QI-Core Implementation Guide
8.0.0-ballot - STU 8 - ballot

QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 8.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions

## Resource Profile: QICore Condition Encounter Diagnosis

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis | Version: 8.0.0-ballot
Standards status: Trial-use Active as of 2022-04-20 | Maturity Level: 4 | Computable Name: QICoreConditionEncounterDiagnosis
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The QI-Core Condition Encounter Diagnosis Profile is based upon the US Core Condition Encounter Diagnosis Profile. In version 5.0.0, the QI-Core Condition Profile has been split into the QI-Core Condition Encounter Diagnosis Profile and QI-Core Condition Problems and Health Concerns Profile. To promote interoperability and adoption through consistent implementation, this profile defines constraints and extensions on the Condition resource for the minimal set of data to record, search, and retrieve information about an encounter diagnosis. It defines the core set of elements and extensions for quality rule and measure authors.

"Must Have", "QI Elements" and "primary code path" are defined in the QI-Core Must Support section.
Must Have:

- category: (QI) category codes
- category(us-core): encounter-diagnosis
- code: (QI) Identification of the condition, problem or diagnosis
- subject: (QI) Who has the condition?

QI Elements:

- clinicalStatus: (QI) active | recurrence | relapse | inactive | remission | resolved
- extension(assertedDate): (QI) Date the condition was first asserted
- encounter: (QI) Encounter created as part of
- recordedDate: (QI) Date record was first recorded
- abatement[x]: (QI) When in resolution/remission
- severity: (QI) Subjective severity of condition
- onset[x]: (QI) Estimated or actual date, date-time, or age
- verificationStatus: (QI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error

Primary code path: code
(PCPath) This element is the primary code path for this resource CQL Retrieve
Usage

    define "Diabetes Encounter Diagnosis":
      [ConditionEncounterDiagnosis: Diabetes]

See the patterns page for implementation and usage patterns.

### Examples

Severe Burn Example
Appendicitis Example

Usages:

- Refer to this Profile: QICore AdverseEvent, QICore Claim, QICore Encounter, QICore MedicationRequest... Show 2 more, QICore Procedure and QICore ServiceRequest
- Examples for this Profile: Condition/appendicitis-example and Condition/example

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | 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 | (QI) Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
clinicalStatus | ?!Σ C | 0..1 | CodeableConcept | (QI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!Σ C | 0..1 | CodeableConcept | (QI) unconfirmed | 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 | S | 1..* | CodeableConcept | (QI) category codes Slice: Unordered, Open by value:$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 | (QI) 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 | (QI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (preferred): Valueset to describe the actual problem experienced by the patient
Additional Bindings | Purpose | Documentation
US Core Condition Codes Current | Current | Required for new records
subject | S Σ | 1..1 | Reference(QICore Patient S | Group) | (QI) Who has the condition?
encounter | S Σ | 0..1 | Reference(QICore Encounter) | (QI) Encounter created as part of
onset[x] | Σ | 0..1 |  | (QI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | C | 0..1 |  | (QI) When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate | S Σ | 0..1 | dateTime | (QI) Date record was first recorded
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.category:us-core | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.severity | Base | preferred | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | preferred | US Core Condition Codes | 📦8.0.0 | US Core v8.0

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition |  | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses
Slices for extension |  |  |  | Content/Rules for all slices
extension:assertedDate | S | 0..1 | dateTime | (QI) Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
clinicalStatus |  | 0..1 | CodeableConcept | (QI) active | recurrence | relapse | inactive | remission | resolved
verificationStatus |  | 0..1 | CodeableConcept | (QI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
category | S | 1..* | CodeableConcept | (QI) category codes Slice: Unordered, Open by value:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
severity |  | 0..1 | CodeableConcept | (QI) Subjective severity of condition
code |  | 1..1 | CodeableConcept | (QI) Identification of the condition, problem or diagnosis
subject | S Σ | 1..1 | Reference(QICore Patient S | Group) | (QI) Who has the condition?
encounter |  | 0..1 | Reference(QICore Encounter) | (QI) Encounter created as part of
onset[x] |  | 0..1 |  | (QI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] |  | 0..1 |  | (QI) When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate |  | 0..1 | dateTime | (QI) Date record was first recorded
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Condition.category | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:assertedDate | S | 0..1 | dateTime | (QI) 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 | ?!Σ C | 0..1 | CodeableConcept | (QI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!Σ C | 0..1 | CodeableConcept | (QI) unconfirmed | 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 | S | 1..* | CodeableConcept | (QI) category codes Slice: Unordered, Open by value:$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 | (QI) 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 | (QI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (preferred): Valueset to describe the actual problem experienced by the patient
Additional Bindings | Purpose | Documentation
US Core Condition Codes Current | Current | Required for new records
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject | S Σ | 1..1 | Reference(QICore Patient S | Group) | (QI) Who has the condition?
encounter | S Σ | 0..1 | Reference(QICore Encounter) | (QI) Encounter created as part of
onset[x] | Σ | 0..1 |  | (QI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | C | 0..1 |  | (QI) When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate | S Σ | 0..1 | dateTime | (QI) Date record was first recorded
recorder | Σ | 0..1 | Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: 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).
evidence | 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(Resource) | Supporting information found elsewhere
note |  | 0..* | Annotation | Additional information about the Condition
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std.
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.category:us-core | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.severity | Base | preferred | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | preferred | US Core Condition Codes | 📦8.0.0 | US Core v8.0
Condition.bodySite | Base | example | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std.
Condition.stage.summary | Base | example | Condition Stage | 📦4.0.1 | FHIR Std.
Condition.stage.type | Base | example | Condition Stage Type | 📦4.0.1 | FHIR Std.
Condition.evidence.code | Base | example | Manifestation and Symptom Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
con-1 | error | Condition.stage | Stage SHALL have summary or assessment | `summary.exists() or assessment.exists()`
con-2 | error | Condition.evidence | 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()`

