# US Core Condition Encounter Diagnosis Profile - US Core Implementation Guide v9.0.0

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **US Core Condition Encounter Diagnosis Profile**

## Resource Profile: US Core Condition Encounter Diagnosis Profile 

| | | |
| :--- | :--- | :--- |
| *Official URL*:http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis | *Version*:9.0.0 | |
| * Standards status: *[Trial-use](http://hl7.org/fhir/R4/versions.html#std-process) | [Maturity Level](changes-between-versions.md#us-core-maturity-levels): 4 | *Computable Name*:USCoreConditionEncounterDiagnosisProfile |
| *Other Identifiers:*OID:2.16.840.1.113883.4.642.40.2.42.17 | | |

 
The US Core Condition Encounter Diagnosis Profile inherits from the FHIR [Condition](https://hl7.org/fhir/R4/condition.html) 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](us-core-roadmap.md#future-candidate-requirements-under-consideration) a Patient's encounter diagnosis

### Mandatory and Must Support Data Elements

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

**Each Condition Must Have:**

1. a category code of "encounter-diagnosis"
1. a code that identifies the condition1
1. a patient

**Each Condition Must Support:**

1. an encounter
1. date record was first recorded

**Additional USCDI Requirements:**

These [Additional USCDI Requirements](must-support.md#additional-uscdi-requirements) elements are not Mandatory or Must Support but are required for ONC Health IT certification testing and are included in the formal definition of the profile and the Condition examples.

1. a recorder2

1,2 see guidance below

### Profile Specific Implementation Guidance

This section provides detailed implementation guidance for the US Core Profile to support implementation and certification.

* For Problems and Health Concerns, use the [US Core Condition Problems and Health Concerns Profile](StructureDefinition-us-core-condition-problems-health-concerns.md).
* 1Unless exchanging legacy or text-only data, condition codes **SHOULD** be taken from SNOMED CT and ICD-10-CM, USCDI's applicable vocabulary standards for the Problem Data Element.[§](requirements.md#CONF-0900) 
* When using ICD codes, only **non-header** ICD-10-CM codes **SHOULD** be used.[§](requirements.md#CONF-0323)
* The [US Core Condition Codes](ValueSet-us-core-condition-code.md) value set supports ICD-9-CM for historical purposes only.
 
* The encounter **SHOULD** always be referenced in `Condition.encounter`.[§](requirements.md#CONF-0324)
* 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](#search) section below.

* 2The profile elements `Condition.asserter and Condition.recorder` communicate the [individual level provenance](basic-provenance.md#individual-level-provenance) author data corresponding to the U.S. Core Data for Interoperability (USCDI) Provenance Author Data Elements.

**Usages:**

* Refer to this Profile: [US Core Encounter Profile](StructureDefinition-us-core-encounter.md)
* Examples for this Profile: [Condition/encounter-diagnosis-example1](Condition-encounter-diagnosis-example1.md) and [Condition/encounter-diagnosis-example2](Condition-encounter-diagnosis-example2.md)
* CapabilityStatements using this Profile: [US Core Client CapabilityStatement](CapabilityStatement-us-core-client.md) and [US Core Server CapabilityStatement](CapabilityStatement-us-core-server.md)

You can also check for [usages in the FHIR IG Statistics](https://packages2.fhir.org/xig/hl7.fhir.us.core|current/StructureDefinition/us-core-condition-encounter-diagnosis)

**Changes since version 8.0.1:**

* The resource metadata has changed (description, copyright)

* The data elements list has changed

### Formal Views of Profile Content

 [Description of Profiles, Differentials, Snapshots and how the different presentations work](http://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#structure-definitions). 

 

Other representations of profile: [CSV](StructureDefinition-us-core-condition-encounter-diagnosis.csv), [Excel](StructureDefinition-us-core-condition-encounter-diagnosis.xlsx), [Schematron](StructureDefinition-us-core-condition-encounter-diagnosis.sch) 

### 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](CapabilityStatement-us-core-server.md) for a complete list of supported RESTful interactions for this IG.

* See the [Scopes Format](scopes.md#scopes-format) section for a description of the SMART scopes syntax.
* See the [Search Syntax](general-guidance.md#search-syntax) section for a description of the US Core search syntax.
* See the [General Requirements](general-requirements.md) section for additional rules and expectations when a Server requires status parameters.
* See the [General Guidance](general-guidance.md) 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](scopes.md#smart-scopes):

* [resource level scopes](http://hl7.org/fhir/smart-app-launch/STU2.2/scopes-and-launch-context.html#scopes-for-requesting-clinical-data): `<patient|user|system>/Condition.rs` [§](requirements.md#CONF-0135)
* [granular scopes](http://hl7.org/fhir/smart-app-launch/STU2.2/scopes-and-launch-context.html#finer-grained-resource-constraints-using-search-parameters): `<patient|user|system>/Condition.rs?category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis` [§](requirements.md#CONF-0159)

-------

#### 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](SearchParameter-us-core-condition-patient.md) search parameter`GET [base]/Condition?patient={Patient/}[id]`Example:
> 
1. GET [base]/Condition?patient=Patient/1032702

**Implementation Notes**: Fetches a bundle of all US Core Condition Encounter Diagnosis Profile resources for the specified patient ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference)).
1. **SHALL** support searching using the combination of the [patient](SearchParameter-us-core-condition-patient.md) and [category](SearchParameter-us-core-condition-category.md) search parameters`GET [base]/Condition?patient={Patient/}[id]&category={system|}[search_code]`Example:
> 
1. GET [base]/Condition?patient=Patient/1032702&category=encounter-diagnosis

**Implementation Notes**: Fetches a bundle of all US Core Condition Encounter Diagnosis Profile resources for the specified patient and category = "encounter-diagnosis" ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference) and [how to search by token](http://hl7.org/fhir/R4/search.html#token)).

#### Optional Search Parameters:

The following search parameters and search parameter combinations **SHOULD** be supported

1. **SHOULD** support searching using the combination of the [patient](SearchParameter-us-core-condition-patient.md) and [clinical-status](SearchParameter-us-core-condition-clinical-status.md) search parameters`GET [base]/Condition?patient={Patient/}[id]&clinical-status={system|}[search_code]`Example:
> 
1. GET [base/Condition?patient=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 US Core Condition Encounter Diagnosis Profile resources for the specified patient and all "active" statuses (active,relapse,remission). This will **exclude** US Core Condition Encounter Diagnosis Profiles with no `clinicalStatus` specified. ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference) and [how to search by token](http://hl7.org/fhir/R4/search.html#token)).
1. **SHOULD** support searching using the combination of the [patient](SearchParameter-us-core-condition-patient.md) and [category](SearchParameter-us-core-condition-category.md) and [clinical-status](SearchParameter-us-core-condition-clinical-status.md) search parameters`GET [base]/Condition?patient={Patient/}[id]&category={system|}[search_code]&clinical-status={system|}[search_code]`Example:
> 
1. GET [base]/Condition?patient=Patient/1032702&category=encounter-diagnosis&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 US Core Condition Encounter Diagnosis Profile resources for the specified patient and category = "encounter-diagnosis" for all "active" statuses (active,relapse,remission). This will **exclude** US Core Condition Encounter Diagnosis Profiles with no `clinicalStatus` specified. ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference) and [how to search by token](http://hl7.org/fhir/R4/search.html#token)).
1. **SHOULD** support searching using the combination of the [patient](SearchParameter-us-core-condition-patient.md) and [category](SearchParameter-us-core-condition-category.md) and [encounter](SearchParameter-us-core-condition-encounter.md) search parameters`GET [base]/Condition?patient={Patient/}[id]&category={system|}[search_code]&encounter={Type/}[id]`Example:
> 
1. GET [base]/Condition?patient=Patient/1032702&category=encounter-diagnosis&encounter=Encounter/1036

**Implementation Notes**: Fetches a bundle of all US Core Condition Encounter Diagnosis Profile resources for the specified patient, encounter, and category = "encounter-diagnosis". When category = "encounter-diagnosis", it will return the encounter diagnosis for the encounter. ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference) and [how to search by token](http://hl7.org/fhir/R4/search.html#token)).
1. **SHOULD** support searching using the combination of the [patient](SearchParameter-us-core-condition-patient.md) and [code](SearchParameter-us-core-condition-code.md) search parameters`GET [base]/Condition?patient={Patient/}[id]&code={system|}[search_code]`Example:
> 
1. GET [base]/Condition?patient=Patient/1032702&code=http://snomed.info/sct|39065001

**Implementation Notes**: Fetches a bundle of all US Core Condition Encounter Diagnosis Profile resources for the specified patient and code. ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference) and [how to search by token](http://hl7.org/fhir/R4/search.html#token)).
1. **SHOULD** support searching using the combination of the [patient](SearchParameter-us-core-condition-patient.md) and [onset-date](SearchParameter-us-core-condition-onset-date.md) search parameters
* Including optional support for **AND** search on `onset-date` (e.g.`onset-date=[date]&onset-date=[date]&...`)
* Including support for these `onset-date` comparators: "gt", "lt", "ge", "le"
`GET [base]/Condition?patient={Patient/}[id]&onset-date={gt|lt|ge|le}[dateTime]{&date={gt|lt|ge|le}[dateTime]&...}`Example:
> 
1. GET [base]/Condition?patient=Patient/1137192&onset-date=ge2018-01-14

