US Core Maturity: 4

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 condition¹
3. a patient

Each Condition Must Support:

1. an encounter
2. date record was first recorded

Additional USCDI Requirements:

This Additional USCDI Requirements element is not Mandatory or Must Support but is required for ONC Health IT certification testing and is 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.
• 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.^§
  • When using ICD codes, only non-header ICD-10-CM codes SHOULD be used.^§
  • The US Core Condition Codes value set supports ICD-9-CM for historical purposes only.
• 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.

• ²The profile elements Condition.asserter and Condition.recorder communicate the individual level provenance author data corresponding to the U.S. Core Data for Interoperability (USCDI) Provenance Author Data Elements.

• For the USCDI Adverse Events Data Class, a change in a patient condition recorded as an encounter diagnosis can be what both USCDI Adverse Event Condition and Adverse Event Outcome describe. Adverse events are recorded as ordinary clinical events and are not tagged as adverse events; see the Adverse Events: Clinical Records and Patient Safety Reporting page.

Changes since version 9.0.0:

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
Condition.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Condition.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Condition.clinicalStatus	?! This element is a modifier element. Σ This element is included in summaries. C	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
Condition.verificationStatus	?! This element is a modifier element. Σ This element is included in summaries. C	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
Condition.Slices for category	S This element must be supported.	1..*	CodeableConcept	category codes Slice: Unordered, Open by value:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Condition.Slices for category.category:us-core	S This element must be supported.	1..1	CodeableConcept	encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/condition-category", "code" : "encounter-diagnosis" } ] }
Condition.code	S This element must be supported. Σ This element is included in summaries.	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
Condition.subject	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(US Core Patient Profile S This type must be supported. | Group)	Who has the condition?
Condition.encounter	S This element must be supported. Σ This element is included in summaries.	0..1	Reference(US Core Encounter Profile)	Encounter created as part of
Condition.recordedDate	S This element must be supported. Σ This element is included in summaries.	0..1	dateTime	Date record was first recorded
Condition.recorder	Σ This element is included in summaries.	0..1	Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Condition.clinicalStatus	Base	required	Condition Clinical Status Codes	📍4.0.1	FHIR Std.
Condition.verificationStatus	Base	required	ConditionVerificationStatus	📍4.0.1	FHIR Std.
Condition.category	Base	extensible	Condition Category Codes	📍4.0.1	FHIR Std.
Condition.category:us-core	Base	extensible	Condition Category Codes	📍4.0.1	FHIR Std.
Condition.code	Base	extensible	US Core Condition Codes	📦10.0.0-ballot	This IG

Constraints

Id

Grade

Path(s)

Description

Expression

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
Condition.Slices for category	S This element must be supported.	1..*	CodeableConcept	category codes Slice: Unordered, Open by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Condition.Slices for category.category:us-core	S This element must be supported.	1..1	CodeableConcept	encounter-diagnosis Required Pattern: { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/condition-category", "code" : "encounter-diagnosis" } ] }
Condition.code	S This element must be supported.	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
Condition.subject	S This element must be supported.	1..1	Reference(US Core Patient Profile S This type must be supported. | Group)	Who has the condition?
Condition.encounter	S This element must be supported.	0..1	Reference(US Core Encounter Profile)	Encounter created as part of
Condition.recordedDate	S This element must be supported.	0..1	dateTime	Date record was first recorded
Condition.recorder		0..1	Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
Condition.code	Base	extensible	US Core Condition Codes	📦10.0.0-ballot	This IG

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

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Condition.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
Condition.clinicalStatus	Base	required	Condition Clinical Status Codes	📍4.0.1	FHIR Std.
Condition.verificationStatus	Base	required	ConditionVerificationStatus	📍4.0.1	FHIR Std.
Condition.category	Base	extensible	Condition Category Codes	📍4.0.1	FHIR Std.
Condition.category:us-core	Base	extensible	Condition Category Codes	📍4.0.1	FHIR Std.
Condition.severity	Base	preferred	Condition/Diagnosis Severity	📍4.0.1	FHIR Std.
Condition.code	Base	extensible	US Core Condition Codes	📦10.0.0-ballot	This IG
Condition.bodySite	Base	example	SNOMED CT Body Structures	📍4.0.1	FHIR Std.
Condition.stage.summary	Base	example	Condition Stage	📍4.0.1	FHIR Std.
Condition.stage.type	Base	example	Condition Stage Type	📍4.0.1	FHIR Std.
Condition.evidence.code	Base	example	Manifestation and Symptom Codes	📍4.0.1	FHIR Std.

