US Core Implementation Guide
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US Core Implementation Guide, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 7.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions

Resource Profile: US Core Condition Encounter Diagnosis Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis Version: 7.0.0
Standards status: Trial-use Maturity Level: 3 Computable Name: USCoreConditionEncounterDiagnosisProfile
Other Identifiers: OID:2.16.840.1.113883.4.642.40.42.14

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The US Core Condition Encounter Diagnosis Profile is based upon the core FHIR Condition Resource and meets the U.S. Core Data for Interoperability (USCDI) Encounter Diagnosis requirements. In version 5.0.0, The US Core Condition Profile has been split into the US Core Condition Encounter Diagnosis Profile and US Core Condition Problems and Health Concerns Profile. To promote interoperability and adoption through common implementation, this profile defines constraints and extensions on the Condition resource for the minimal set of data to record, search, and fetch information about an encounter diagnosis. It identifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains the way the elements are used when using this profile. It provides the floor for standards development for specific use cases.

Example Usage Scenarios:

The following are example usage scenarios for this profile:

  • Query for a Patient’s current or historical encounter diagnosis
  • Record or update a Patient’s encounter diagnosis

Mandatory and Must Support Data Elements

The following data-elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each Condition Must Have:

  1. a category code of ‘encounter-diagnosis’
  2. a code that identifies the condition
  3. a patient

Each Condition Must Support:

  1. a clinical status of the condition (e.g., active or resolved)
  2. a verification status
  3. an encounter
  4. a date of diagnosis*
  5. abatement date (in other words, date of resolution or remission)
  6. a date when recorded*

*see guidance below

Profile Specific Implementation Guidance:

  • For Problems and Health Concerns use the US Core Condition Problems and Health Concerns Profile.
  • For USCDI the applicable vocabulary standards for Encounter Diagnosis are SNOMED CT and ICD-10-CM. For general guidance on extensible binding to coded data, review this section in the General Requirements page.
    • The US Core Condition Codes supports ICD-9-CM for historical purposes only. ICD-10-CM is available and SHOULD be used as the primary code for current encounter diagnoses.
  • The encounter SHOULD always be referenced in Condition.encounter.
  • To search for an encounter diagnosis, query for Conditions that reference the Encounter of interest and have a category of encounter-diagnosis. An example search is shown in the Quick Start section below.
  • *There is no single element in Condition that represents the date of diagnosis. It may be the assertedDate Extension, Condition.onsetDateTime, or Condition.recordedDate.
    • Although all three are marked as Must Support, the server is not required to support all.
    • A server SHALL support Condition.recordedDate.
    • A server SHALL support at least one of assertedDate Extension and Condition.onsetDateTime. A server may support both, which means they support all 3 dates.
    • The client application SHALL support all three elements.

Usage:

Changes since version 7.0.0-ballot:

  • The resource metadata has changed (description)
  • The data elements list has changed
  • One or more text definitions, invariants or bindings have changed
  • Formal Views of Profile Content

    Description of Profiles, Differentials, Snapshots and how the different presentations work.

    This structure is derived from Condition

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
    ... assertedDate S0..1dateTimeDate the condition was first asserted
    URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
    ... clinicalStatus S0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ... verificationStatus S0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ... Slices for category S1..*CodeableConceptcategory codes
    Slice: Unordered, Open by pattern:$this
    .... category:us-core S1..1CodeableConceptencounter-diagnosis
    Required Pattern: At least the following
    ..... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ...... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... code1..1codeSymbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
    Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

    ... subject S1..1Reference(US Core Patient Profile S | Group)Who has the condition?
    ... encounter S0..1Reference(US Core Encounter Profile)Encounter created as part of
    ... onset[x] S0..1Estimated or actual date, date-time, or age
    .... onsetDateTimedateTime S
    .... onsetAgeAge
    .... onsetPeriodPeriod
    .... onsetRangeRange
    .... onsetStringstring
    ... abatement[x] S0..1When in resolution/remission
    .... abatementDateTimedateTime S
    .... abatementAgeAge
    .... abatementPeriodPeriod
    .... abatementRangeRange
    .... abatementStringstring
    ... recordedDate S0..1dateTimeDate record was first recorded

