED CT Canadian edition value set |
Slices for coding | S | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:binding.valueSet |
coding:HealthConcernCode | 0..1 | Coding | CHI identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode (required): Represents the patient's relevant clinical problems, conditions, diagnoses, symptoms, findings and complaints, as interpreted by the provider. | |
coding:@default | 0..1 | Coding | Other identifications of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example) | |
subject | S | 1..1 | Reference(Patient Profile) | Who has the condition? |
encounter | 0..1 | Reference(Encounter Profile) | Encounter created as part of | |
onset[x] | S | 0..1 | dateTime, Age, Period, Range, string | Estimated or actual date, date-time, or age |
recorder | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Who recorded the condition | |
asserter | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Person who asserts this condition | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcodehttps://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode | |
Condition.code.coding:HealthConcernCode | required | https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncodehttps://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode | |
Condition.code.coding:@default | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | Condition | Condition Profile con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. |
verificationStatus | ?!ΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. |
code | SΣ | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode (preferred): Codes for problems from the SNOMED CT Canadian edition value set |
Slices for coding | SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:binding.valueSet |
coding:HealthConcernCode | Σ | 0..1 | Coding | CHI identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode (required): Represents the patient's relevant clinical problems, conditions, diagnoses, symptoms, findings and complaints, as interpreted by the provider. |
coding:@default | Σ | 0..1 | Coding | Other identifications of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example) |
subject | SΣ | 1..1 | Reference(Patient Profile) | Who has the condition? |
encounter | Σ | 0..1 | Reference(Encounter Profile) | Encounter created as part of |
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |
onsetDateTime | dateTime | |||
onsetAge | Age | |||
onsetPeriod | Period | |||
onsetRange | Range | |||
onsetString | string | |||
recorder | Σ | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Who recorded the condition |
asserter | Σ | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Person who asserts this condition |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | |
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | |
Condition.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcodehttps://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode | |
Condition.code.coding:HealthConcernCode | required | https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncodehttps://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode | |
Condition.code.coding:@default | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | Condition | Condition Profile con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||
verificationStatus | ?!ΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | ||||
category | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. | |||||
severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | |||||
code | SΣ | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode (preferred): Codes for problems from the SNOMED CT Canadian edition value set | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:binding.valueSet | ||||
coding:HealthConcernCode | Σ | 0..1 | Coding | CHI identification of the condition, problem or diagnosis Binding: https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode (required): Represents the patient's relevant clinical problems, conditions, diagnoses, symptoms, findings and complaints, as interpreted by the provider. | ||||
coding:@default | Σ | 0..1 | Coding | Other identifications of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example) | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
subject | SΣ | 1..1 | Reference(Patient Profile) | Who has the condition? | ||||
encounter | Σ | 0..1 | Reference(Encounter Profile) | Encounter created as part of | ||||
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||
onsetDateTime | dateTime | |||||||
onsetAge | Age | |||||||
onsetPeriod | Period | |||||||
onsetRange | Range | |||||||
onsetString | string | |||||||
abatement[x] | C | 0..1 | When in resolution/remission | |||||
abatementDateTime | dateTime | |||||||
abatementAge | Age | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
recordedDate | Σ | 0..1 | dateTime | Date record was first recorded | ||||
recorder | Σ | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Who recorded the condition | ||||
asserter | Σ | 0..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Patient Profile | RelatedPerson) | Person who asserts this condition | ||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||
evidence | C | 0..* | BackboneElement | Supporting evidence con-2: evidence SHALL have code or details | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||
detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||
note | 0..* | Annotation | Additional information about the Condition | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | preferred | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcodehttps://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode | ||||
Condition.code.coding:HealthConcernCode | required | https://fhir.infoway-inforoute.ca/ValueSet/healthconcerncodehttps://fhir.infoway-inforoute.ca/ValueSet/healthconcerncode | ||||
Condition.code.coding:@default | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.stage.summary | example | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | example | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | example | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Condition
Summary
Must-Support: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
Rules derived from the FHIR Condition resource description:
Rational: Most systems will expect a clinicalStatus to be valued for problem-list-items that are managed over time, but might not need a clinicalStatus for point in time encounter-diagnosis.
The verification status supports the clinical status of the condition.
The verification status 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.
The Condition.verificationStatus is optional considering the use case of using the Condition to populate a problem list where clinically documented problems range from general descriptions (e.g. "short of breath") to specific diagnoses with no verification step.
The identification of the the client's relevant condition, problem or diagnosis or recording of "problem absent" or of "problems unknown", as interpreted by the provider.
The Condition.code element is CodeableConcept data type meaning that more than one Coding sub-elements can be present. One of these Coding sub-elements SHALL use Health Concern Code value set from Canada Health Infoway. Other Coding component are transaltion of the HealthConcernCode to other code systems.