Birth Defects Reporting - STU1
0.1.2 - draft

Birth Defects Reporting - STU1, published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 0.1.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-birthdefectsreporting-ig/ and changes regularly. See the Directory of published versions

## Resource Profile: Condition - Reportable Diagnosis

Official URL: http://hl7.org/fhir/us/birthdefectreporting/StructureDefinition/bdr-reportablediagnosis | Version: 0.1.2
Draft as of 2025-06-12 | Computable Name: BDRReportableDiagnosis

A description of a reportable birth defect diagnosis for the report subject

Usages:

- Refer to this Profile: MessageHeader - Birth Defect
- Examples for this Profile: Condition/ReportableDiagnosisBirthingExample and Condition/ReportableDiagnosisExample

### Formal Views of Profile Content

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

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile(7.0.0) | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  |  |  | Content/Rules for all slices
extension:assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
clinicalStatus | ?!S Σ C | 1..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus | ?!S Σ C | 1..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category | S | 1..* | CodeableConcept | category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core | S | 1..1 | CodeableConcept | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Birth Defect Diagnosis (preferred)
Additional Bindings | Purpose
US Core Condition Codes | Current
subject | S Σ | 1..1 | Reference(Patient - Child Vital Records(2.0.0)) | Who has the condition?
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile(7.0.0)) | Encounter created as part of
onset[x] | S Σ | 1..1 | dateTime S | Estimated or actual date, date-time, or age
abatement[x] | S C | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime S |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
abatementString |  |  | string |
recordedDate | S Σ | 0..1 | dateTime | Date record was first recorded
Slices for evidence | C | 0..* | BackboneElement | Supporting evidence Slice: Unordered, Open by type:detail.resolve() Constraints: con-2
evidence:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
evidence:ConfirmatoryTest | S C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detail | Σ C | 0..* | Reference(Procedure - Diagnosis Confirmatory Test) | Supporting information found elsewhere
evidence:SupportingProblems | S C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detail | Σ C | 0..* | Reference(US Core Condition Problems and Health Concerns Profile(7.0.0)) | Supporting information found elsewhere
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Condition.clinicalStatus | required | ConditionClinicalStatusCodes `http://hl7.org/fhir/ValueSet/condition-clinical` From the FHIR Standard
Condition.verificationStatus | required | ConditionVerificationStatus `http://hl7.org/fhir/ValueSet/condition-ver-status` From the FHIR Standard
Condition.category | extensible | ConditionCategoryCodes `http://hl7.org/fhir/ValueSet/condition-category` From the FHIR Standard
Condition.category:us-core | extensible | Pattern Value: encounter-diagnosis `http://hl7.org/fhir/ValueSet/condition-category` From the FHIR Standard
Condition.code | preferred | PHVS_BirthDefectDiagnosis_CDC `http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.113883.13.277`

#### Constraints

Id | Grade | Path(s) | Details | Requirements
con-2 | error | Condition.evidence, Condition.evidence:ConfirmatoryTest, Condition.evidence:SupportingProblems | 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 USCoreConditionEncounterDiagnosisProfile