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Condition.clinicalStatusrequiredConditionClinicalStatusCodes
    http://hl7.org/fhir/ValueSet/condition-clinical
    from the FHIR Standard
    Condition.verificationStatusrequiredConditionVerificationStatus
    http://hl7.org/fhir/ValueSet/condition-ver-status
    from the FHIR Standard
    Condition.codeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
    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 ?!Σ0..1uriA set of rules under which this content was created
    ... assertedDate S0..1dateTimeDate the condition was first asserted
    URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ... verificationStatus ?!SΣC0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ... Slices for category S1..*CodeableConceptcategory codes
    Slice: Unordered, Open by pattern:$this
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


    .... category:us-core S1..1CodeableConceptencounter-diagnosis
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



    Required Pattern: At least the following
    ..... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ...... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... code1..1codeSymbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
    Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

    ... subject SΣ1..1Reference(US Core Patient Profile)Who has the condition?
    ... encounter SΣ0..1Reference(US Core Encounter Profile)Encounter created as part of
    ... onset[x] SΣ0..1Estimated or actual date, date-time, or age
    .... onsetDateTimedateTime
    ... abatement[x] SC0..1When in resolution/remission
    .... abatementDateTimedateTime
    ... recordedDate SΣ0..1dateTimeDate record was first recorded

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Condition.clinicalStatusrequiredConditionClinicalStatusCodes
    http://hl7.org/fhir/ValueSet/condition-clinical
    from the FHIR Standard
    Condition.verificationStatusrequiredConditionVerificationStatus
    http://hl7.org/fhir/ValueSet/condition-ver-status
    from the FHIR Standard
    Condition.categoryextensibleConditionCategoryCodes
    http://hl7.org/fhir/ValueSet/condition-category
    from the FHIR Standard
    Condition.category:us-coreextensiblePattern: encounter-diagnosis
    http://hl7.org/fhir/ValueSet/condition-category
    from the FHIR Standard
    Condition.codeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceConditionA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
    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 Σ0..1idLogical id of this artifact
    ... meta Σ0..1MetaMetadata about the resource
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... language 0..1codeLanguage of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    ... text 0..1NarrativeText summary of the resource, for human interpretation
    ... contained 0..*ResourceContained, inline Resources
    ... Slices for extension 0..*ExtensionExtension
    Slice: Unordered, Open by value:url
    ... assertedDate S0..1dateTimeDate the condition was first asserted
    URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... identifier Σ0..*IdentifierExternal Ids for this condition
    ... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ... verificationStatus ?!SΣC0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ... Slices for category S1..*CodeableConceptcategory codes
    Slice: Unordered, Open by pattern:$this
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


    .... category:us-core S1..1CodeableConceptencounter-diagnosis
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



    Required Pattern: At least the following
    ..... id0..1stringUnique id for inter-element referencing
    ..... extension0..*ExtensionAdditional content defined by implementations
    ..... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ...... id0..1stringUnique id for inter-element referencing
    ...... extension0..*ExtensionAdditional content defined by implementations
    ...... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... version0..1stringVersion of the system - if relevant
    ...... code1..1codeSymbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ...... display0..1stringRepresentation defined by the system
    ...... userSelected0..1booleanIf this coding was chosen directly by the user
    ..... text0..1stringPlain text representation of the concept
    ... severity 0..1CodeableConceptSubjective severity of condition
    Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

    ... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
    Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

    ... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
    Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