**Implementation Notes**: Fetches a bundle of all US Core Condition Encounter Diagnosis Profile resources for the specified patient and date. ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference) and [how to search by date](http://hl7.org/fhir/R4/search.html#date)).
1. **SHOULD** support searching using the combination of the [patient](SearchParameter-us-core-condition-patient.md) and [asserted-date](SearchParameter-us-core-condition-asserted-date.md) search parameters
* Including optional support for **AND** search on `asserted-date` (e.g.`asserted-date=[date]&asserted-date=[date]&...`)
* Including support for these `asserted-date` comparators: "gt", "lt", "ge", "le"
`GET [base]/Condition?patient={Patient/}[id]&asserted-date={gt|lt|ge|le}[dateTime]{&date={gt|lt|ge|le}[dateTime]&...}`Example:
> 
1. GET [base]/Condition?patient=Patient/1137192&asserted-date=ge2018-01-14

**Implementation Notes**: Fetches a bundle of all US Core Condition Encounter Diagnosis Profile resources for the specified patient and date ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference) and [how to search by date](http://hl7.org/fhir/R4/search.html#date)).
1. **SHOULD** support searching using the combination of the [patient](SearchParameter-us-core-condition-patient.md) and [recorded-date](SearchParameter-us-core-condition-recorded-date.md) search parameters
* Including optional support for **AND** search on `recorded-date` (e.g.`recorded-date=[date]&recorded-date=[date]&...`)
* Including support for these `recorded-date` comparators: "gt", "lt", "ge", "le"
`GET [base]/Condition?patient={Patient/}[id]&recorded-date={gt|lt|ge|le}[dateTime]{&date={gt|lt|ge|le}[dateTime]&...}`Example:
> 
1. GET [base]/Condition?patient=Patient/1137192&recorded-date=ge2018-01-14

**Implementation Notes**: Fetches a bundle of all US Core Condition Encounter Diagnosis Profile resources for the specified patient and date. ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference) and [how to search by date](http://hl7.org/fhir/R4/search.html#date)).
1. **SHOULD** support searching using the combination of the [patient](SearchParameter-us-core-condition-patient.md) and [abatement-date](SearchParameter-us-core-condition-abatement-date.md) search parameters
* Including optional support for **AND** search on `abatement-date` (e.g.`abatement-date=[date]&abatement-date=[date]&...`)
* Including support for these `abatement-date` comparators: "gt", "lt", "ge", "le"
`GET [base]/Condition?patient={Patient/}[id]&abatement-date={gt|lt|ge|le}[dateTime]{&date={gt|lt|ge|le}[dateTime]&...}`Example:
> 
1. GET [base]/Condition?patient=Patient/1137192&abatement-date=ge2018-01-14

**Implementation Notes**: Fetches a bundle of all US Core Condition Encounter Diagnosis Profile resources for the specified patient and date. ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference) and [how to search by date](http://hl7.org/fhir/R4/search.html#date)).
1. **SHOULD** support searching using the combination of the [patient](SearchParameter-us-core-condition-patient.md) and [_lastUpdated](SearchParameter-us-core-condition-lastupdated.md) search parameters
* Including optional support for **AND** search on `_lastUpdated` (e.g.`_lastUpdated=[date]&_lastUpdated=[date]&...`)
* Including support for these `_lastUpdated` comparators: "gt", "lt", "ge", "le"
`GET [base]/Condition?patient={Patient/}[id]&_lastUpdated=[dateTime]`Example:
> 
1. GET [base]/Condition?patient=Patient/1032702&_lastUpdated=ge2024-01-01T00:00:00Z

**Implementation Notes**: Fetches a bundle of all resources for the specified for the specified patient and last updated date.. See the US Core General Guidance page for [Searching Using lastUpdated](general-guidance.md#searching-using-lastupdated). ( see [how to search by reference](http://hl7.org/fhir/R4/search.html#reference) and [how to search by date](http://hl7.org/fhir/R4/search.html#date)).