Constraints

Id

Grade

Path(s)

Description

Expression

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
Condition.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Condition.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Condition.clinicalStatus	?! This element is a modifier element. Σ This element is included in summaries. C	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
Condition.verificationStatus	?! This element is a modifier element. Σ This element is included in summaries. C	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
Condition.Slices for category	S This element must be supported.	1..*	CodeableConcept	category codes Slice: Unordered, Open by value:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Condition.Slices for category.category:us-core	S This element must be supported.	1..1	CodeableConcept	encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/condition-category", "code" : "encounter-diagnosis" } ] }
Condition.code	S This element must be supported. Σ This element is included in summaries.	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
Condition.subject	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(US Core Patient Profile S This type must be supported. | Group)	Who has the condition?
Condition.encounter	S This element must be supported. Σ This element is included in summaries.	0..1	Reference(US Core Encounter Profile)	Encounter created as part of
Condition.recordedDate	S This element must be supported. Σ This element is included in summaries.	0..1	dateTime	Date record was first recorded
Condition.recorder	Σ This element is included in summaries.	0..1	Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Condition.clinicalStatus	Base	required	Condition Clinical Status Codes	📍4.0.1	FHIR Std.
Condition.verificationStatus	Base	required	ConditionVerificationStatus	📍4.0.1	FHIR Std.
Condition.category	Base	extensible	Condition Category Codes	📍4.0.1	FHIR Std.
Condition.category:us-core	Base	extensible	Condition Category Codes	📍4.0.1	FHIR Std.
Condition.code	Base	extensible	US Core Condition Codes	📦10.0.0-ballot	This IG

Constraints

Id

Grade

Path(s)

Description

Expression

Differential View

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
Condition.Slices for category	S This element must be supported.	1..*	CodeableConcept	category codes Slice: Unordered, Open by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Condition.Slices for category.category:us-core	S This element must be supported.	1..1	CodeableConcept	encounter-diagnosis Required Pattern: { "coding" : [ { "system" : "http://terminology.hl7.org/CodeSystem/condition-category", "code" : "encounter-diagnosis" } ] }
Condition.code	S This element must be supported.	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
Condition.subject	S This element must be supported.	1..1	Reference(US Core Patient Profile S This type must be supported. | Group)	Who has the condition?
Condition.encounter	S This element must be supported.	0..1	Reference(US Core Encounter Profile)	Encounter created as part of
Condition.recordedDate	S This element must be supported.	0..1	dateTime	Date record was first recorded
Condition.recorder		0..1	Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
Condition.code	Base	extensible	US Core Condition Codes	📦10.0.0-ballot	This IG

Snapshot View

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

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Condition.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
Condition.clinicalStatus	Base	required	Condition Clinical Status Codes	📍4.0.1	FHIR Std.
Condition.verificationStatus	Base	required	ConditionVerificationStatus	📍4.0.1	FHIR Std.
Condition.category	Base	extensible	Condition Category Codes	📍4.0.1	FHIR Std.
Condition.category:us-core	Base	extensible	Condition Category Codes	📍4.0.1	FHIR Std.
Condition.severity	Base	preferred	Condition/Diagnosis Severity	📍4.0.1	FHIR Std.
Condition.code	Base	extensible	US Core Condition Codes	📦10.0.0-ballot	This IG
Condition.bodySite	Base	example	SNOMED CT Body Structures	📍4.0.1	FHIR Std.
Condition.stage.summary	Base	example	Condition Stage	📍4.0.1	FHIR Std.
Condition.stage.type	Base	example	Condition Stage Type	📍4.0.1	FHIR Std.
Condition.evidence.code	Base	example	Manifestation and Symptom Codes	📍4.0.1	FHIR Std.

Constraints

Id

Grade

Path(s)

Description

Expression

This structure is derived from Condition

Summary

Mandatory: 3 elements
Must-Support: 6 elements

Structures

This structure refers to these other structures:

• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)
• US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)
• US Core Practitioner Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner)
• US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Condition.category

Maturity: 5

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={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).

2. SHALL support searching using the combination of the patient and category 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 and how to search by 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 and clinical-status 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 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={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 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={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 and how to search by token).

4. SHOULD support searching using the combination of the patient and code 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 and how to search by token).

5. SHOULD support searching using the combination of the patient and onset-date 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 and how to search by date).

6. SHOULD support searching using the combination of the patient and asserted-date 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 and how to search by date).

7. SHOULD support searching using the combination of the patient and recorded-date 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 and how to search by date).

8. SHOULD support searching using the combination of the patient and abatement-date 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 and how to search by date).

9. SHOULD support searching using the combination of the patient and _lastUpdated 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. ( see how to search by reference and how to search by date).