US Core Implementation Guide
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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

Resource Profile: US Core Condition Encounter Diagnosis Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis Version: 8.0.0
Standards status: Trial-use Computable Name: USCoreConditionEncounterDiagnosisProfile
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.17

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The US Core Condition Encounter Diagnosis Profile inherits from the FHIR Condition resource; refer to it for scope and usage definitions. US Core version 5.0.0 split the US Core Condition Profile into this profile and the US Core Condition Problems and Health Concerns Profile. This profile meets the requirements of the U.S. Core Data for Interoperability (USCDI) Encounter Diagnosis Data Element. It sets minimum expectations for the Condition resource to record, search, and fetch information about an encounter diagnosis. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

Example Usage Scenarios:

The following are example usage scenarios for this profile:

  • Query for a Patient's current or historical encounter diagnosis
  • Record or update a Patient's encounter diagnosis

Mandatory and Must Support Data Elements

The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each Condition Must Have:

  1. a category code of 'encounter-diagnosis'
  2. a code that identifies the condition*
  3. a patient

Each Condition Must Support:

  1. a clinical status of the condition (e.g., active or resolved)
  2. a verification status
  3. an encounter
  4. a date of diagnosis*
  5. abatement date (in other words, date of resolution or remission)
  6. a date when recorded*

*see guidance below

Profile Specific Implementation Guidance:

  • For Problems and Health Concerns, use the US Core Condition Problems and Health Concerns Profile.
  • *The Condition.code has an additional binding of "current" and a base "preferred" binding.
    • For the conformance rules on the current binding for coded data, review this section in the General Requirements page.
    • USCDI's applicable vocabulary standards for Encounter Diagnosis are SNOMED CT and ICD-10-CM.
      • The US Core Condition Codes only supports ICD-9-CM for historical purposes. ICD-10-CM is available and SHOULD be used as the primary code for current encounter diagnoses.
  • The encounter SHOULD always be referenced in Condition.encounter.
  • To search for an encounter diagnosis, query for Conditions that reference the Encounter of interest and have a category of encounter-diagnosis. An example search is shown in the Quick Start section below.
  • *There is no single element in Condition that represents the date of diagnosis. It may be the assertedDate Extension, Condition.onsetDateTime, or Condition.recordedDate.
    • Although all three are marked as Must Support, the Server is not required to support all.
    • A Server SHALL support Condition.recordedDate.
    • A Server SHALL support at least one of assertedDate Extension and Condition.onsetDateTime. A Server may support both, which means they support all three dates.
    • The Client application SHALL support all three elements.

Usage:

Changes since version 7.0.0:

  • No changes

    • Formal Views of Profile Content

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

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
    con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
    con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
    con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
    dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    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
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    dom-6: A resource should have narrative for robust management
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ele-1: All FHIR elements must have a @value or children
    ... Slices for extension Content/Rules for all slices
    .... extension:assertedDate S 0..1 dateTime Date the condition was first asserted
    URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... clinicalStatus ?!SΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ele-1: All FHIR elements must have a @value or children
    ... verificationStatus ?!SΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ele-1: All FHIR elements must have a @value or children
    ... Slices for category S 1..* CodeableConcept category codes
    Slice: Unordered, Open by value:$this
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


    ele-1: All FHIR elements must have a @value or children
    .... category:us-core S 1..1 CodeableConcept encounter-diagnosis
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


    ele-1: All FHIR elements must have a @value or children

    Required Pattern: At least the following
    ..... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ...... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
    Binding: US Core Condition Codes (preferred): Valueset to describe the actual problem experienced by the patient

    Additional BindingsPurpose
    US Core Condition Codes Required

    ele-1: All FHIR elements must have a @value or children
    ... subject SΣ 1..1 Reference(US Core Patient Profile) Who has the condition?
    ele-1: All FHIR elements must have a @value or children
    ... encounter SΣ 0..1 Reference(US Core Encounter Profile) Encounter created as part of
    ele-1: All FHIR elements must have a @value or children
    ... onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
    ele-1: All FHIR elements must have a @value or children
    .... onsetDateTime dateTime
    ... abatement[x] SC 0..1 When in resolution/remission
    ele-1: All FHIR elements must have a @value or children
    .... abatementDateTime dateTime
    ... recordedDate SΣ 0..1 dateTime Date record was first recorded
    ele-1: All FHIR elements must have a @value or children

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Condition.clinicalStatusrequiredConditionClinicalStatusCodes
    http://hl7.org/fhir/ValueSet/condition-clinical
    from the FHIR Standard
    Condition.verificationStatusrequiredConditionVerificationStatus
    http://hl7.org/fhir/ValueSet/condition-ver-status
    from the FHIR Standard
    Condition.categoryextensibleConditionCategoryCodes
    http://hl7.org/fhir/ValueSet/condition-category
    from the FHIR Standard
    Condition.category:us-coreextensiblePattern: encounter-diagnosis
    http://hl7.org/fhir/ValueSet/condition-category
    from the FHIR Standard
    Condition.codepreferredUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG

     

    Other representations of profile: CSV, Excel, Schematron

    Notes:

    Quick Start

    Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile's information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

    • See the Scopes Format section for a description of the SMART scopes syntax.
    • See the Search Syntax section for a description of the US Core search syntax.
    • See the General Requirements section for additional rules and expectations when a Server requires status parameters.
    • See the General Guidance section for additional guidance on searching for multiple patients.

    US Core Scopes

    Servers providing access to encounter diagnosis data SHALL support these US Core SMART Scopes:

    • resource level scopes: <patient|user|system>/Condition.rs

    • granular scopes: <patient|user|system>/Condition.rs?category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis

    Mandatory Search Parameters:

    The following search parameters and search parameter combinations SHALL be supported:

    1. SHALL support searching for all conditions including problems, health concerns, and encounter diagnosis for a patient using the patient search parameter:

      GET [base]/Condition?patient={Type/}[id]

      Example:

      1. GET [base]/Condition?patient=1137192

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient (how to search by reference)

    2. SHALL support searching using the combination of the patient and category search parameters:

      GET [base]/Condition?patient={Type/}[id]&category={system|}[code]

      Example:

      1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|problem-list-item
      2. GET [base]/Condition?patient=1032702&category=http://hl7.org/fhir/us/core/CodeSystem/condition-category|health-concern
      3. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category. (how to search by reference and how to search by token)

    Optional Search Parameters:

    The following search parameter combinations SHOULD be supported:

    1. SHOULD support searching using the combination of the patient and clinical-status search parameters:

      GET [base]/Condition?patient={Type/}[id]&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

      Example:

      1. GET [base/Condition?patient=1032702&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and all "active" statuses (active,relapse,remission). This will exclude diagnoses and health concerns without a clinicalStatus specified. (how to search by reference and how to search by token)

    2. SHOULD support searching using the combination of the patient and category and clinical-status search parameters:

      GET [base]/Condition?patient={Type/}[id]&category={system|}[code]&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

      Example:

      1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|problem-list-item&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category for all "active" statuses (active,relapse,remission). This will exclude diagnoses and health concerns without a clinicalStatus specified. (how to search by reference and how to search by token)

    3. SHOULD support searching using the combination of the patient and category and encounter search parameters:

      GET [base]/Condition?patient={Type/}[id]&category={system|}[code]&encounter={Type/}[id]

      Example:

      1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis&encounter=1036

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category and encounter. When category = "encounter-diagnosis" will return the encounter diagnosis for the encounter. (how to search by reference and how to search by token)

    4. SHOULD support searching using the combination of the patient and code search parameters:

      GET [base]/Condition?patient={Type/}[id]&code={system|}[code]

      Example:

      1. GET [base]/Condition?patient=1032702&code=[http://snomed.info/sct|442311008]

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and code. (how to search by reference and how to search by token)

    5. SHOULD support searching using the combination of the patient and onset-date search parameters:
      • including support for these onset-date comparators: gt,lt,ge,le
      • including optional support for AND search on onset-date (e.g.onset-date=[date]&onset-date=[date]]&...)

      GET [base]/Condition?patient={Type/}[id]&onset-date={gt|lt|ge|le}[date]{&onset-date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]Condition?patient=555580&onset-date=ge2018-01-14

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)

    6. SHOULD support searching using the combination of the patient and asserted-date search parameters:
      • including support for these asserted-date comparators: gt,lt,ge,le
      • including optional support for AND search on asserted-date (e.g.asserted-date=[date]&asserted-date=[date]]&...)

      GET [base]/Condition?patient={Type/}[id]&asserted-date={gt|lt|ge|le}[date]{&asserted-date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]Condition?patient=555580&asserted-date=ge2018-01-14

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)

    7. SHOULD support searching using the combination of the patient and recorded-date search parameters:
      • including support for these recorded-date comparators: gt,lt,ge,le
      • including optional support for AND search on recorded-date (e.g.recorded-date=[date]&recorded-date=[date]]&...)

      GET [base]/Condition?patient={Type/}[id]&recorded-date={gt|lt|ge|le}[date]{&recorded-date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]Condition?patient=555580&recorded-date=ge2018-01-14

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)

    8. SHOULD support searching using the combination of the patient and abatement-date search parameters:
      • including support for these abatement-date comparators: gt,lt,ge,le
      • including optional support for AND search on abatement-date (e.g.abatement-date=[date]&abatement-date=[date]]&...)

      GET [base]/Condition?patient={Type/}[id]&abatement-date={gt|lt|ge|le}[date]{&abatement-date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]Condition?patient=555580&abatement-date=ge2018-01-14

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)

    9. SHOULD support searching using the combination of the patient and _lastUpdated search parameters:
      • including support for these _lastUpdated comparators: gt,lt,ge,les
      • including optional support for AND search on _lastUpdated (e.g._lastUpdated=[date]&_lastUpdated=[date]]&...)

      GET [base]/Condition?patient={Type/}[id]&_lastUpdated={gt|lt|ge|le}[date]{&_lastUpdated={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]/Condition?patient=1032702&_lastUpdated=ge2024-01-01T00:00:00Z

      Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and _lastUpdated. See the US Core General Guidance page for Searching Using lastUpdated. (how to search by reference and how to search by token and how to search by date)