US Core Implementation Guide, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 8.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions
Page standards status: Trial-use | Maturity Level: 3 |
Definitions for the us-core-condition-encounter-diagnosis resource profile.
Guidance on how to interpret the contents of this table can be found here
0. Condition | |
Must Support | false |
2. Condition.extension:assertedDate | |
Slice Name | assertedDate |
Short | Date the condition was first asserted |
Control | 0..1 |
Type | Extension(Condition Asserted Date) (Extension Type: dateTime) |
Must Support | true |
4. Condition.clinicalStatus | |
Binding | The codes SHALL be taken from ConditionClinicalStatusCodes (required to http://hl7.org/fhir/ValueSet/condition-clinical ) |
Must Support | true |
6. Condition.verificationStatus | |
Binding | The codes SHALL be taken from ConditionVerificationStatus (required to http://hl7.org/fhir/ValueSet/condition-ver-status ) |
Must Support | true |
8. Condition.category | |
Short | category codes |
Control | 1..? |
Must Support | true |
Slicing | This element introduces a set of slices on Condition.category . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
10. Condition.category:us-core | |
Slice Name | us-core |
Short | encounter-diagnosis |
Control | 1..1 |
Must Support | true |
Pattern Value | { |
12. Condition.code | |
Control | 1..? |
Binding | The codes SHOULD be taken from US Core Condition Codes (preferred to http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code )Valueset to describe the actual problem experienced by the patient |
Must Support | true |
14. Condition.subject | |
Type | Reference(US Core Patient Profile, Group) |
Must Support | true |
Must Support Types | Reference(US Core Patient Profile) |
16. Condition.encounter | |
Type | Reference(US Core Encounter Profile) |
Must Support | true |
18. Condition.onset[x] | |
Type | Choice of: dateTime, Age, Period, Range, string |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Must Support Types | dateTime |
20. Condition.abatement[x] | |
Type | Choice of: dateTime, Age, Period, Range, string |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Must Support Types | dateTime |
22. Condition.recordedDate | |
Must Support | true |
Guidance on how to interpret the contents of this table can be found here
0. Condition | |
Definition | A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. |
Short | Detailed information about conditions, problems or diagnoses |
Control | 0..* |
Is Modifier | false |
Must Support | false |
Summary | false |
Invariants | con-3: 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($this='problem-list-item').empty() )con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission ( abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() )con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error ( verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() )dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item (clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()) con-4: 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: 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()) |
2. Condition.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Short | A set of rules under which this content was created |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Control | 0..1 |
Type | uri |
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
4. Condition.extension:assertedDate | |
Slice Name | assertedDate |
Definition | When the asserter identified the allergy, intolerance, condition, problem, or diagnosis or other event, situation, issue, or clinical concept that may have risen to a level of or remains a concern. For example, when the patient experiences chest pain, the asserted date represents when the clinician began following the chest pain - not when the patient experienced the chest pain. Asserted date supports the recognition that information is not always entered in a system immediately. Assertion and recording are different acts, so asserted date and recorded date are semantically different. However, they may be the same date and close in time. If this difference is significant for your use case, assertion date may be useful. |
Short | Date the condition was first asserted |
Comments | The assertedDate is in the context of the recording practitioner and might not be the same as the recordedDate. |
Control | 0..1 |
Type | Extension(Condition Asserted Date) (Extension Type: dateTime) |
Is Modifier | false |
Must Support | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
6. Condition.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
Summary | false |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
8. Condition.clinicalStatus | |
Definition | The clinical status of the condition. |
Short | active | recurrence | relapse | inactive | remission | resolved |
Comments | The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. |
Control | 0..1 This element is affected by the following invariants: con-3, con-4, con-5 |
Binding | The codes SHALL be taken from ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 (required to http://hl7.org/fhir/ValueSet/condition-clinical ) |
Type | CodeableConcept |
Is Modifier | true because This element is labeled as a modifier because the status contains codes that mark the condition as no longer active. |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
10. Condition.verificationStatus | |
Definition | The verification status to support the clinical status of the condition. |
Short | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error |
Comments | verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. |
Control | 0..1 This element is affected by the following invariants: con-3, con-5 |
Binding | The codes SHALL be taken from ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/condition-ver-status ) |
Type | CodeableConcept |
