XpanDH Hospital Discharge Report
0.1.0 - ci-build 150

XpanDH Hospital Discharge Report, published by XpanDH Project. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/xpandh-hdr/ and changes regularly. See the Directory of published versions

Resource Profile: Condition Xpandh Hospital Dischage Encounter

Official URL: http://hl7.eu/fhir/ig/xpandh/hdr/StructureDefinition/condition-encounter-hdr-xpandh Version: 0.1.0
Draft as of 2024-06-19 Computable Name: ConditionEncounterHdrXpandh

Copyright/Legal: Used by permission of the XpanDH project, all rights reserved Creative Commons License

This profile represents the constraint applied to the Condition in the scope of Xpandh hospital discharge encounter resource. Encounter conditions implements Diagnostic summary part of the eHN data model adding two additional categories: First category distingueshes conditions present at admission and acquired during hospital stay (POA, HAC, NA - Not applicable or unknown) while second category is used to indicate impact of the condition to the treatement during hospital stay (treated, untreated).

Usage:

Formal Views of Profile Content

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

This structure is derived from ConditionHdrXpandh

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition ConditionHdrXpandh
... Slices for category 3..* CodeableConceptIPS category codes
Slice: Unordered, Open by value:$this
.... category:hdr-core 1..1 CodeableConceptIPS encounter-diagnosis
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
.... category:poa 1..1 CodeableConceptIPS POA, HAC, NA
Binding: Condition Present on Admission (POA) Value Set (required)
.... category:treated 1..1 CodeableConceptIPS Treated or untreated
Binding: Treatment Class Value Set (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Condition.category:poarequiredHdrPOAIndicatorXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-poa-indicator-xpandh-vs
from this IG
Condition.category:treatedrequiredHdrTreatedXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-treated-xpandh-vs
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* ConditionHdrXpandh Documentation of a health problem of the patient
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 1..1 Narrative Text summary of the resource, for human interpretation
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... verificationStatus S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: ConditionVerificationStatus (required)
... Slices for category S 3..* CodeableConceptIPS category codes
Slice: Unordered, Open by value:$this
Binding: Problem Type - IPS (preferred)
Additional BindingsPurpose
Problem Type (LOINC) candidate

.... category:hdr-core S 1..1 CodeableConceptIPS encounter-diagnosis
Binding: Problem Type - IPS (preferred)
Additional BindingsPurpose
Problem Type (LOINC) candidate


Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
.... category:poa S 1..1 CodeableConceptIPS POA, HAC, NA
Binding: Condition Present on Admission (POA) Value Set (required)
.... category:treated S 1..1 CodeableConceptIPS Treated or untreated
Binding: Treatment Class Value Set (required)
... severity S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Condition/DiagnosisSeverity (preferred)
Additional BindingsPurpose
Problem Severity - IPS candidate
... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Condition Value Set (required): Valueset to describe the actual problem experienced by the patient

... bodySite 0..* CodeableConceptIPS Concept - reference to a terminology or just text
Binding: SNOMEDCTBodyStructures (example)
.... Slices for extension Content/Rules for all slices
..... laterality 0..1 CodeableConcept Laterality Qualifier Extension
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier
Binding: Laterality Qualifier Value Set (required)
.... coding S 0..* CodingIPS A reference to a code defined by a terminology system
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient: HDR) Who has the condition?
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... Slices for onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Estimated or actual date, date-time, or age
... Slices for abatement[x] SC 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime
.... abatement[x]:abatementDateTime C 0..1 dateTime When in resolution/remission
... recordedDate SΣ 0..1 dateTime Date record was first recorded

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categorypreferredProblemTypeUvIps
Additional Bindings Purpose Documentation
Problem Type (LOINC) candidate

An alternative additional binding to the LOINC "Problem" code - retained for backward compatibility.
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips
Condition.category:hdr-corepreferredPattern: encounter-diagnosis
Additional Bindings Purpose Documentation
Problem Type (LOINC) candidate

An alternative additional binding to the LOINC "Problem" code - retained for backward compatibility.
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips
Condition.category:poarequiredHdrPOAIndicatorXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-poa-indicator-xpandh-vs
from this IG
Condition.category:treatedrequiredHdrTreatedXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-treated-xpandh-vs
from this IG
Condition.severitypreferredCondition/DiagnosisSeverity
Additional Bindings Purpose Documentation
Problem Severity - IPS candidate

An alternative additional binding to LOINC answer codes for condition/problem severity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.coderequiredHdrConditionXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-condition-xpandh-vs
from this IG
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* ConditionHdrXpandh Documentation of a health problem of the patient
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... 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 1..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Ids for this condition
... clinicalStatus S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: ConditionVerificationStatus (required)
... Slices for category S 3..* CodeableConceptIPS category codes
Slice: Unordered, Open by value:$this
Binding: Problem Type - IPS (preferred)
Additional BindingsPurpose
Problem Type (LOINC) candidate

