US Quality Core Implementation Guide
0.1.0 - cibuild

US Quality Core Implementation Guide, published by ASTP. 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/FHIR/us-quality-core/ and changes regularly. See the Directory of published versions

## Resource Profile: US Quality Core Condition Encounter Diagnosis

Official URL: http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-condition-encounter-diagnosis | Version: 0.1.0
Active as of 2022-04-20 | Computable Name: USQualityCoreConditionEncounterDiagnosis
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The US Quality Core Condition Encounter Diagnosis Profile is based upon the US Core Condition Encounter Diagnosis Profile. In version 5.0.0, The US Quality Core Condition Profile has been split into the US Quality Core Condition Encounter Diagnosis Profile and US Quality Core Condition Problems and Health Concerns Profile. To promote interoperability and adoption through common implementation, this profile defines constraints and extensions on the Condition resource for the minimal set of data to record, search, and fetch information about an encounter diagnosis. It Defines the core set of elements and extensions for quality rule and measure authors.

Usage

See the patterns page for implementation and usage patterns.

    [ConditionEncounterDiagnosis: Diabetes] Condition
      where Condition.getEncounter().status = 'finished'

### Examples

Severe Burn Example
Appendicitis Example

USCDI+ Quality Elements:

- code: (USCDI+ Quality) (USCDI) Identification of the condition, problem or diagnosis
- encounter: (USCDI+ Quality) (USCDI) Encounter created as part of
- recordedDate: (USCDI+ Quality) (USCDI) Date record was first recorded

Usages:

- Refer to this Profile: US Quality Core AdverseEvent, US Quality Core Claim, US Quality Core Encounter, US Quality Core Medication Not Requested... Show 4 more, US Quality Core MedicationRequest, US Quality Core Procedure, US Quality Core Service Not Requested and US Quality Core ServiceRequest
- Examples for this Profile: Condition/appendicitis-example and Condition/example
- CapabilityStatements using this Profile: US Quality Core Client CapabilityStatement and US Quality Core Server CapabilityStatement

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  |  |  | Content/Rules for all slices
extension:assertedDate | S | 0..1 | dateTime | (USCDI) Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
clinicalStatus | ?!S Σ C | 0..1 | CodeableConcept | (USCDI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus | ?!S Σ C | 0..1 | CodeableConcept | (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category | S | 1..* | CodeableConcept | (USCDI) category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core | S | 1..1 | CodeableConcept | (USCDI) encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | (USCDI+ Quality) (USCDI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
subject | S Σ | 1..1 | Reference(US Quality Core Patient) | (USCDI) Who has the condition?
encounter | S Σ | 0..1 | Reference(US Quality Core Encounter) | (USCDI+ Quality) (USCDI) Encounter created as part of
onset[x] | S Σ | 0..1 |  | (USCDI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime S |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | S C | 0..1 |  | (USCDI) When in resolution/remission
abatementDateTime |  |  | dateTime S |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate | S Σ | 0..1 | dateTime | (USCDI+ Quality) (USCDI) Date record was first recorded
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📦4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📦4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.category:us-core | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.code | Base | extensible | US Core Condition Codes | 📦6.1.0 | US Core v6.1

#### Constraints

Id | Grade | Path(s) | Description | Expression
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item | `clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()`
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission | `abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()`
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | `verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()`
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Condition | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition |  | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses
code |  | 1..1 | CodeableConcept | (USCDI+ Quality) (USCDI) Identification of the condition, problem or diagnosis
subject |  | 1..1 | Reference(US Quality Core Patient) | (USCDI) Who has the condition?
encounter |  | 0..1 | Reference(US Quality Core Encounter) | (USCDI+ Quality) (USCDI) Encounter created as part of
onset[x] |  | 0..1 |  | (USCDI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] |  | 0..1 |  | (USCDI) When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate |  | 0..1 | dateTime | (USCDI+ Quality) (USCDI) Date record was first recorded
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:assertedDate | S | 0..1 | dateTime | (USCDI) Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | External Ids for this condition
clinicalStatus | ?!S Σ C | 0..1 | CodeableConcept | (USCDI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus | ?!S Σ C | 0..1 | CodeableConcept | (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category | S | 1..* | CodeableConcept | (USCDI) category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core | S | 1..1 | CodeableConcept | (USCDI) encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
severity |  | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
code | S Σ | 1..1 | CodeableConcept | (USCDI+ Quality) (USCDI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject | S Σ | 1..1 | Reference(US Quality Core Patient) | (USCDI) Who has the condition?
encounter | S Σ | 0..1 | Reference(US Quality Core Encounter) | (USCDI+ Quality) (USCDI) Encounter created as part of
onset[x] | S Σ | 0..1 |  | (USCDI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime S |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | S C | 0..1 |  | (USCDI) When in resolution/remission
abatementDateTime |  |  | dateTime S |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate | S Σ | 0..1 | dateTime | (USCDI+ Quality) (USCDI) Date record was first recorded
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally Constraints: con-1
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment
type |  | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
evidence | C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ C | 0..* | Reference(Resource) | Supporting information found elsewhere
note |  | 0..* | Annotation | Additional information about the Condition
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std.
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📦4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📦4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.category:us-core | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.severity | Base | preferred | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | extensible | US Core Condition Codes | 📦6.1.0 | US Core v6.1
Condition.bodySite | Base | example | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std.
Condition.stage.summary | Base | example | Condition Stage | 📦4.0.1 | FHIR Std.
Condition.stage.type | Base | example | Condition Stage Type | 📦4.0.1 | FHIR Std.
Condition.evidence.code | Base | example | Manifestation and Symptom Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
con-1 | error | Condition.stage | Stage SHALL have summary or assessment | `summary.exists() or assessment.exists()`
con-2 | error | Condition.evidence | evidence SHALL have code or details | `code.exists() or detail.exists()`
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item | `clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()`
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission | `abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()`
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | `verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()`
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Condition | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Summary