    ... subject SΣ1..1Reference(US Core Patient Profile S | Group)Who has the condition?
    ... encounter SΣ0..1Reference(US Core Encounter Profile)Encounter created as part of
    ... onset[x] SΣ0..1Estimated or actual date, date-time, or age
    .... onsetDateTimedateTime S
    .... onsetAgeAge
    .... onsetPeriodPeriod
    .... onsetRangeRange
    .... onsetStringstring
    ... abatement[x] SC0..1When in resolution/remission
    .... abatementDateTimedateTime S
    .... abatementAgeAge
    .... abatementPeriodPeriod
    .... abatementRangeRange
    .... abatementStringstring
    ... recordedDate SΣ0..1dateTimeDate record was first recorded
    ... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
    ... asserter Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Person who asserts this condition
    ... stage C0..*BackboneElementStage/grade, usually assessed formally
    con-1: Stage SHALL have summary or assessment
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... summary C0..1CodeableConceptSimple summary (disease specific)
    Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

    .... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
    .... type 0..1CodeableConceptKind of staging
    Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

    ... evidence C0..*BackboneElementSupporting evidence
    con-2: evidence SHALL have code or details
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... code ΣC0..*CodeableConceptManifestation/symptom
    Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


    .... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
    ... note 0..*AnnotationAdditional information about the Condition

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Condition.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Condition.clinicalStatusrequiredConditionClinicalStatusCodes
    http://hl7.org/fhir/ValueSet/condition-clinical
    from the FHIR Standard
    Condition.verificationStatusrequiredConditionVerificationStatus
    http://hl7.org/fhir/ValueSet/condition-ver-status
    from the FHIR Standard
    Condition.categoryextensibleConditionCategoryCodes
    http://hl7.org/fhir/ValueSet/condition-category
    from the FHIR Standard
    Condition.category:us-coreextensiblePattern: encounter-diagnosis
    http://hl7.org/fhir/ValueSet/condition-category
    from the FHIR Standard
    Condition.severitypreferredCondition/DiagnosisSeverity
    http://hl7.org/fhir/ValueSet/condition-severity
    from the FHIR Standard
    Condition.codeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG
    Condition.bodySiteexampleSNOMEDCTBodyStructures
    http://hl7.org/fhir/ValueSet/body-site
    from the FHIR Standard
    Condition.stage.summaryexampleConditionStage
    http://hl7.org/fhir/ValueSet/condition-stage
    from the FHIR Standard
    Condition.stage.typeexampleConditionStageType
    http://hl7.org/fhir/ValueSet/condition-stage-type
    from the FHIR Standard
    Condition.evidence.codeexampleManifestationAndSymptomCodes
    http://hl7.org/fhir/ValueSet/manifestation-or-symptom
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    con-1errorCondition.stageStage SHALL have summary or assessment
    : summary.exists() or assessment.exists()
    con-2errorCondition.evidenceevidence SHALL have code or details
    : code.exists() or detail.exists()
    con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceConditionA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    This structure is derived from Condition

    Summary

    Mandatory: 3 elements
    Must-Support: 11 elements

    Structures

    This structure refers to these other structures:

    Extensions

    This structure refers to these extensions:

    Slices

    This structure defines the following Slices:

    • The element Condition.category is sliced based on the value of pattern:$this

    Maturity: 3

    Differential View

    This structure is derived from Condition

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
    ... assertedDate S0..1dateTimeDate the condition was first asserted
    URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
    ... clinicalStatus S0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ... verificationStatus S0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ... Slices for category S1..*CodeableConceptcategory codes
    Slice: Unordered, Open by pattern:$this
    .... category:us-core S1..1CodeableConceptencounter-diagnosis
    Required Pattern: At least the following
    ..... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ...... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... code1..1codeSymbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
    Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

    ... subject S1..1Reference(US Core Patient Profile S | Group)Who has the condition?
    ... encounter S0..1Reference(US Core Encounter Profile)Encounter created as part of
    ... onset[x] S0..1Estimated or actual date, date-time, or age
    .... onsetDateTimedateTime S
    .... onsetAgeAge
    .... onsetPeriodPeriod
    .... onsetRangeRange
    .... onsetStringstring
    ... abatement[x] S0..1When in resolution/remission
    .... abatementDateTimedateTime S
    .... abatementAgeAge
    .... abatementPeriodPeriod
    .... abatementRangeRange
    .... abatementStringstring
    ... recordedDate S0..1dateTimeDate record was first recorded

