My Health Record FHIR Gateway Conformance Artefacts
0.0.1 - draft
My Health Record FHIR Gateway Conformance Artefacts
0.0.1 - draft
My Health Record FHIR Gateway Conformance Artefacts, published by Australian Digital Health Agency. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AuDigitalHealth/mcv/ and changes regularly. See the Directory of published versions
| Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-condition-mcv-1 | Version: 0.0.1 | |||
| Draft as of 2024-09-11 | Computable Name: DHConditionMCV | |||
Copyright/Legal: Copyright © 2024 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/. |
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The purpose of this profile is to support a consolidated view of medical conditions and past medical history contained in a patient's My Health Record. It is based on the AU Core Condition profile and describes the data structures and obligations to be met when conforming to this profile.
The following are supported usage scenarios for this profile:
Condition.category that contains a code value of 'problem-list-item'. Some CDA source documents may also contain information about the type of problem or diagnosis that is relevant to a view of medical conditions. If present, this data will be supplied in an additional instance of Condition.category, which may be either a coding or a text value.Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from AUCoreCondition
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
  Condition |
0..* | AUCoreCondition | A condition, problem or diagnosis statement in an Australian healthcare context | |||||
  id |
1..1 | id | Logical id of this artifact | |||||
| clinicalStatus |
O | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved
| ||||
| category |
O | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis
| ||||
| code |
O | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis
| ||||
 subject |
O | 1..1 | Reference(ADHA Patient Match) | Who has the condition?
| ||||
 onset[x] |
O | 0..1 | dateTime | Estimated or actual date or date-time
| ||||
| abatement[x] |
O | 0..1 | dateTime | When in resolution/remission
| ||||
| recordedDate |
SO | 1..1 | dateTime | Date record was first recorded
| ||||
 note |
O | 0..1 | Annotation | Additional information about the Condition
| ||||
| Documentation for this format | ||||||||
| Name | Flags | Card. | Type | Description & Constraints | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
C | 0..* | AUCoreCondition | A condition, problem or diagnosis statement in an Australian healthcare context 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 | 1..1 | id | Logical id of this artifact | ||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
 clinicalStatus |
?!SOΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||||
| verificationStatus |
?!SOΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||||
| category |
SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||||
| severity |
SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
| ||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition  (extensible)
| ||||||||
| subject |
SOΣ | 1..1 | Reference(ADHA Patient Match) | Who has the condition?
| ||||||||
| onset[x] |
SOΣ | 0..1 | dateTime | Estimated or actual date or date-time
| ||||||||
| abatement[x] |
SOC | 0..1 | dateTime | When in resolution/remission
| ||||||||
| recordedDate |
SOΣ | 1..1 | dateTime | Date record was first recorded
| ||||||||
| note |
SO | 0..1 | Annotation | Additional information about the Condition
| ||||||||
| Documentation for this format | ||||||||||||
| Path | Conformance | ValueSet | URI |
| Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1from the FHIR Standard | |
| Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1from the FHIR Standard | |
| Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-categoryfrom the FHIR Standard | |
| Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severityfrom the FHIR Standard | |
| Condition.code | extensible | ClinicalCondition https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 |
| Id | Grade | Path(s) | Details | Requirements |
| con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
| con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
| con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
| dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
C | 0..* | AUCoreCondition | A condition, problem or diagnosis statement in an Australian healthcare context 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 | 1..1 | id | Logical id of this artifact | ||||||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||||
| text |
0..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 |
?!SOΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||||
| verificationStatus |
?!SOΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||||
| category |
SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||||
| severity |
SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
| ||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
| ||||||||
| bodySite |
ΣC | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible)au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT | ||||||||
| subject |
SOΣ | 1..1 | Reference(ADHA Patient Match) | Who has the condition?