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition |  |  | USCoreConditionEncounterDiagnosisProfile(7.0.0) |
clinicalStatus |  | 1..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved
verificationStatus |  | 1..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
code |  | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Birth Defect Diagnosis (preferred)
subject |  | 1..1 | Reference(Patient - Child Vital Records(2.0.0)) | Who has the condition?
onset[x] |  | 1..1 | dateTime | Estimated or actual date, date-time, or age
Slices for evidence |  | 0..* | BackboneElement | Supporting evidence Slice: Unordered, Open by type:detail.resolve()
evidence:ConfirmatoryTest | S | 0..* | BackboneElement | Supporting evidence
detail |  | 0..* | Reference(Procedure - Diagnosis Confirmatory Test) | Supporting information found elsewhere
evidence:SupportingProblems | S | 0..* | BackboneElement | Supporting evidence
detail |  | 0..* | Reference(US Core Condition Problems and Health Concerns Profile(7.0.0)) | Supporting information found elsewhere
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Condition.code | preferred | PHVS_BirthDefectDiagnosis_CDC `http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.113883.13.277`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile(7.0.0) | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | External Ids for this condition
clinicalStatus | ?!S Σ C | 1..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus | ?!S Σ C | 1..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category | S | 1..* | CodeableConcept | category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core | S | 1..1 | CodeableConcept | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
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 | S Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Birth Defect Diagnosis (preferred)
Additional Bindings | Purpose
US Core Condition Codes | Current
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject | S Σ | 1..1 | Reference(Patient - Child Vital Records(2.0.0)) | Who has the condition?
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile(7.0.0)) | Encounter created as part of
onset[x] | S Σ | 1..1 | dateTime S | Estimated or actual date, date-time, or age
abatement[x] | S C | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime S |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
abatementString |  |  | string |
recordedDate | S Σ | 0..1 | dateTime | Date record was first recorded
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally Constraints: con-1
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).
Slices for evidence | C | 0..* | BackboneElement | Supporting evidence Slice: Unordered, Open by type:detail.resolve() Constraints: con-2
evidence:All Slices |  |  |  | Content/Rules for all slices
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 | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ C | 0..* | Reference(Resource) | Supporting information found elsewhere
evidence:ConfirmatoryTest | S C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
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 | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ C | 0..* | Reference(Procedure - Diagnosis Confirmatory Test) | Supporting information found elsewhere
evidence:SupportingProblems | S C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
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 | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ C | 0..* | Reference(US Core Condition Problems and Health Concerns Profile(7.0.0)) | Supporting information found elsewhere
note |  | 0..* | Annotation | Additional information about the Condition
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Condition.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Condition.clinicalStatus | required | ConditionClinicalStatusCodes `http://hl7.org/fhir/ValueSet/condition-clinical` From the FHIR Standard
Condition.verificationStatus | required | ConditionVerificationStatus `http://hl7.org/fhir/ValueSet/condition-ver-status` From the FHIR Standard
Condition.category | extensible | ConditionCategoryCodes `http://hl7.org/fhir/ValueSet/condition-category` From the FHIR Standard
Condition.category:us-core | extensible | Pattern Value: encounter-diagnosis `http://hl7.org/fhir/ValueSet/condition-category` From the FHIR Standard
Condition.severity | preferred | Condition/DiagnosisSeverity `http://hl7.org/fhir/ValueSet/condition-severity` From the FHIR Standard
Condition.code | preferred | PHVS_BirthDefectDiagnosis_CDC `http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.113883.13.277`
Condition.bodySite | example | SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` From the FHIR Standard
Condition.stage.summary | example | ConditionStage `http://hl7.org/fhir/ValueSet/condition-stage` From the FHIR Standard
Condition.stage.type | example | ConditionStageType `http://hl7.org/fhir/ValueSet/condition-stage-type` From the FHIR Standard
Condition.evidence.code | example | ManifestationAndSymptomCodes `http://hl7.org/fhir/ValueSet/manifestation-or-symptom` From the FHIR Standard
Condition.evidence:ConfirmatoryTest.code | example | ManifestationAndSymptomCodes `http://hl7.org/fhir/ValueSet/manifestation-or-symptom` From the FHIR Standard
Condition.evidence:SupportingProblems.code | example | ManifestationAndSymptomCodes `http://hl7.org/fhir/ValueSet/manifestation-or-symptom` From the FHIR Standard

#### Constraints

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, Condition.evidence:ConfirmatoryTest, Condition.evidence:SupportingProblems | 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 USCoreConditionEncounterDiagnosisProfile

Summary

Mandatory: 3 elements
Must-Support: 2 elements

Structures

This structure refers to these other structures:

