Qi-Core Implementation Guide (Release 2.1 Draft)

D.4.1 StructureDefinition: qicore-condition

Examples:

Severe Burn Example

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is:

http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition

This profile builds on Condition.

This profile was published on Mon Aug 21 00:00:00 UTC 2017 as a draft by Health Level Seven International (Clinical Quality Information - QICore).

Description of Profiles, Differentials, and Snapshots.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*Detailed information about conditions, problems or diagnoses
... id 0..1id
... clinicalStatus S0..1codeactive | recurrence | inactive | remission | resolved
Binding: Condition Clinical Status Codes (required)
... verificationStatus S0..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding: ConditionVerificationStatus (required)
... category S0..*CodeableConceptproblem-list-item | encounter-diagnosis | problem | health-concern
Binding: US Core Condition Category Codes (preferred)
... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (preferred)
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (preferred)
... bodySite S0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (example)
... subject S1..1Reference(QICore-Patient), Reference(Group)Who has the condition?
... context S0..1Reference(QICore-Encounter), Reference(EpisodeOfCare)Encounter or episode when condition first asserted
... onset[x] S0..1dateTime, Age, Period, RangeEstimated or actual date, date-time, or age
... abatement[x] S0..1dateTime, Age, boolean, Period, RangeIf/when in resolution/remission
... assertedDate S0..1dateTimeDate record was believed accurate
... asserter 0..1Reference(QICore-Patient), Reference(QICore-Practitioner), Reference(QICore-RelatedPerson)Person who asserts this condition
... stage S0..1BackboneElementStage/grade, usually assessed formally
.... summary S0..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment 0..*Reference(ClinicalImpression), Reference(DiagnosticReport), Reference(Observation)Formal record of assessment
... evidence 0..*BackboneElementSupporting evidence
.... code 0..*CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example)
.... detail 0..*Reference(Any)Supporting information found elsewhere
... condition-criticality 0..1CodeableConceptPotential impact of the condition
URL: http://hl7.org/fhir/StructureDefinition/condition-criticality
Binding: QICore Condition Criticality Codes (example)
... condition-dueTo 0..*CodeableConcept, Reference(Condition), Reference(Procedure), Reference(MedicationAdministration), Reference(Immunization), Reference(MedicationStatement)What caused the Condition?
URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo
Binding: Condition Cause Codes (example)
... condition-occurredFollowing 0..*CodeableConcept, Reference(Condition), Reference(Procedure), Reference(MedicationAdministration), Reference(Immunization), Reference(MedicationStatement)Precedent for this Condition
URL: http://hl7.org/fhir/StructureDefinition/condition-occurredFollowing
Binding: Condition Predecessor Codes (example)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*Detailed information about conditions, problems or diagnoses
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... condition-criticality I0..1CodeableConceptExtension
URL: http://hl7.org/fhir/StructureDefinition/condition-criticality
... condition-dueTo I0..*CodeableConcept, Reference(Condition), Reference(Procedure), Reference(MedicationAdministration), Reference(Immunization), Reference(MedicationStatement)What caused the Condition?
URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo
Binding: Condition Cause Codes (example)
... condition-occurredFollowing I0..*CodeableConcept, Reference(Condition), Reference(Procedure), Reference(MedicationAdministration), Reference(Immunization), Reference(MedicationStatement)Extension
URL: http://hl7.org/fhir/StructureDefinition/condition-occurredFollowing
Binding: Condition Predecessor Codes (example)
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI0..1codeactive | recurrence | inactive | remission | resolved
Binding: Condition Clinical Status Codes (required)
... verificationStatus ?!SΣI0..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding: ConditionVerificationStatus (required)
... category S0..*CodeableConceptproblem-list-item | encounter-diagnosis | problem | health-concern
Binding: US Core Condition Category Codes (preferred)
... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (preferred)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (preferred)
... bodySite SΣ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (example)
... subject SΣ1..1Reference(QICore-Patient), Reference(Group)Who has the condition?
... context SΣ0..1Reference(QICore-Encounter), Reference(EpisodeOfCare)Encounter or episode when condition first asserted
... onset[x] SΣ0..1dateTime, Age, Period, RangeEstimated or actual date, date-time, or age
... abatement[x] SI0..1dateTime, Age, boolean, Period, RangeIf/when in resolution/remission
... assertedDate SΣ0..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(QICore-Patient), Reference(QICore-Practitioner), Reference(QICore-RelatedPerson)Person who asserts this condition
... stage SI0..1BackboneElementStage/grade, usually assessed formally
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... summary SI0..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment I0..*Reference(ClinicalImpression), Reference(DiagnosticReport), Reference(Observation)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example)
.... detail ΣI0..*Reference(Any)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*Detailed information about conditions, problems or diagnoses
... id 0..1id
... clinicalStatus S0..1codeactive | recurrence | inactive | remission | resolved
Binding: Condition Clinical Status Codes (required)
... verificationStatus S0..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding: ConditionVerificationStatus (required)
... category S0..*CodeableConceptproblem-list-item | encounter-diagnosis | problem | health-concern
Binding: US Core Condition Category Codes (preferred)
... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (preferred)
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (preferred)
