FHIR Clinical Guidelines (v1.0.0) (STU1)

Clinical Practice Guidelines, published by Clinical Decision Support WG. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/cqf-recommendations/ and changes regularly. See the Directory of published versions

D.4.1 StructureDefinition-cpg-condition

Introduction:

Examples:

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is:

http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-condition

CPG condition represents the minimum expectations for communicating condition/problem information as part of a CPG case

This profile builds on Condition.

This profile was published on Thu Jun 06 00:00:00 UTC 2019 as a draft by Health Level Seven, Inc. - CDS WG.

Description of Profiles, Differentials, and Snapshots.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... cpg-instantiatesCaseFeature S0..1canonical(StructureDefinition)Definition of this case feature
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature
... cpg-caseFeatureType S0..1codeasserted | inferred
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType
Binding: CPG Case Feature Type (required): Whether the case feature is asserted or inferred

... cpg-caseFeaturePertinence S0..1codeweakly-positive | weakly-negative | strongly-positive | strongly-negative | pathognomonic
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence
Binding: CPG Case Feature Pertinence (required): Describes the pertinence of a case feature

... identifier 0..*IdentifierExternal Ids for this condition
... clinicalStatus S0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
... verificationStatus S0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
... category 1..*CodeableConceptproblem-list-item | encounter-diagnosis
... code 1..1CodeableConceptIdentification of the condition, problem or diagnosis
... subject S1..1Reference(CPGPatient)Who has the condition?
... encounter S0..1Reference(CPGEncounter)Encounter created as part of
... onset[x] S0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] S0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... evidence S0..*BackboneElementSupporting evidence
.... code S0..*CodeableConceptManifestation/symptom
.... detail S0..*Reference(Resource)Supporting information found elsewhere

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*ConditionDetailed information about conditions, problems or diagnoses
... id Σ0..1stringLogical 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)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... cpg-instantiatesCaseFeature S0..1canonical(StructureDefinition)Definition of this case feature
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature
... cpg-caseFeatureType S0..1codeasserted | inferred
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType
Binding: CPG Case Feature Type (required): Whether the case feature is asserted or inferred


... cpg-caseFeaturePertinence S0..1codeweakly-positive | weakly-negative | strongly-positive | strongly-negative | pathognomonic
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence
Binding: CPG Case Feature Pertinence (required): Describes the pertinence of a case feature


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!SΣI0..1CodeableConceptunconfirmed | 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 1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... 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 Σ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

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


... subject SΣ1..1Reference(CPGPatient)Who has the condition?
... encounter SΣ0..1Reference(CPGEncounter)Encounter created as part of
... onset[x] SΣ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] SI0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recordedDate Σ0..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 I0..*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 I0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment I0..*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 SI0..*BackboneElementSupporting evidence
.... 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 SΣI0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail SΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... cpg-instantiatesCaseFeature S0..1canonical(StructureDefinition)Definition of this case feature
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature
... cpg-caseFeatureType S0..1codeasserted | inferred
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType
Binding: CPG Case Feature Type (required): Whether the case feature is asserted or inferred

... cpg-caseFeaturePertinence S0..1codeweakly-positive | weakly-negative | strongly-positive | strongly-negative | pathognomonic
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence
Binding: CPG Case Feature Pertinence (required): Describes the pertinence of a case feature

... identifier 0..*IdentifierExternal Ids for this condition
... clinicalStatus S0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
... verificationStatus S0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
... category 1..*CodeableConceptproblem-list-item | encounter-diagnosis
... code 1..1CodeableConceptIdentification of the condition, problem or diagnosis
... subject S1..1Reference(CPGPatient)Who has the condition?
... encounter S0..1Reference(CPGEncounter)Encounter created as part of
... onset[x] S0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] S0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... evidence S0..*BackboneElementSupporting evidence
.... code S0..*CodeableConceptManifestation/symptom
.... detail S0..*Reference(Resource)Supporting information found elsewhere

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*ConditionDetailed information about conditions, problems or diagnoses
... id Σ0..1stringLogical 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)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... cpg-instantiatesCaseFeature S0..1canonical(StructureDefinition)Definition of this case feature
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature
... cpg-caseFeatureType S0..1codeasserted | inferred
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType
Binding: CPG Case Feature Type (required): Whether the case feature is asserted or inferred


... cpg-caseFeaturePertinence S0..1codeweakly-positive | weakly-negative | strongly-positive | strongly-negative | pathognomonic
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence
Binding: CPG Case Feature Pertinence (required): Describes the pertinence of a case feature


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!SΣI0..1CodeableConceptunconfirmed | 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 1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... 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 Σ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

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


... subject SΣ1..1Reference(CPGPatient)Who has the condition?
... encounter SΣ0..1Reference(CPGEncounter)Encounter created as part of
... onset[x] SΣ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] SI0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recordedDate Σ0..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 I0..*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 I0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment I0..*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 SI0..*BackboneElementSupporting evidence
.... 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 SΣI0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail SΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathConformanceValueSet
Condition.languagepreferredCommonLanguages
Max Binding: AllLanguages
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codeexampleCondition/Problem/DiagnosisCodes
Condition.bodySiteexampleSNOMEDCTBodyStructures
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleManifestationAndSymptomCodes

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
con-3ConditionCondition.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-4ConditionIf 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-5ConditionCondition.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-2ConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3ConditionIf 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-4ConditionIf 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-5ConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6ConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1Condition.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.extension:instantiatesCaseFeatureAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.extension:instantiatesCaseFeatureMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.extension:caseFeatureTypeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.extension:caseFeatureTypeMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.extension:caseFeaturePertinenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.extension:caseFeaturePertinenceMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.clinicalStatusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.verificationStatusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.severityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.bodySiteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.onset[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.abatement[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.recordedDateAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.recorderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.asserterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
con-1Condition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
ele-1Condition.stageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.stage.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.stage.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.stage.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.stage.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.stage.summaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.stage.assessmentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.stage.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
con-2Condition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
ele-1Condition.evidenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.evidence.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.evidence.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.evidence.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.evidence.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.evidence.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.evidence.detailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.noteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())