Is Modifier | true because This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid. |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
12. Condition.category | |
Definition | A category assigned to the condition. |
Short | category codesproblem-list-item | encounter-diagnosis |
Comments | The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. |
Control | 10..* |
Binding | Unless not suitable, these codes SHALL be taken from ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category (extensible to http://hl7.org/fhir/ValueSet/condition-category )A category assigned to the condition. |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on Condition.category . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
14. Condition.category:us-core | |
Slice Name | us-core |
Definition | A category assigned to the condition. |
Short | encounter-diagnosisproblem-list-item | encounter-diagnosis |
Comments | The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. |
Control | 10..1* |
Binding | Unless not suitable, these codes SHALL be taken from ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category (extensible to http://hl7.org/fhir/ValueSet/condition-category )A category assigned to the condition. |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | false |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
16. Condition.code | |
Definition | Identification of the condition, problem or diagnosis. |
Short | Identification of the condition, problem or diagnosis |
Control | 10..1 |
Binding | The codes SHOULD be taken from For example codes, see US Core Condition Codeshttp://hl7.org/fhir/ValueSet/condition-code (preferred to http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code )Valueset to describe the actual problem experienced by the patient Identification of the condition or diagnosis. |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | 0..1 to account for primarily narrative only resources. |
Alternate Names | type |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
18. Condition.subject | |
Definition | Indicates the patient or group who the condition record is associated with. |
Short | Who has the condition? |
Control | 1..1 |
Type | Reference(US Core Patient Profile, Group, Patient) |
Is Modifier | false |
Must Support | true |
Must Support Types | Reference(US Core Patient Profile) |
Summary | true |
Requirements | Group is typically used for veterinary or public health use cases. |
Alternate Names | patient |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
20. Condition.encounter | |
Definition | The Encounter during which this Condition was created or to which the creation of this record is tightly associated. |
Short | Encounter created as part of |
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known". |
Control | 0..1 |
Type | Reference(US Core Encounter Profile, Encounter) |
Is Modifier | false |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
22. Condition.onset[x] | |
Definition | Estimated or actual date or date-time the condition began, in the opinion of the clinician. |
Short | Estimated or actual date, date-time, or age |
Comments | Age is generally used when the patient reports an age at which the Condition began to occur. |
Control | 0..1 |
Type | Choice of: dateTime, Age, Period, Range, string |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Must Support Types | dateTime |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
24. Condition.abatement[x] | |
Definition | The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate. |
Short | When in resolution/remission |
Comments | There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated. |
Control | 0..1 This element is affected by the following invariants: con-4 |
Type | Choice of: dateTime, Age, Period, Range, string |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Must Support Types | dateTime |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
26. Condition.recordedDate | |
Definition | The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date. |
Short | Date record was first recorded |
Control | 0..1 |
Type | dateTime |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be found here
0. Condition | |||||
Definition | A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. | ||||
Short | Detailed information about conditions, problems or diagnoses | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Must Support | false | ||||
Summary | false | ||||
Invariants | con-3: 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: 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: 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: If the resource is contained in another resource, it SHALL NOT contain nested Resources ( contained.contained.empty() )dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty() )dom-6: A resource should have narrative for robust management ( text.`div`.exists() ) | ||||
2. Condition.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Short | Logical id of this artifact | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. Condition.meta | |||||
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
Short | Metadata about the resource | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
6. Condition.implicitRules | |||||
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
Short | A set of rules under which this content was created | ||||
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
8. Condition.language | |||||
Definition | The base language in which the resource is written. | ||||
Short | Language of the resource content | ||||
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
10. Condition.text | |||||
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
Short | Text summary of the resource, for human interpretation | ||||
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
12. Condition.contained | |||||
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
Short | Contained, inline Resources | ||||
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
