International Patient Access
1.0.0-preview - STU1 International flag

International Patient Access, published by HL7 International - Patient Care Work Group. This is not an authorized publication; it is the continuous build for version 1.0.0-preview). This version is based on the current content of https://github.com/HL7/fhir-ipa/ and changes regularly. See the Directory of published versions

Resource Profile: IPA-Condition

Official URL: http://hl7.org/fhir/uv/ipa/StructureDefinition/ipa-condition Version: 1.0.0-preview
Active as of 2022-08-02 Computable Name: IPACondition

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

Minimum expectations for a Condition resource when accessed via an International Patient Access API. This profile communicates information about a patient’s condition or diagnosis, such as recording primary and secondary diagnoses for encounters or justification for past medications. For the use of the condition resource to get a list of the patient’s current problem list, use the IPA-Problem-List-Item profile instead. The difference between this profile and the IPA Problem List Item profile is that this profile does not specify or require a category.

Mandatory and Must Support Data Elements

The following data elements must always be present (in other words, mandatory resource properties with a minimum cardinality of 1) or must be supported (Must Support definition). Servers cannot restrict access to mandatory elements when authorizing an application. However, servers may choose to provide additional information or may be required to do so by national or other profiles that apply to the server’s context.

Each Condition SHALL have:

  • a code identifying the condition, problem, or diagnosis
  • a patient

Applications must also support:

  • a clinical status
  • a verification status
  • one or more category codes used to group conditions

Profile Specific Implementation Rules and Guidance

Accessing Condition Resources

Clients can access a Condition resources using:

GET [url]/Condition/[id]

where id is found in some other resource that refers to a Condition. The result of this read is a Condition resource, or an error if there is no resource the client can access for that id. Alternatively, the client may search for condition resources.

Condition Codes

All Condition resources are required to have a code, but the coding systems used around the world and even within jurisdictions very wildly. This specification does not fix any kind of value set that controls what kind of codes can be used - other national specifications etc will place their own restrictions on the codes.

Client Applications should be prepared to encounter codes they do not recognize and handle the records accordingly. Servers SHOULD populate Condition.code.coding.display and/or Condition.code.text so that clients can always at least display the condition even if they do not know the codes that are used.

Clients should be careful making use of the code search parameter given that the codes used vary so much.

Safety Issues

  • Clients SHALL not treat all conditions as if they are part of the patient’s current problem list
    • Note that some Condition resources may not have these status codes - this is usually due to poor record keeping reflected in legacy data
    • Servers SHOULD avoid leaving these status codes missing
  • Clients SHALL pay attention to the clinicalStatus and verificationStatus and display and process them correctly
  • Clients SHALL still work safely when the server does not support all the search parameters listed in the IPA Server Capability Statement. (see also Search advice)

Usage:

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
... clinicalStatus S0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
... verificationStatus S0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
... category S0..*CodeableConceptproblem-list-item | encounter-diagnosis
... subject S1..1Reference(IPA-Patient)Who has the condition?

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... category S0..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

... subject SΣ1..1Reference(IPA-Patient)Who has the condition?

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.codeexampleCondition/Problem/DiagnosisCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... 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
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... 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): The clinical status of the condition or diagnosis.

... verificationStatus ?!SΣC0..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 S0..*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 SΣ1..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(IPA-Patient)Who has the condition?
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... onset[x] Σ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] C0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... 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 C0..*BackboneElementStage/grade, usually assessed formally
.... 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
.... 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
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codeexampleCondition/Problem/DiagnosisCodes
Condition.bodySiteexampleSNOMEDCTBodyStructures
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleManifestationAndSymptomCodes

This structure is derived from Condition

Summary

Mandatory: 1 element
Must-Support: 5 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... clinicalStatus S0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
... verificationStatus S0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
... category S0..*CodeableConceptproblem-list-item | encounter-diagnosis
... subject S1..1Reference(IPA-Patient)Who has the condition?

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... category S0..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

... subject SΣ1..1Reference(IPA-Patient)Who has the condition?

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.codeexampleCondition/Problem/DiagnosisCodes

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... 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
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... 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): The clinical status of the condition or diagnosis.

... verificationStatus ?!SΣC0..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 S0..*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 SΣ1..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(IPA-Patient)Who has the condition?
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... onset[x] Σ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] C0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... 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 C0..*BackboneElementStage/grade, usually assessed formally
.... 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
.... 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
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codeexampleCondition/Problem/DiagnosisCodes
Condition.bodySiteexampleSNOMEDCTBodyStructures
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleManifestationAndSymptomCodes

This structure is derived from Condition

Summary

Mandatory: 1 element
Must-Support: 5 elements

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron