Primary Care Practice-to-Practice
0.0.3 - CI Build

Primary Care Practice-to-Practice, published by . This is not an authorized publication; it is the continuous build for version 0.0.3). This version is based on the current content of https://github.com/aehrc/primary-care-data-technical/ and changes regularly. See the Directory of published versions

Resource Profile: AU Primary Care Condition

Defining URL:https://aehrc.com/fhir/StructureDefinition/AUPrimaryCareCondition
Version:0.0.3
Name:AUPrimaryCareCondition
Title:AU Primary Care Condition
Status:Active as of 2021-06-27T13:53:23+00:00
Definition:

Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.

Usage

  • Use to record details about a single, identified health problem or diagnosis.
  • Clear delineation between the scope of a problem versus a diagnosis is often not easy to achieve in practice. For the purposes of clinical documentation using this item, problem and diagnosis are regarded as a continuum, with increasing information and reaching or exceeding diagnostic criteria supporting formalisation of the label of 'diagnosis'. It is not necessary to classify the condition as a 'problem' or 'diagnosis', especially as a problem may evolve into a formal diagnosis as evidence is gathered. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between.

Misuse

  • Not to be used to describe reasons for encounter - use the 'Reason for encounter' item.
  • Not to be used to describe procedures - use the 'Procedure' item.
  • Not to be used to describe adverse reactions - use the 'Adverse reaction' item.
  • Not to be used to describe symptoms, examination findings, diagnostic test results or health risk assessments.
  • Not to be used to describe differential diagnoses.
Source Resource:XML / JSON / Turtle

The official URL for this profile is:

https://aehrc.com/fhir/StructureDefinition/AUPrimaryCareCondition

Formal Views of Profile Content

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

This structure is derived from AUBaseCondition

Summary

Mandatory: 2 elements
Must-Support: 12 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

This structure is derived from AUBaseCondition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*AUBaseConditionA condition, problem or diagnosis statement in an Australian healthcare context
... meta
.... lastUpdated S0..1instantWhen the resource version last changed
... bodySite S0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... clinicalStatus S1..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
... severity S0..1CodeableConceptSubjective severity of condition
... code S1..1CodeableConceptCoding of a condition, may also describe abscence of condition
Binding: Condition Code Valueset (preferred)
.... coding S0..*CodingCode defined by a terminology system
... bodySite S0..*CodeableConceptBody site for named body site
... subject S1..1Reference(AU Primary Care Patient)Who has the condition?
... onsetDateTime S0..1dateTimeEstimated or actual date, date-time, or age
... note S0..1AnnotationAdditional information about the Condition
.... text S1..1markdownThe annotation - text content (as markdown)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*AUBaseConditionA condition, problem or diagnosis statement in an Australian healthcare context
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ0..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... 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
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite S0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI1..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!SΣI0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.

... category 0..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ1..1CodeableConceptCoding of a condition, may also describe abscence of condition
Binding: Condition Code Valueset (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... bodySite SΣ0..*CodeableConceptBody site for named body site
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... subject SΣ1..1Reference(AU Primary Care Patient)Who has the condition?
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... Slices for onset[x] Σ0..1dateTimeEstimated or actual date, date-time, or age
Slice: Unordered, Closed by type:$this
.... onset[x]:onsetDateTime SΣ0..1dateTimeEstimated or actual date, date-time, or age
... abatement[x] I0..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 I0..*BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... 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 I0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment I0..*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 I0..*BackboneElementSupporting evidence for condition
.... 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 ΣI0..*CodeableConceptEvidence manifestation/symptom
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred): Preferred SNOMED-CT Codes that describe the manifestation or symptoms of a condition.


.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note S0..1AnnotationAdditional information about the Condition
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... author[x] Σ0..1Individual responsible for the annotation
..... authorReferenceReference(Practitioner | Patient | RelatedPerson | Organization)
..... authorStringstring
.... time Σ0..1dateTimeWhen the annotation was made
.... text SΣ1..1markdownThe annotation - text content (as markdown)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*AUBaseConditionA condition, problem or diagnosis statement in an Australian healthcare context
... meta Σ0..1MetaMetadata about the resource
.... lastUpdated Σ0..1instantWhen the resource version last changed
... bodySite 0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... clinicalStatus ?!ΣI1..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... 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 Σ1..1CodeableConceptCoding of a condition, may also describe abscence of condition
Binding: Condition Code Valueset (preferred)
.... coding Σ0..*CodingCode defined by a terminology system
... bodySite Σ0..*CodeableConceptBody site for named body site
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... subject Σ1..1Reference(AU Primary Care Patient)Who has the condition?
... onset[x]:onsetDateTime Σ0..1dateTimeEstimated or actual date, date-time, or age
... note 0..1AnnotationAdditional information about the Condition
.... text Σ1..1markdownThe annotation - text content (as markdown)

doco Documentation for this format

This structure is derived from AUBaseCondition

Summary

Mandatory: 2 elements
Must-Support: 12 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from AUBaseCondition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*AUBaseConditionA condition, problem or diagnosis statement in an Australian healthcare context
... meta
.... lastUpdated S0..1instantWhen the resource version last changed
... bodySite S0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... clinicalStatus S1..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
... severity S0..1CodeableConceptSubjective severity of condition
... code S1..1CodeableConceptCoding of a condition, may also describe abscence of condition
Binding: Condition Code Valueset (preferred)
.... coding S0..*CodingCode defined by a terminology system
... bodySite S0..*CodeableConceptBody site for named body site
... subject S1..1Reference(AU Primary Care Patient)Who has the condition?
... onsetDateTime S0..1dateTimeEstimated or actual date, date-time, or age
... note S0..1AnnotationAdditional information about the Condition
.... text S1..1markdownThe annotation - text content (as markdown)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*AUBaseConditionA condition, problem or diagnosis statement in an Australian healthcare context
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ0..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... 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
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... bodySite S0..1Reference(BodyStructure)Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI1..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!SΣI0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.

... category 0..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ1..1CodeableConceptCoding of a condition, may also describe abscence of condition
Binding: Condition Code Valueset (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... bodySite SΣ0..*CodeableConceptBody site for named body site
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... subject SΣ1..1Reference(AU Primary Care Patient)Who has the condition?
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... Slices for onset[x] Σ0..1dateTimeEstimated or actual date, date-time, or age
Slice: Unordered, Closed by type:$this
.... onset[x]:onsetDateTime SΣ0..1dateTimeEstimated or actual date, date-time, or age
... abatement[x] I0..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 I0..*BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... 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 I0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment I0..*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 I0..*BackboneElementSupporting evidence for condition
.... 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 ΣI0..*CodeableConceptEvidence manifestation/symptom
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred): Preferred SNOMED-CT Codes that describe the manifestation or symptoms of a condition.


.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note S0..1AnnotationAdditional information about the Condition
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... author[x] Σ0..1Individual responsible for the annotation
..... authorReferenceReference(Practitioner | Patient | RelatedPerson | Organization)
..... authorStringstring
.... time Σ0..1dateTimeWhen the annotation was made
.... text SΣ1..1markdownThe annotation - text content (as markdown)

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
Condition.meta.securityextensibleAll Security Labels
Condition.meta.tagexampleCommonTags
Condition.languagepreferredCommonLanguages
Max Binding: AllLanguages
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codepreferredCondition_Code_Valueset
Condition.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdPathDetailsRequirements
con-1Condition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()