International Patient Access
1.0.0 - STU1 International flag

International Patient Access, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. 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-problem-list-item

Official URL: http://hl7.org/fhir/uv/ipa/StructureDefinition/ipa-problem-list-item Version: 1.0.0
Standards status: Trial-use Computable Name: IPAProblemListItem

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

Minimum expectations for a Condition resource for representing the patient’s problem list items. The most important and prominent use of the condition resource is to get a list of the patient’s current problem list. This Condition profile communicates information about a patient’s problems. For other uses for the Condition resource, such as recording primary and secondary diagnoses for encounters or justification for past medications, use the IPA-Condition profile instead. The difference between this profile and the IPA Condition profile is that this profile requires a mandatory category of ‘problem-list-item’.

Mandatory and Must Support Data Elements

The following data elements must always be present (in other words, mandatory resource properties where the minimum cardinality is 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
  • at least a category code of “problem-list-item”

Applications must also support:

  • a clinical status
  • a verification status

Profile Specific Implementation Rules and Guidance

Retrieving the Current Problem List:

The current problem list is retrieved by specifying the patient, category and clinical-status:

GET [url]/Condition?patient=[patient-id]&category=problem-list-item&clinical-status=active

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
... Slices for category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Slice: Unordered, Open by pattern:$this
.... category:problem-list-item S1..1CodeableConceptproblem-list-item | encounter-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: problem-list-item
... 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.

... Slices for category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:problem-list-item S1..1CodeableConceptproblem-list-item | encounter-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: problem-list-item
... 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 / Code
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.category:problem-list-itemextensiblePattern: problem-list-item
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.

... Slices for category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:problem-list-item S1..1CodeableConceptproblem-list-item | encounter-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: problem-list-item
...... 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: 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 / Code
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.category:problem-list-itemextensiblePattern: problem-list-item
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: 3 elements
Must-Support: 6 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

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
... Slices for category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Slice: Unordered, Open by pattern:$this
.... category:problem-list-item S1..1CodeableConceptproblem-list-item | encounter-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: problem-list-item
... 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.

... Slices for category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:problem-list-item S1..1CodeableConceptproblem-list-item | encounter-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: problem-list-item
... 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 / Code
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.category:problem-list-itemextensiblePattern: problem-list-item
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.

... Slices for category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:problem-list-item S1..1CodeableConceptproblem-list-item | encounter-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: problem-list-item
...... 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: 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 / Code
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.category:problem-list-itemextensiblePattern: problem-list-item
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: 3 elements
Must-Support: 6 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel, Schematron