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Condition.clinicalStatusrequiredConditionClinicalStatusCodes
    http://hl7.org/fhir/ValueSet/condition-clinical
    from the FHIR Standard
    Condition.verificationStatusrequiredConditionVerificationStatus
    http://hl7.org/fhir/ValueSet/condition-ver-status
    from the FHIR Standard
    Condition.codeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
    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 ?!Σ0..1uriA set of rules under which this content was created
    ... assertedDate S0..1dateTimeDate the condition was first asserted
    URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ... verificationStatus ?!SΣC0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ... Slices for category S1..*CodeableConceptcategory codes
    Slice: Unordered, Open by pattern:$this
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


    .... category:us-core S1..1CodeableConceptencounter-diagnosis
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



    Required Pattern: At least the following
    ..... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ...... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... code1..1codeSymbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
    Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

    ... subject SΣ1..1Reference(US Core Patient Profile)Who has the condition?
    ... encounter SΣ0..1Reference(US Core Encounter Profile)Encounter created as part of
    ... onset[x] SΣ0..1Estimated or actual date, date-time, or age
    .... onsetDateTimedateTime
    ... abatement[x] SC0..1When in resolution/remission
    .... abatementDateTimedateTime
    ... recordedDate SΣ0..1dateTimeDate record was first recorded

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Condition.clinicalStatusrequiredConditionClinicalStatusCodes
    http://hl7.org/fhir/ValueSet/condition-clinical
    from the FHIR Standard
    Condition.verificationStatusrequiredConditionVerificationStatus
    http://hl7.org/fhir/ValueSet/condition-ver-status
    from the FHIR Standard
    Condition.categoryextensibleConditionCategoryCodes
    http://hl7.org/fhir/ValueSet/condition-category
    from the FHIR Standard
    Condition.category:us-coreextensiblePattern: encounter-diagnosis
    http://hl7.org/fhir/ValueSet/condition-category
    from the FHIR Standard
    Condition.codeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceConditionA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
    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 Σ0..1idLogical id of this artifact
    ... meta Σ0..1MetaMetadata about the resource
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... language 0..1codeLanguage of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    ... text 0..1NarrativeText summary of the resource, for human interpretation
    ... contained 0..*ResourceContained, inline Resources
    ... Slices for extension 0..*ExtensionExtension
    Slice: Unordered, Open by value:url
    ... assertedDate S0..1dateTimeDate the condition was first asserted
    URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... identifier Σ0..*IdentifierExternal Ids for this condition
    ... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ... verificationStatus ?!SΣC0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ... Slices for category S1..*CodeableConceptcategory codes
    Slice: Unordered, Open by pattern:$this
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


    .... category:us-core S1..1CodeableConceptencounter-diagnosis
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



    Required Pattern: At least the following
    ..... id0..1stringUnique id for inter-element referencing
    ..... extension0..*ExtensionAdditional content defined by implementations
    ..... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ...... id0..1stringUnique id for inter-element referencing
    ...... extension0..*ExtensionAdditional content defined by implementations
    ...... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... version0..1stringVersion of the system - if relevant
    ...... code1..1codeSymbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ...... display0..1stringRepresentation defined by the system
    ...... userSelected0..1booleanIf this coding was chosen directly by the user
    ..... text0..1stringPlain text representation of the concept
    ... severity 0..1CodeableConceptSubjective severity of condition
    Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

    ... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
    Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

    ... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
    Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