.... category:hdr-core S 1..1 CodeableConceptIPS encounter-diagnosis
Binding: Problem Type - IPS (preferred)
Additional BindingsPurpose
Problem Type (LOINC) candidate


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
.... category:poa S 1..1 CodeableConceptIPS POA, HAC, NA
Binding: Condition Present on Admission (POA) Value Set (required)
.... category:treated S 1..1 CodeableConceptIPS Treated or untreated
Binding: Treatment Class Value Set (required)
... severity S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Condition/DiagnosisSeverity (preferred)
Additional BindingsPurpose
Problem Severity - IPS candidate
... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Condition Value Set (required): Valueset to describe the actual problem experienced by the patient

... bodySite 0..* CodeableConceptIPS Concept - reference to a terminology or just text
Binding: SNOMEDCTBodyStructures (example)
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... laterality 0..1 CodeableConcept Laterality Qualifier Extension
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier
Binding: Laterality Qualifier Value Set (required)
.... coding S 0..* CodingIPS A reference to a code defined by a terminology system
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient: HDR) Who has the condition?
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
... Slices for onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
.... onset[x]:onsetDateTime SΣ 0..1 dateTime S Estimated or actual date, date-time, or age
... Slices for abatement[x] SC 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
.... abatement[x]:abatementDateTime C 0..1 dateTime When in resolution/remission
... recordedDate SΣ 0..1 dateTime 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
con-1: Stage SHALL have summary or assessment
.... 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 Most recent Stage Group
Binding: Cancer Stage Grading: Snomed CT (required)
.... assessment C 0..* Reference(Observation: Cancer Stage Group) Formal record of assessment
.... type 0..1 CodeableConcept Staging system used.
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C 0..* BackboneElement Supporting evidence
con-2: evidence SHALL have code or details
.... 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

PathConformanceValueSet / CodeURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categorypreferredProblemTypeUvIps
Additional Bindings Purpose Documentation
Problem Type (LOINC) candidate

An alternative additional binding to the LOINC "Problem" code - retained for backward compatibility.
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips
Condition.category:hdr-corepreferredPattern: encounter-diagnosis
Additional Bindings Purpose Documentation
Problem Type (LOINC) candidate

An alternative additional binding to the LOINC "Problem" code - retained for backward compatibility.
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips
Condition.category:poarequiredHdrPOAIndicatorXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-poa-indicator-xpandh-vs
from this IG
Condition.category:treatedrequiredHdrTreatedXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-treated-xpandh-vs
from this IG
Condition.severitypreferredCondition/DiagnosisSeverity
Additional Bindings Purpose Documentation
Problem Severity - IPS candidate

An alternative additional binding to LOINC answer codes for condition/problem severity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.coderequiredHdrConditionXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-condition-xpandh-vs
from this IG
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Condition.stage.summaryrequiredCancerStageGradingVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/cancer-stage-grading-vs
from this IG
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from ConditionHdrXpandh

Differential View

This structure is derived from ConditionHdrXpandh

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition ConditionHdrXpandh
... Slices for category 3..* CodeableConceptIPS category codes
Slice: Unordered, Open by value:$this
.... category:hdr-core 1..1 CodeableConceptIPS encounter-diagnosis
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
.... category:poa 1..1 CodeableConceptIPS POA, HAC, NA
Binding: Condition Present on Admission (POA) Value Set (required)
.... category:treated 1..1 CodeableConceptIPS Treated or untreated
Binding: Treatment Class Value Set (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Condition.category:poarequiredHdrPOAIndicatorXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-poa-indicator-xpandh-vs
from this IG
Condition.category:treatedrequiredHdrTreatedXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-treated-xpandh-vs
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* ConditionHdrXpandh Documentation of a health problem of the patient
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 1..1 Narrative Text summary of the resource, for human interpretation
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... verificationStatus S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: ConditionVerificationStatus (required)
... Slices for category S 3..* CodeableConceptIPS category codes
Slice: Unordered, Open by value:$this
Binding: Problem Type - IPS (preferred)
Additional BindingsPurpose
Problem Type (LOINC) candidate

.... category:hdr-core S 1..1 CodeableConceptIPS encounter-diagnosis
Binding: Problem Type - IPS (preferred)
Additional BindingsPurpose
Problem Type (LOINC) candidate


Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
.... category:poa S 1..1 CodeableConceptIPS POA, HAC, NA
Binding: Condition Present on Admission (POA) Value Set (required)
.... category:treated S 1..1 CodeableConceptIPS Treated or untreated
Binding: Treatment Class Value Set (required)
... severity S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Condition/DiagnosisSeverity (preferred)
Additional BindingsPurpose
Problem Severity - IPS candidate
... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Condition Value Set (required): Valueset to describe the actual problem experienced by the patient