| ||||||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||||||
| onset[x] |
SOΣ | 0..1 | dateTime | Estimated or actual date or date-time
| ||||||||
| abatement[x] |
SOC | 0..1 | dateTime | When in resolution/remission
| ||||||||
| recordedDate |
SOΣ | 1..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 | 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 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: Clinical Finding (preferred) | ||||||||
| detail |
ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||||||
| note |
SO | 0..1 | Annotation | Additional information about the Condition
| ||||||||
| Documentation for this format | ||||||||||||
| Path | Conformance | ValueSet | URI | |||
| Condition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1from the FHIR Standard | ||||
| Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1from the FHIR Standard | ||||
| Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-categoryfrom the FHIR Standard | ||||
| Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severityfrom the FHIR Standard | ||||
| Condition.code | extensible | ClinicalCondition https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 | ||||
| Condition.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 | ||||
| Condition.stage.summary | example | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stagefrom the FHIR Standard | ||||
| Condition.stage.type | example | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-typefrom the FHIR Standard | ||||
| Condition.evidence.code | preferred | ClinicalFinding https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
| Id | Grade | Path(s) | Details | Requirements |
| au-core-cond-02 | error | Condition.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
| 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 AUCoreCondition
Differential View
This structure is derived from AUCoreCondition
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Condition |
0..* | AUCoreCondition | A condition, problem or diagnosis statement in an Australian healthcare context | |||||
| id |
1..1 | id | Logical id of this artifact | |||||
| clinicalStatus |
O | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved
| ||||
| category |
O | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis
| ||||
| code |
O | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis
| ||||
| subject |
O | 1..1 | Reference(ADHA Patient Match) | Who has the condition?
| ||||
| onset[x] |
O | 0..1 | dateTime | Estimated or actual date or date-time
| ||||
| abatement[x] |
O | 0..1 | dateTime | When in resolution/remission
| ||||
| recordedDate |
SO | 1..1 | dateTime | Date record was first recorded
| ||||
| note |
O | 0..1 | Annotation | Additional information about the Condition
| ||||
| Documentation for this format | ||||||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
C | 0..* | AUCoreCondition | A condition, problem or diagnosis statement in an Australian healthcare context 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 | 1..1 | id | Logical id of this artifact | ||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
| clinicalStatus |
?!SOΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||||
| verificationStatus |
?!SOΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||||
| category |
SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||||
| severity |
SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
| ||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
| ||||||||
| subject |
SOΣ | 1..1 | Reference(ADHA Patient Match) | Who has the condition?
| ||||||||
| onset[x] |
SOΣ | 0..1 | dateTime | Estimated or actual date or date-time
| ||||||||
| abatement[x] |
SOC | 0..1 | dateTime | When in resolution/remission
| ||||||||
| recordedDate |
SOΣ | 1..1 | dateTime | Date record was first recorded
| ||||||||
| note |
SO | 0..1 | Annotation | Additional information about the Condition
| ||||||||
| Documentation for this format | ||||||||||||
| Path | Conformance | ValueSet | URI |
| Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1from the FHIR Standard | |
| Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1from the FHIR Standard | |
| Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-categoryfrom the FHIR Standard | |
| Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severityfrom the FHIR Standard | |
| Condition.code | extensible | ClinicalCondition https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 |
| Id | Grade | Path(s) | Details | Requirements |
| 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() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Condition |
C | 0..* | AUCoreCondition | A condition, problem or diagnosis statement in an Australian healthcare context 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 | 1..1 | id | Logical id of this artifact | ||||||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||||
| text |
0..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 |
?!SOΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||||
| verificationStatus |
?!SOΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||||
| category |
SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||||
| severity |
SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
| ||||||||
| code |
SOΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
| ||||||||
| bodySite |
ΣC | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible)au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT | ||||||||
| subject |
SOΣ | 1..1 | Reference(ADHA Patient Match) | Who has the condition?
| ||||||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||||||
| onset[x] |
SOΣ | 0..1 | dateTime | Estimated or actual date or date-time
| ||||||||
| abatement[x] |
SOC | 0..1 | dateTime | When in resolution/remission
| ||||||||
| recordedDate |
SOΣ | 1..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 | 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 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: Clinical Finding (preferred) | ||||||||
| detail |
ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||||||
| note |
SO | 0..1 | Annotation | Additional information about the Condition
| ||||||||
| Documentation for this format | ||||||||||||
| Path | Conformance | ValueSet | URI | |||
| Condition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1from the FHIR Standard | ||||
| Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1from the FHIR Standard | ||||
| Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-categoryfrom the FHIR Standard | ||||
| Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severityfrom the FHIR Standard | ||||
| Condition.code | extensible | ClinicalCondition https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 | ||||
| Condition.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 | ||||
| Condition.stage.summary | example | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stagefrom the FHIR Standard | ||||
| Condition.stage.type | example | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-typefrom the FHIR Standard | ||||
| Condition.evidence.code | preferred | ClinicalFinding https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
| Id | Grade | Path(s) | Details | Requirements |
| au-core-cond-02 | error | Condition.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
| 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 AUCoreCondition
Other representations of profile: CSV, Excel, Schematron
IG © 2024+ Australian Digital Health Agency. Package au.digitalhealth.r4.mhr-fhir-gw#0.0.1 based on FHIR 4.0.1. Generated 2024-09-11
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