    ... subject SΣ1..1Reference(US Core Patient Profile S | Group)Who has the condition?
    ... encounter SΣ0..1Reference(US Core Encounter Profile)Encounter created as part of
    ... onset[x] SΣ0..1Estimated or actual date, date-time, or age
    .... onsetDateTimedateTime S
    .... onsetAgeAge
    .... onsetPeriodPeriod
    .... onsetRangeRange
    .... onsetStringstring
    ... abatement[x] SC0..1When in resolution/remission
    .... abatementDateTimedateTime S
    .... abatementAgeAge
    .... abatementPeriodPeriod
    .... abatementRangeRange
    .... abatementStringstring
    ... recordedDate SΣ0..1dateTimeDate record was first recorded
    ... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
    ... asserter Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Person who asserts this condition
    ... stage C0..*BackboneElementStage/grade, usually assessed formally
    con-1: Stage SHALL have summary or assessment
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... summary C0..1CodeableConceptSimple summary (disease specific)
    Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

    .... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
    .... type 0..1CodeableConceptKind of staging
    Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

    ... evidence C0..*BackboneElementSupporting evidence
    con-2: evidence SHALL have code or details
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... code ΣC0..*CodeableConceptManifestation/symptom
    Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


    .... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
    ... note 0..*AnnotationAdditional information about the Condition

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Condition.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Condition.clinicalStatusrequiredConditionClinicalStatusCodes
    http://hl7.org/fhir/ValueSet/condition-clinical
    from the FHIR Standard
    Condition.verificationStatusrequiredConditionVerificationStatus
    http://hl7.org/fhir/ValueSet/condition-ver-status
    from the FHIR Standard
    Condition.categoryextensibleConditionCategoryCodes
    http://hl7.org/fhir/ValueSet/condition-category
    from the FHIR Standard
    Condition.category:us-coreextensiblePattern: encounter-diagnosis
    http://hl7.org/fhir/ValueSet/condition-category
    from the FHIR Standard
    Condition.severitypreferredCondition/DiagnosisSeverity
    http://hl7.org/fhir/ValueSet/condition-severity
    from the FHIR Standard
    Condition.codeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG
    Condition.bodySiteexampleSNOMEDCTBodyStructures
    http://hl7.org/fhir/ValueSet/body-site
    from the FHIR Standard
    Condition.stage.summaryexampleConditionStage
    http://hl7.org/fhir/ValueSet/condition-stage
    from the FHIR Standard
    Condition.stage.typeexampleConditionStageType
    http://hl7.org/fhir/ValueSet/condition-stage-type
    from the FHIR Standard
    Condition.evidence.codeexampleManifestationAndSymptomCodes
    http://hl7.org/fhir/ValueSet/manifestation-or-symptom
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    con-1errorCondition.stageStage SHALL have summary or assessment
    : summary.exists() or assessment.exists()
    con-2errorCondition.evidenceevidence SHALL have code or details
    : code.exists() or detail.exists()
    con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceConditionA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    This structure is derived from Condition

    Summary

    Mandatory: 3 elements
    Must-Support: 11 elements

    Structures

    This structure refers to these other structures:

    Extensions

    This structure refers to these extensions:

    Slices

    This structure defines the following Slices:

    • The element Condition.category is sliced based on the value of pattern:$this

    Maturity: 3

     

    Other representations of profile: CSV, Excel, Schematron

    Notes:


    Quick Start


    Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

    • See the Scopes Format section for a description of the SMART scopes syntax.
    • See the Search Syntax section for a description of the US Core search syntax.
    • See the General Requirements section for additional rules and expectations when a server requires status parameters.
    • See the General Guidance section for additional guidance on searching for multiple <patient user system>s.

