QI-Core Implementation Guide
7.0.2 - STU 7 United States of America flag

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 7.0.2 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: 7.0.2
Standards status: Trial-use 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:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... verificationStatus ?!SΣC 0..1 CodeableConcept (QI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept (QI) 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 (QI) Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code SΣ 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 BindingsPurpose
US Core Condition Codes Current
... subject SΣ 1..1 Reference(QICore Patient S | Group) (QI) Who has the condition?
... encounter SΣ 0..1 Reference(QICore Encounter) (QI) Encounter created as part of
... onset[x] SΣ 0..1 (QI) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] SC 0..1 (QI) When in resolution/remission
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
... recordedDate SΣ 0..1 dateTime (QI) Date record was first recorded

doco 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 📦7.0.0 US Core v7.0

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()

This structure is derived from USCoreConditionEncounterDiagnosisProfile

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... severity 0..1 CodeableConcept (QI) Subjective severity of condition
... code 1..1 CodeableConcept (QI) Identification of the condition, problem or diagnosis
... subject SΣ 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

doco 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.
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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 ?!SΣC 0..1 CodeableConcept (QI) active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC 0..1 CodeableConcept (QI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept (QI) 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 (QI) Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code SΣ 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 BindingsPurpose
US Core Condition Codes Current
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... subject SΣ 1..1 Reference(QICore Patient S | Group) (QI) Who has the condition?
... encounter SΣ 0..1 Reference(QICore Encounter) (QI) Encounter created as part of
... onset[x] SΣ 0..1 (QI) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] SC 0..1 (QI) When in resolution/remission
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
... recordedDate SΣ 0..1 dateTime (QI) 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).
... 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 ΣC 0..* CodeableConcept Manifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco 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 📦7.0.0 US Core v7.0
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()

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Summary

Mandatory: 1 element
Must-Support: 3 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

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

Maturity: 4

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... verificationStatus ?!SΣC 0..1 CodeableConcept (QI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept (QI) 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 (QI) Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code SΣ 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 BindingsPurpose
US Core Condition Codes Current
... subject SΣ 1..1 Reference(QICore Patient S | Group) (QI) Who has the condition?
... encounter SΣ 0..1 Reference(QICore Encounter) (QI) Encounter created as part of
... onset[x] SΣ 0..1 (QI) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] SC 0..1 (QI) When in resolution/remission
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
... recordedDate SΣ 0..1 dateTime (QI) Date record was first recorded

doco 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 📦7.0.0 US Core v7.0

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

This structure is derived from USCoreConditionEncounterDiagnosisProfile

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... severity 0..1 CodeableConcept (QI) Subjective severity of condition
... code 1..1 CodeableConcept (QI) Identification of the condition, problem or diagnosis
... subject SΣ 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

doco 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 View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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 ?!SΣC 0..1 CodeableConcept (QI) active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC 0..1 CodeableConcept (QI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept (QI) 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 (QI) Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code SΣ 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 BindingsPurpose
US Core Condition Codes Current
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... subject SΣ 1..1 Reference(QICore Patient S | Group) (QI) Who has the condition?
... encounter SΣ 0..1 Reference(QICore Encounter) (QI) Encounter created as part of
... onset[x] SΣ 0..1 (QI) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] SC 0..1 (QI) When in resolution/remission
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
... recordedDate SΣ 0..1 dateTime (QI) 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).
... 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 ΣC 0..* CodeableConcept Manifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco 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 📦7.0.0 US Core v7.0
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()

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Summary

Mandatory: 1 element
Must-Support: 3 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

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