14. Condition.extension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Condition.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
16. Condition.extension:assertedDate | |||||
Slice Name | assertedDate | ||||
Definition | When the asserter identified the allergy, intolerance, condition, problem, or diagnosis or other event, situation, issue, or clinical concept that may have risen to a level of or remains a concern. For example, when the patient experiences chest pain, the asserted date represents when the clinician began following the chest pain - not when the patient experienced the chest pain. Asserted date supports the recognition that information is not always entered in a system immediately. Assertion and recording are different acts, so asserted date and recorded date are semantically different. However, they may be the same date and close in time. If this difference is significant for your use case, assertion date may be useful. | ||||
Short | Date the condition was first asserted | ||||
Comments | The assertedDate is in the context of the recording practitioner and might not be the same as the recordedDate. | ||||
Control | 0..1 | ||||
Type | Extension(Condition Asserted Date) (Extension Type: dateTime) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
18. Condition.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
20. Condition.identifier | |||||
Definition | Business identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server. | ||||
Short | External Ids for this condition | ||||
Comments | This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
22. Condition.clinicalStatus | |||||
Definition | The clinical status of the condition. | ||||
Short | active | recurrence | relapse | inactive | remission | resolved | ||||
Comments | The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. | ||||
Control | 0..1 This element is affected by the following invariants: con-3, con-4, con-5 | ||||
Binding | The codes SHALL be taken from ConditionClinicalStatusCodes (required to http://hl7.org/fhir/ValueSet/condition-clinical ) | ||||
Type | CodeableConcept | ||||
Is Modifier | true because This element is labeled as a modifier because the status contains codes that mark the condition as no longer active. | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
24. Condition.verificationStatus | |||||
Definition | The verification status to support the clinical status of the condition. | ||||
Short | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | ||||
Comments | verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. | ||||
Control | 0..1 This element is affected by the following invariants: con-3, con-5 | ||||
Binding | The codes SHALL be taken from ConditionVerificationStatus (required to http://hl7.org/fhir/ValueSet/condition-ver-status ) | ||||
Type | CodeableConcept | ||||
Is Modifier | true because This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid. | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
26. Condition.category | |||||
Definition | A category assigned to the condition. | ||||
Short | category codes | ||||
Comments | The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. | ||||
Control | 1..* | ||||
Binding | Unless not suitable, these codes SHALL be taken from ConditionCategoryCodes (extensible to http://hl7.org/fhir/ValueSet/condition-category )A category assigned to the condition. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on Condition.category . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
28. Condition.category:us-core | |||||
Slice Name | us-core | ||||
Definition | A category assigned to the condition. | ||||
Short | encounter-diagnosis | ||||
Comments | The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ConditionCategoryCodes (extensible to http://hl7.org/fhir/ValueSet/condition-category )A category assigned to the condition. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
30. Condition.severity | |||||
Definition | A subjective assessment of the severity of the condition as evaluated by the clinician. | ||||
Short | Subjective severity of condition | ||||
Comments | Coding of the severity with a terminology is preferred, where possible. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from Condition/DiagnosisSeverity (preferred to http://hl7.org/fhir/ValueSet/condition-severity )A subjective assessment of the severity of the condition as evaluated by the clinician. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
32. Condition.code | |||||
Definition | Identification of the condition, problem or diagnosis. | ||||
Short | Identification of the condition, problem or diagnosis | ||||
Control | 1..1 | ||||
Binding | The codes SHOULD be taken from US Core Condition Codes (preferred to http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code )Valueset to describe the actual problem experienced by the patient | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 0..1 to account for primarily narrative only resources. | ||||
Alternate Names | type | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
34. Condition.bodySite | |||||
Definition | The anatomical location where this condition manifests itself. | ||||
Short | Anatomical location, if relevant | ||||
Comments | Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension bodySite. May be a summary code, or a reference to a very precise definition of the location, or both. | ||||
Control | 0..* | ||||
Binding | For example codes, see SNOMEDCTBodyStructures (example to http://hl7.org/fhir/ValueSet/body-site )Codes describing anatomical locations. May include laterality. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
36. Condition.subject | |||||
Definition | Indicates the patient or group who the condition record is associated with. | ||||
Short | Who has the condition? | ||||
Control | 1..1 | ||||
Type | Reference(US Core Patient Profile, Group) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | Reference(US Core Patient Profile) | ||||