    US Core Scopes

    Servers providing access to encounter diagnosis data SHALL support these US Core SMART Scopes:

    • resource level scopes: <patient|user|system>/Condition.rs

    • [granular scope]: <patient|user|system>.Condition.rs?category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis

    Mandatory Search Parameters:

    The following search parameters and search parameter combinations SHALL be supported:

    1. SHALL support searching for all conditions including problems, health concerns, and encounter diagnosis for a patient using the patient search parameter:

      GET [base]/Condition?patient={Type/}[id]

      Example:

      1. GET [base]/Condition?patient=1137192

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient (how to search by reference)

    2. SHALL support searching using the combination of the patient and category search parameters:

      GET [base]/Condition?patient={Type/}[id]&category={system|}[code]

      Example:

      1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|problem-list-item
      2. GET [base]/Condition?patient=1032702&category=http://hl7.org/fhir/us/core/CodeSystem/condition-category|health-concern
      3. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category. (how to search by reference and how to search by token)

    Optional Search Parameters:

    The following search parameter combinations SHOULD be supported:

    1. SHOULD support searching using the combination of the patient and clinical-status search parameters:

      GET [base]/Condition?patient={Type/}[id]&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

      Example:

      1. GET [base/Condition?patient=1032702&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and all "active" statuses (active,relapse,remission). This will exclude diagnoses and health concerns without a clinicalStatus specified. (how to search by reference and how to search by token)

    2. SHOULD support searching using the combination of the patient and category and clinical-status search parameters:

      GET [base]/Condition?patient={Type/}[id]&category={system|}[code]&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

      Example:

      1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|problem-list-item&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category for all "active" statuses (active,relapse,remission). This will exclude diagnoses and health concerns without a clinicalStatus specified. (how to search by reference and how to search by token)

    3. SHOULD support searching using the combination of the patient and category and encounter search parameters:

      GET [base]/Condition?patient={Type/}[id]&category={system|}[code]&encounter={Type/}[id]

      Example:

      1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis&encounter=1036

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category and encounter. When category = "encounter-diagnosis" will return the encounter diagnosis for the encounter. (how to search by reference and how to search by token)

    4. SHOULD support searching using the combination of the patient and code search parameters:

      GET [base]/Condition?patient={Type/}[id]&code={system|}[code]

      Example:

      1. GET [base]/Condition?patient=1032702&code=[http://snomed.info/sct|442311008]

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and code. (how to search by reference and how to search by token)

    5. SHOULD support searching using the combination of the patient and onset-date search parameters:
      • including support for these onset-date comparators: gt,lt,ge,le
      • including optional support for AND search on onset-date (e.g.onset-date=[date]&onset-date=[date]]&...)

      GET [base]/Condition?patient={Type/}[id]&onset-date={gt|lt|ge|le}[date]{&onset-date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]Condition?patient=555580&onset-date=ge2018-01-14

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)

    6. SHOULD support searching using the combination of the patient and asserted-date search parameters:
      • including support for these asserted-date comparators: gt,lt,ge,le
      • including optional support for AND search on asserted-date (e.g.asserted-date=[date]&asserted-date=[date]]&...)

      GET [base]/Condition?patient={Type/}[id]&asserted-date={gt|lt|ge|le}[date]{&asserted-date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]Condition?patient=555580&asserted-date=ge2018-01-14

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)

    7. SHOULD support searching using the combination of the patient and recorded-date search parameters:
      • including support for these recorded-date comparators: gt,lt,ge,le
      • including optional support for AND search on recorded-date (e.g.recorded-date=[date]&recorded-date=[date]]&...)

      GET [base]/Condition?patient={Type/}[id]&recorded-date={gt|lt|ge|le}[date]{&recorded-date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]Condition?patient=555580&recorded-date=ge2018-01-14

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)

    8. SHOULD support searching using the combination of the patient and abatement-date search parameters:
      • including support for these abatement-date comparators: gt,lt,ge,le
      • including optional support for AND search on abatement-date (e.g.abatement-date=[date]&abatement-date=[date]]&...)

      GET [base]/Condition?patient={Type/}[id]&abatement-date={gt|lt|ge|le}[date]{&abatement-date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]Condition?patient=555580&abatement-date=ge2018-01-14

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)