Structures

This structure refers to these other structures:

- US Quality Core Patient (http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-patient)
- US Quality Core Encounter (http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-encounter)

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  |  |  | Content/Rules for all slices
extension:assertedDate | S | 0..1 | dateTime | (USCDI) Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
clinicalStatus | ?!S Σ C | 0..1 | CodeableConcept | (USCDI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus | ?!S Σ C | 0..1 | CodeableConcept | (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category | S | 1..* | CodeableConcept | (USCDI) category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core | S | 1..1 | CodeableConcept | (USCDI) encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | (USCDI+ Quality) (USCDI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
subject | S Σ | 1..1 | Reference(US Quality Core Patient) | (USCDI) Who has the condition?
encounter | S Σ | 0..1 | Reference(US Quality Core Encounter) | (USCDI+ Quality) (USCDI) Encounter created as part of
onset[x] | S Σ | 0..1 |  | (USCDI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime S |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | S C | 0..1 |  | (USCDI) When in resolution/remission
abatementDateTime |  |  | dateTime S |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate | S Σ | 0..1 | dateTime | (USCDI+ Quality) (USCDI) Date record was first recorded
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📦4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📦4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.category:us-core | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.code | Base | extensible | US Core Condition Codes | 📦6.1.0 | US Core v6.1

#### Constraints

Id | Grade | Path(s) | Description | Expression
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item | `clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()`
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission | `abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()`
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | `verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()`
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Condition | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Differential View

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition |  | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses
code |  | 1..1 | CodeableConcept | (USCDI+ Quality) (USCDI) Identification of the condition, problem or diagnosis
subject |  | 1..1 | Reference(US Quality Core Patient) | (USCDI) Who has the condition?
encounter |  | 0..1 | Reference(US Quality Core Encounter) | (USCDI+ Quality) (USCDI) Encounter created as part of
onset[x] |  | 0..1 |  | (USCDI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] |  | 0..1 |  | (USCDI) When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate |  | 0..1 | dateTime | (USCDI+ Quality) (USCDI) Date record was first recorded
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:assertedDate | S | 0..1 | dateTime | (USCDI) Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | External Ids for this condition
clinicalStatus | ?!S Σ C | 0..1 | CodeableConcept | (USCDI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus | ?!S Σ C | 0..1 | CodeableConcept | (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category | S | 1..* | CodeableConcept | (USCDI) category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core | S | 1..1 | CodeableConcept | (USCDI) encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
severity |  | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
code | S Σ | 1..1 | CodeableConcept | (USCDI+ Quality) (USCDI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject | S Σ | 1..1 | Reference(US Quality Core Patient) | (USCDI) Who has the condition?
encounter | S Σ | 0..1 | Reference(US Quality Core Encounter) | (USCDI+ Quality) (USCDI) Encounter created as part of
onset[x] | S Σ | 0..1 |  | (USCDI) Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime S |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | S C | 0..1 |  | (USCDI) When in resolution/remission
abatementDateTime |  |  | dateTime S |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate | S Σ | 0..1 | dateTime | (USCDI+ Quality) (USCDI) Date record was first recorded
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally Constraints: con-1
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment
type |  | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
evidence | C | 0..* | BackboneElement | Supporting evidence Constraints: con-2
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ C | 0..* | Reference(Resource) | Supporting information found elsewhere
note |  | 0..* | Annotation | Additional information about the Condition
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std.
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📦4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📦4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.category:us-core | Base | extensible | Condition Category Codes | 📦4.0.1 | FHIR Std.
Condition.severity | Base | preferred | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | extensible | US Core Condition Codes | 📦6.1.0 | US Core v6.1
Condition.bodySite | Base | example | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std.
Condition.stage.summary | Base | example | Condition Stage | 📦4.0.1 | FHIR Std.
Condition.stage.type | Base | example | Condition Stage Type | 📦4.0.1 | FHIR Std.
Condition.evidence.code | Base | example | Manifestation and Symptom Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
con-1 | error | Condition.stage | Stage SHALL have summary or assessment | `summary.exists() or assessment.exists()`
con-2 | error | Condition.evidence | evidence SHALL have code or details | `code.exists() or detail.exists()`
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item | `clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()`
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission | `abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()`
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | `verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()`
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Condition | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Summary

Structures

This structure refers to these other structures:

- US Quality Core Patient (http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-patient)
- US Quality Core Encounter (http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-encounter)

Other representations of profile: CSV, Excel, Schematron