... bodySite S0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (example)
... subject S1..1Reference(QICore-Patient), Reference(Group)Who has the condition?
... context S0..1Reference(QICore-Encounter), Reference(EpisodeOfCare)Encounter or episode when condition first asserted
... onset[x] S0..1dateTime, Age, Period, RangeEstimated or actual date, date-time, or age
... abatement[x] S0..1dateTime, Age, boolean, Period, RangeIf/when in resolution/remission
... assertedDate S0..1dateTimeDate record was believed accurate
... asserter 0..1Reference(QICore-Patient), Reference(QICore-Practitioner), Reference(QICore-RelatedPerson)Person who asserts this condition
... stage S0..1BackboneElementStage/grade, usually assessed formally
.... summary S0..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment 0..*Reference(ClinicalImpression), Reference(DiagnosticReport), Reference(Observation)Formal record of assessment
... evidence 0..*BackboneElementSupporting evidence
.... code 0..*CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example)
.... detail 0..*Reference(Any)Supporting information found elsewhere
... condition-criticality 0..1CodeableConceptPotential impact of the condition
URL: http://hl7.org/fhir/StructureDefinition/condition-criticality
Binding: QICore Condition Criticality Codes (example)
... condition-dueTo 0..*CodeableConcept, Reference(Condition), Reference(Procedure), Reference(MedicationAdministration), Reference(Immunization), Reference(MedicationStatement)What caused the Condition?
URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo
Binding: Condition Cause Codes (example)
... condition-occurredFollowing 0..*CodeableConcept, Reference(Condition), Reference(Procedure), Reference(MedicationAdministration), Reference(Immunization), Reference(MedicationStatement)Precedent for this Condition
URL: http://hl7.org/fhir/StructureDefinition/condition-occurredFollowing
Binding: Condition Predecessor Codes (example)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*Detailed information about conditions, problems or diagnoses
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... condition-criticality I0..1CodeableConceptExtension
URL: http://hl7.org/fhir/StructureDefinition/condition-criticality
... condition-dueTo I0..*CodeableConcept, Reference(Condition), Reference(Procedure), Reference(MedicationAdministration), Reference(Immunization), Reference(MedicationStatement)What caused the Condition?
URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo
Binding: Condition Cause Codes (example)
... condition-occurredFollowing I0..*CodeableConcept, Reference(Condition), Reference(Procedure), Reference(MedicationAdministration), Reference(Immunization), Reference(MedicationStatement)Extension
URL: http://hl7.org/fhir/StructureDefinition/condition-occurredFollowing
Binding: Condition Predecessor Codes (example)
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI0..1codeactive | recurrence | inactive | remission | resolved
Binding: Condition Clinical Status Codes (required)
... verificationStatus ?!SΣI0..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding: ConditionVerificationStatus (required)
... category S0..*CodeableConceptproblem-list-item | encounter-diagnosis | problem | health-concern
Binding: US Core Condition Category Codes (preferred)
... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (preferred)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (preferred)
... bodySite SΣ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (example)
... subject SΣ1..1Reference(QICore-Patient), Reference(Group)Who has the condition?
... context SΣ0..1Reference(QICore-Encounter), Reference(EpisodeOfCare)Encounter or episode when condition first asserted
... onset[x] SΣ0..1dateTime, Age, Period, RangeEstimated or actual date, date-time, or age
... abatement[x] SI0..1dateTime, Age, boolean, Period, RangeIf/when in resolution/remission
... assertedDate SΣ0..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(QICore-Patient), Reference(QICore-Practitioner), Reference(QICore-RelatedPerson)Person who asserts this condition
... stage SI0..1BackboneElementStage/grade, usually assessed formally
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... summary SI0..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment I0..*Reference(ClinicalImpression), Reference(DiagnosticReport), Reference(Observation)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example)
.... detail ΣI0..*Reference(Any)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathNameConformanceValueSet
Condition.languageCommon LanguagesextensibleCommon Languages
Condition.clinicalStatusCondition Clinical Status CodesrequiredCondition Clinical Status Codes
Condition.verificationStatusConditionVerificationStatusrequiredConditionVerificationStatus
Condition.categoryUS Core Condition Category CodespreferredUS Core Condition Category Codes
Condition.severityCondition/Diagnosis SeveritypreferredCondition/Diagnosis Severity
Condition.codeProblem Value SetpreferredProblem Value Set
Condition.bodySiteSNOMED CT Body StructuresexampleSNOMED CT Body Structures
Condition.stage.summaryCondition StageexampleCondition Stage
Condition.evidence.codeManifestation and Symptom CodesexampleManifestation and Symptom Codes

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2ConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-1ConditionIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-4ConditionIf 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-3ConditionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
con-4ConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive'
con-3ConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error
: verificationStatus='entered-in-error' or clinicalStatus.exists()
ele-1Condition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Condition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Condition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Condition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1Condition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.stageAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
con-1Condition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
ele-1Condition.evidenceAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
con-2Condition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()