Summary

Mandatory: 1 element
Must-Support: 3 elements

Structures

This structure refers to these other structures:

- QICore Patient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
- QICore Encounter (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/condition-assertedDate|5.2.0-ballot

Slices

This structure defines the following Slices:

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

Maturity: 4

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | 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 | (QI) Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
clinicalStatus | ?!Σ C | 0..1 | CodeableConcept | (QI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!Σ C | 0..1 | CodeableConcept | (QI) unconfirmed | 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 | S | 1..* | CodeableConcept | (QI) category codes Slice: Unordered, Open by value:$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 | (QI) 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 | (QI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (preferred): Valueset to describe the actual problem experienced by the patient
Additional Bindings | Purpose | Documentation
US Core Condition Codes Current | Current | Required for new records
subject | S Σ | 1..1 | Reference(QICore Patient S | Group) | (QI) Who has the condition?
encounter | S Σ | 0..1 | Reference(QICore Encounter) | (QI) Encounter created as part of
onset[x] | Σ | 0..1 |  | (QI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | C | 0..1 |  | (QI) When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate | S Σ | 0..1 | dateTime | (QI) Date record was first recorded
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.category:us-core | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.severity | Base | preferred | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | preferred | US Core Condition Codes | 📦8.0.0 | US Core v8.0

#### Constraints

Id | Grade | Path(s) | Description | Expression
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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition |  | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses
Slices for extension |  |  |  | Content/Rules for all slices
extension:assertedDate | S | 0..1 | dateTime | (QI) Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
clinicalStatus |  | 0..1 | CodeableConcept | (QI) active | recurrence | relapse | inactive | remission | resolved
verificationStatus |  | 0..1 | CodeableConcept | (QI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
category | S | 1..* | CodeableConcept | (QI) category codes Slice: Unordered, Open by value:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
severity |  | 0..1 | CodeableConcept | (QI) Subjective severity of condition
code |  | 1..1 | CodeableConcept | (QI) Identification of the condition, problem or diagnosis
subject | S Σ | 1..1 | Reference(QICore Patient S | Group) | (QI) Who has the condition?
encounter |  | 0..1 | Reference(QICore Encounter) | (QI) Encounter created as part of
onset[x] |  | 0..1 |  | (QI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] |  | 0..1 |  | (QI) When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate |  | 0..1 | dateTime | (QI) Date record was first recorded
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Condition.category | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.

Snapshot ViewView

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:assertedDate | S | 0..1 | dateTime | (QI) 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 | ?!Σ C | 0..1 | CodeableConcept | (QI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!Σ C | 0..1 | CodeableConcept | (QI) unconfirmed | 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 | S | 1..* | CodeableConcept | (QI) category codes Slice: Unordered, Open by value:$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 | (QI) 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 | (QI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (preferred): Valueset to describe the actual problem experienced by the patient
Additional Bindings | Purpose | Documentation
US Core Condition Codes Current | Current | Required for new records
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject | S Σ | 1..1 | Reference(QICore Patient S | Group) | (QI) Who has the condition?
encounter | S Σ | 0..1 | Reference(QICore Encounter) | (QI) Encounter created as part of
onset[x] | Σ | 0..1 |  | (QI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | C | 0..1 |  | (QI) When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate | S Σ | 0..1 | dateTime | (QI) Date record was first recorded
recorder | Σ | 0..1 | Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: 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).
evidence | 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(Resource) | Supporting information found elsewhere
note |  | 0..* | Annotation | Additional information about the Condition
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std.
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.category:us-core | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.severity | Base | preferred | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | preferred | US Core Condition Codes | 📦8.0.0 | US Core v8.0
Condition.bodySite | Base | example | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std.
Condition.stage.summary | Base | example | Condition Stage | 📦4.0.1 | FHIR Std.
Condition.stage.type | Base | example | Condition Stage Type | 📦4.0.1 | FHIR Std.
Condition.evidence.code | Base | example | Manifestation and Symptom Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
con-1 | error | Condition.stage | Stage SHALL have summary or assessment | `summary.exists() or assessment.exists()`
con-2 | error | Condition.evidence | 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()`

Summary

Mandatory: 1 element
Must-Support: 3 elements

Structures

This structure refers to these other structures:

- QICore Patient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
- QICore Encounter (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/condition-assertedDate|5.2.0-ballot

Slices

This structure defines the following Slices:

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

Maturity: 4

Other representations of profile: CSV, Excel, Schematron