- Patient - Child Vital Records (http://hl7.org/fhir/us/vr-common-library/StructureDefinition/Patient-child-vr)
- Procedure - Diagnosis Confirmatory Test (http://hl7.org/fhir/us/birthdefectreporting/StructureDefinition/bdr-confirmatorytest)
- US Core Condition Problems and Health Concerns Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns)

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Condition.evidence

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile(7.0.0) | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  |  |  | Content/Rules for all slices
extension:assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
clinicalStatus | ?!S Σ C | 1..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus | ?!S Σ C | 1..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category | S | 1..* | CodeableConcept | category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core | S | 1..1 | CodeableConcept | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Birth Defect Diagnosis (preferred)
Additional Bindings | Purpose
US Core Condition Codes | Current
subject | S Σ | 1..1 | Reference(Patient - Child Vital Records(2.0.0)) | Who has the condition?
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile(7.0.0)) | Encounter created as part of
onset[x] | S Σ | 1..1 | dateTime S | Estimated or actual date, date-time, or age
abatement[x] | S C | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime S |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
abatementString |  |  | string |
recordedDate | S Σ | 0..1 | dateTime | Date record was first recorded
Slices for evidence | C | 0..* | BackboneElement | Supporting evidence Slice: Unordered, Open by type:detail.resolve() Constraints: con-2
evidence:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
evidence:ConfirmatoryTest | S C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detail | Σ C | 0..* | Reference(Procedure - Diagnosis Confirmatory Test) | Supporting information found elsewhere
evidence:SupportingProblems | S C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detail | Σ C | 0..* | Reference(US Core Condition Problems and Health Concerns Profile(7.0.0)) | Supporting information found elsewhere
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Condition.clinicalStatus | required | ConditionClinicalStatusCodes `http://hl7.org/fhir/ValueSet/condition-clinical` From the FHIR Standard
Condition.verificationStatus | required | ConditionVerificationStatus `http://hl7.org/fhir/ValueSet/condition-ver-status` From the FHIR Standard
Condition.category | extensible | ConditionCategoryCodes `http://hl7.org/fhir/ValueSet/condition-category` From the FHIR Standard
Condition.category:us-core | extensible | Pattern Value: encounter-diagnosis `http://hl7.org/fhir/ValueSet/condition-category` From the FHIR Standard
Condition.code | preferred | PHVS_BirthDefectDiagnosis_CDC `http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.113883.13.277`

#### Constraints

Id | Grade | Path(s) | Details | Requirements
con-2 | error | Condition.evidence, Condition.evidence:ConfirmatoryTest, Condition.evidence:SupportingProblems | 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() |