... bodySite 0..* CodeableConceptIPS Concept - reference to a terminology or just text
Binding: SNOMEDCTBodyStructures (example)
.... Slices for extension Content/Rules for all slices
..... laterality 0..1 CodeableConcept Laterality Qualifier Extension
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier
Binding: Laterality Qualifier Value Set (required)
.... coding S 0..* CodingIPS A reference to a code defined by a terminology system
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient: HDR) Who has the condition?
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... Slices for onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Estimated or actual date, date-time, or age
... Slices for abatement[x] SC 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime
.... abatement[x]:abatementDateTime C 0..1 dateTime When in resolution/remission
... recordedDate SΣ 0..1 dateTime Date record was first recorded

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categorypreferredProblemTypeUvIps
Additional Bindings Purpose Documentation
Problem Type (LOINC) candidate

An alternative additional binding to the LOINC "Problem" code - retained for backward compatibility.
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips
Condition.category:hdr-corepreferredPattern: encounter-diagnosis
Additional Bindings Purpose Documentation
Problem Type (LOINC) candidate

An alternative additional binding to the LOINC "Problem" code - retained for backward compatibility.
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips
Condition.category:poarequiredHdrPOAIndicatorXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-poa-indicator-xpandh-vs
from this IG
Condition.category:treatedrequiredHdrTreatedXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-treated-xpandh-vs
from this IG
Condition.severitypreferredCondition/DiagnosisSeverity
Additional Bindings Purpose Documentation
Problem Severity - IPS candidate

An alternative additional binding to LOINC answer codes for condition/problem severity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.coderequiredHdrConditionXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-condition-xpandh-vs
from this IG
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* ConditionHdrXpandh Documentation of a health problem of the patient
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... 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 1..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Ids for this condition
... clinicalStatus S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: ConditionVerificationStatus (required)
... Slices for category S 3..* CodeableConceptIPS category codes
Slice: Unordered, Open by value:$this
Binding: Problem Type - IPS (preferred)
Additional BindingsPurpose
Problem Type (LOINC) candidate

.... category:hdr-core S 1..1 CodeableConceptIPS encounter-diagnosis
Binding: Problem Type - IPS (preferred)
Additional BindingsPurpose
Problem Type (LOINC) candidate


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
.... category:poa S 1..1 CodeableConceptIPS POA, HAC, NA
Binding: Condition Present on Admission (POA) Value Set (required)
.... category:treated S 1..1 CodeableConceptIPS Treated or untreated
Binding: Treatment Class Value Set (required)
... severity S 0..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Condition/DiagnosisSeverity (preferred)
Additional BindingsPurpose
Problem Severity - IPS candidate
... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: Condition Value Set (required): Valueset to describe the actual problem experienced by the patient

... bodySite 0..* CodeableConceptIPS Concept - reference to a terminology or just text
Binding: SNOMEDCTBodyStructures (example)
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... laterality 0..1 CodeableConcept Laterality Qualifier Extension
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier
Binding: Laterality Qualifier Value Set (required)
.... coding S 0..* CodingIPS A reference to a code defined by a terminology system
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient: HDR) Who has the condition?
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
... Slices for onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
.... onset[x]:onsetDateTime SΣ 0..1 dateTime S Estimated or actual date, date-time, or age
... Slices for abatement[x] SC 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
.... abatement[x]:abatementDateTime C 0..1 dateTime When in resolution/remission
... recordedDate SΣ 0..1 dateTime 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
con-1: Stage SHALL have summary or assessment
.... 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 Most recent Stage Group
Binding: Cancer Stage Grading: Snomed CT (required)
.... assessment C 0..* Reference(Observation: Cancer Stage Group) Formal record of assessment
.... type 0..1 CodeableConcept Staging system used.
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C 0..* BackboneElement Supporting evidence
con-2: evidence SHALL have code or details
.... 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

PathConformanceValueSet / CodeURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categorypreferredProblemTypeUvIps
Additional Bindings Purpose Documentation
Problem Type (LOINC) candidate

An alternative additional binding to the LOINC "Problem" code - retained for backward compatibility.
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips
Condition.category:hdr-corepreferredPattern: encounter-diagnosis
Additional Bindings Purpose Documentation
Problem Type (LOINC) candidate

An alternative additional binding to the LOINC "Problem" code - retained for backward compatibility.
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips
Condition.category:poarequiredHdrPOAIndicatorXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-poa-indicator-xpandh-vs
from this IG
Condition.category:treatedrequiredHdrTreatedXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-treated-xpandh-vs
from this IG
Condition.severitypreferredCondition/DiagnosisSeverity
Additional Bindings Purpose Documentation
Problem Severity - IPS candidate

An alternative additional binding to LOINC answer codes for condition/problem severity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.coderequiredHdrConditionXpandhVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/hdr-condition-xpandh-vs
from this IG
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Condition.stage.summaryrequiredCancerStageGradingVS
http://hl7.eu/fhir/ig/xpandh/hdr/ValueSet/cancer-stage-grading-vs
from this IG
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from ConditionHdrXpandh

 

Other representations of profile: CSV, Excel, Schematron