## Resource Content

```json
{
  "resourceType" : "StructureDefinition",
  "id" : "us-core-condition-encounter-diagnosis",
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
    "valueInteger" : 4
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "cgp"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "trial-use",
    "_valueCode" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/us/core/ImplementationGuide/hl7.fhir.us.core"
      }]
    }
  }],
  "url" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis",
  "identifier" : [{
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:oid:2.16.840.1.113883.4.642.40.2.42.17"
  }],
  "version" : "9.0.0",
  "name" : "USCoreConditionEncounterDiagnosisProfile",
  "title" : "US Core Condition Encounter Diagnosis Profile",
  "status" : "active",
  "experimental" : false,
  "date" : "2023-10-17",
  "publisher" : "HL7 International / Cross-Group Projects",
  "contact" : [{
    "name" : "HL7 International / Cross-Group Projects",
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/cgp"
    },
    {
      "system" : "email",
      "value" : "cgp@lists.HL7.org"
    }]
  }],
  "description" : "The US Core Condition Encounter Diagnosis Profile inherits from the FHIR [Condition](https://hl7.org/fhir/R4/condition.html) 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.",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "urn:iso:std:iso:3166",
      "code" : "US"
    }]
  }],
  "fhirVersion" : "4.0.1",
  "mapping" : [{
    "identity" : "workflow",
    "uri" : "http://hl7.org/fhir/workflow",
    "name" : "Workflow Pattern"
  },
  {
    "identity" : "sct-concept",
    "uri" : "http://snomed.info/conceptdomain",
    "name" : "SNOMED CT Concept Domain Binding"
  },
  {
    "identity" : "v2",
    "uri" : "http://hl7.org/v2",
    "name" : "HL7 v2 Mapping"
  },
  {
    "identity" : "rim",
    "uri" : "http://hl7.org/v3",
    "name" : "RIM Mapping"
  },
  {
    "identity" : "w5",
    "uri" : "http://hl7.org/fhir/fivews",
    "name" : "FiveWs Pattern Mapping"
  },
  {
    "identity" : "sct-attr",
    "uri" : "http://snomed.org/attributebinding",
    "name" : "SNOMED CT Attribute Binding"
  }],
  "kind" : "resource",
  "abstract" : false,
  "type" : "Condition",
  "baseDefinition" : "http://hl7.org/fhir/StructureDefinition/Condition",
  "derivation" : "constraint",
  "differential" : {
    "element" : [{
      "id" : "Condition",
      "path" : "Condition",
      "mustSupport" : false
    },
    {
      "id" : "Condition.category",
      "path" : "Condition.category",
      "slicing" : {
        "discriminator" : [{
          "type" : "value",
          "path" : "$this"
        }],
        "rules" : "open"
      },
      "short" : "category codes",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "Condition.category:us-core",
      "path" : "Condition.category",
      "sliceName" : "us-core",
      "short" : "encounter-diagnosis",
      "min" : 1,
      "max" : "1",
      "patternCodeableConcept" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
          "code" : "encounter-diagnosis"
        }]
      },
      "mustSupport" : true
    },
    {
      "id" : "Condition.code",
      "path" : "Condition.code",
      "min" : 1,
      "mustSupport" : true,
      "binding" : {
        "strength" : "extensible",
        "description" : "Valueset to describe the actual problem experienced by the patient",
        "valueSet" : "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code"
      }
    },
    {
      "id" : "Condition.subject",
      "path" : "Condition.subject",
      "type" : [{
        "code" : "Reference",
        "targetProfile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient",
        "http://hl7.org/fhir/StructureDefinition/Group"],
        "_targetProfile" : [{
          "extension" : [{
            "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support",
            "valueBoolean" : true
          }]
        },
        {
          "extension" : [{
            "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support",
            "valueBoolean" : false
          }]
        }]
      }],
      "mustSupport" : true
    },
    {
      "id" : "Condition.encounter",
      "path" : "Condition.encounter",
      "type" : [{
        "code" : "Reference",
        "targetProfile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "Condition.recordedDate",
      "path" : "Condition.recordedDate",
      "mustSupport" : true
    },
    {
      "id" : "Condition.recorder",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/core/StructureDefinition/uscdi-requirement",
        "valueBoolean" : true
      }],
      "path" : "Condition.recorder",
      "short" : "𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition",
      "type" : [{
        "code" : "Reference",
        "targetProfile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner",
        "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient",
        "http://hl7.org/fhir/StructureDefinition/PractitionerRole",
        "http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson"],
        "_targetProfile" : [{
          "extension" : [{
            "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support",
            "valueBoolean" : false
          }]
        },
        {
          "extension" : [{
            "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support",
            "valueBoolean" : false
          }]
        },
        {
          "extension" : [{
            "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support",
            "valueBoolean" : false
          }]
        },
        {
          "extension" : [{
            "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-type-must-support",
            "valueBoolean" : false
          }]
        }]
      }]
    }]
  }
}

```