Differential View

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition |  |  | USCoreConditionEncounterDiagnosisProfile(7.0.0) |
clinicalStatus |  | 1..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved
verificationStatus |  | 1..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
code |  | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Birth Defect Diagnosis (preferred)
subject |  | 1..1 | Reference(Patient - Child Vital Records(2.0.0)) | Who has the condition?
onset[x] |  | 1..1 | dateTime | Estimated or actual date, date-time, or age
Slices for evidence |  | 0..* | BackboneElement | Supporting evidence Slice: Unordered, Open by type:detail.resolve()
evidence:ConfirmatoryTest | S | 0..* | BackboneElement | Supporting evidence
detail |  | 0..* | Reference(Procedure - Diagnosis Confirmatory Test) | Supporting information found elsewhere
evidence:SupportingProblems | S | 0..* | BackboneElement | Supporting evidence
detail |  | 0..* | Reference(US Core Condition Problems and Health Concerns Profile(7.0.0)) | Supporting information found elsewhere
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Condition.code | preferred | PHVS_BirthDefectDiagnosis_CDC `http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.113883.13.277`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile(7.0.0) | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | External Ids for this condition
clinicalStatus | ?!S Σ C | 1..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus | ?!S Σ C | 1..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category | S | 1..* | CodeableConcept | category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core | S | 1..1 | CodeableConcept | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
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 | S Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Birth Defect Diagnosis (preferred)
Additional Bindings | Purpose
US Core Condition Codes | Current
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject | S Σ | 1..1 | Reference(Patient - Child Vital Records(2.0.0)) | Who has the condition?
encounter | S Σ | 0..1 | Reference(US Core Encounter Profile(7.0.0)) | Encounter created as part of
onset[x] | S Σ | 1..1 | dateTime S | Estimated or actual date, date-time, or age
abatement[x] | S C | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime S |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
abatementString |  |  | string |
recordedDate | S Σ | 0..1 | dateTime | Date record was first recorded
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally Constraints: con-1
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).
Slices for evidence | C | 0..* | BackboneElement | Supporting evidence Slice: Unordered, Open by type:detail.resolve() Constraints: con-2
evidence:All Slices |  |  |  | Content/Rules for all slices
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 | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ C | 0..* | Reference(Resource) | Supporting information found elsewhere
evidence:ConfirmatoryTest | S C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
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 | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ C | 0..* | Reference(Procedure - Diagnosis Confirmatory Test) | Supporting information found elsewhere
evidence:SupportingProblems | S C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
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 | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ C | 0..* | Reference(US Core Condition Problems and Health Concerns Profile(7.0.0)) | Supporting information found elsewhere
note |  | 0..* | Annotation | Additional information about the Condition
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Condition.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Condition.clinicalStatus | required | ConditionClinicalStatusCodes `http://hl7.org/fhir/ValueSet/condition-clinical` From the FHIR Standard
Condition.verificationStatus | required | ConditionVerificationStatus `http://hl7.org/fhir/ValueSet/condition-ver-status` From the FHIR Standard
Condition.category | extensible | ConditionCategoryCodes `http://hl7.org/fhir/ValueSet/condition-category` From the FHIR Standard
Condition.category:us-core | extensible | Pattern Value: encounter-diagnosis `http://hl7.org/fhir/ValueSet/condition-category` From the FHIR Standard
Condition.severity | preferred | Condition/DiagnosisSeverity `http://hl7.org/fhir/ValueSet/condition-severity` From the FHIR Standard
Condition.code | preferred | PHVS_BirthDefectDiagnosis_CDC `http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.113883.13.277`
Condition.bodySite | example | SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` From the FHIR Standard
Condition.stage.summary | example | ConditionStage `http://hl7.org/fhir/ValueSet/condition-stage` From the FHIR Standard
Condition.stage.type | example | ConditionStageType `http://hl7.org/fhir/ValueSet/condition-stage-type` From the FHIR Standard
Condition.evidence.code | example | ManifestationAndSymptomCodes `http://hl7.org/fhir/ValueSet/manifestation-or-symptom` From the FHIR Standard
Condition.evidence:ConfirmatoryTest.code | example | ManifestationAndSymptomCodes `http://hl7.org/fhir/ValueSet/manifestation-or-symptom` From the FHIR Standard
Condition.evidence:SupportingProblems.code | example | ManifestationAndSymptomCodes `http://hl7.org/fhir/ValueSet/manifestation-or-symptom` From the FHIR Standard

#### Constraints

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, Condition.evidence:ConfirmatoryTest, Condition.evidence:SupportingProblems | 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 USCoreConditionEncounterDiagnosisProfile

Summary

Mandatory: 3 elements
Must-Support: 2 elements

Structures

This structure refers to these other structures:

- Patient - Child Vital Records (http://hl7.org/fhir/us/vr-common-library/StructureDefinition/Patient-child-vr)
- Procedure - Diagnosis Confirmatory Test (http://hl7.org/fhir/us/birthdefectreporting/StructureDefinition/bdr-confirmatorytest)
- US Core Condition Problems and Health Concerns Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns)

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Condition.evidence

Other representations of profile: CSV, Excel, Schematron