Summary | true | ||||
Requirements | Group is typically used for veterinary or public health use cases. | ||||
Alternate Names | patient | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
38. Condition.encounter | |||||
Definition | The Encounter during which this Condition was created or to which the creation of this record is tightly associated. | ||||
Short | Encounter created as part of | ||||
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known". | ||||
Control | 0..1 | ||||
Type | Reference(US Core Encounter Profile) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
40. Condition.onset[x] | |||||
Definition | Estimated or actual date or date-time the condition began, in the opinion of the clinician. | ||||
Short | Estimated or actual date, date-time, or age | ||||
Comments | Age is generally used when the patient reports an age at which the Condition began to occur. | ||||
Control | 0..1 | ||||
Type | Choice of: dateTime, Age, Period, Range, string | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Must Support Types | dateTime | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
42. Condition.abatement[x] | |||||
Definition | The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate. | ||||
Short | When in resolution/remission | ||||
Comments | There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated. | ||||
Control | 0..1 This element is affected by the following invariants: con-4 | ||||
Type | Choice of: dateTime, Age, Period, Range, string | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Must Support Types | dateTime | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
44. Condition.recordedDate | |||||
Definition | The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date. | ||||
Short | Date record was first recorded | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
46. Condition.recorder | |||||
Definition | Individual who recorded the record and takes responsibility for its content. | ||||
Short | Who recorded the condition | ||||
Control | 0..1 | ||||
Type | Reference(Practitioner, PractitionerRole, Patient, RelatedPerson) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
48. Condition.asserter | |||||
Definition | Individual who is making the condition statement. | ||||
Short | Person who asserts this condition | ||||
Control | 0..1 | ||||
Type | Reference(Practitioner, PractitionerRole, Patient, RelatedPerson) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
50. Condition.stage | |||||
Definition | Clinical stage or grade of a condition. May include formal severity assessments. | ||||
Short | Stage/grade, usually assessed formally | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | con-1: Stage SHALL have summary or assessment (summary.exists() or assessment.exists() )ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count()) ) | ||||
52. Condition.stage.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
54. Condition.stage.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
56. Condition.stage.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
58. Condition.stage.summary | |||||
Definition | A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. | ||||
Short | Simple summary (disease specific) | ||||
Control | 0..1 This element is affected by the following invariants: con-1 | ||||
Binding | For example codes, see ConditionStage (example to http://hl7.org/fhir/ValueSet/condition-stage )Codes describing condition stages (e.g. Cancer stages). | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
60. Condition.stage.assessment | |||||
Definition | Reference to a formal record of the evidence on which the staging assessment is based. | ||||
Short | Formal record of assessment | ||||
Control | 0..* This element is affected by the following invariants: con-1 | ||||
Type | Reference(ClinicalImpression, DiagnosticReport, Observation) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
62. Condition.stage.type | |||||
Definition | The kind of staging, such as pathological or clinical staging. | ||||
Short | Kind of staging | ||||
Control | 0..1 | ||||
Binding | For example codes, see ConditionStageType (example to http://hl7.org/fhir/ValueSet/condition-stage-type )Codes describing the kind of condition staging (e.g. clinical or pathological). | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
64. Condition.evidence | |||||
Definition | Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. | ||||
Short | Supporting evidence | ||||
Comments | The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | con-2: evidence SHALL have code or details (code.exists() or detail.exists() )ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count()) ) | ||||
66. Condition.evidence.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
68. Condition.evidence.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
70. Condition.evidence.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
72. Condition.evidence.code | |||||
Definition | A manifestation or symptom that led to the recording of this condition. | ||||
Short | Manifestation/symptom | ||||
Control | 0..* This element is affected by the following invariants: con-2 | ||||
Binding | For example codes, see ManifestationAndSymptomCodes (example to http://hl7.org/fhir/ValueSet/manifestation-or-symptom )Codes that describe the manifestation or symptoms of a condition. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
74. Condition.evidence.detail | |||||
Definition | Links to other relevant information, including pathology reports. | ||||
Short | Supporting information found elsewhere | ||||
Control | 0..* This element is affected by the following invariants: con-2 | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
76. Condition.note | |||||
Definition | Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. | ||||
Short | Additional information about the Condition | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) |