De-Identification, Anonymization, Redaction Toolkit Services
0.1.0 - STU1 Release 1 - Standard for Trial-Use United States of America flag

De-Identification, Anonymization, Redaction Toolkit Services, published by HL7 International / Cross Group Projects. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-darts/ and changes regularly. See the Directory of published versions

Resource Profile: De-Identified UDS Plus Diagnosis

Official URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-diagnosis Version: 0.1.0
Standards status: Trial-use Maturity Level: 1 Computable Name: UDSPlusDiagnosis

The UDS+ profile is based on the Condition resource and establishes the core elements, extensions, vocabularies and value sets for representing Diagnosis for UDS+ program.

All canonical (Official) URLs will be changed in the future and are not available currently on the web.

Introduction

This profile is used to represent de-identified diagnosis information. The de-identification process has to remove all data elements not explicitly identified as "SUPPORTED" in the profile.

The HHS De-identification Guidance is to be followed to ensure appropriate level of de-identification is performed.

According to the HHS guidance, dates should not have a precision of more than the year. This means month and day cannot be included. This includes diagnosis dates, visit dates, onset dates etc.

In FHIR Resources, text elements and reference.display elements which provide human readable information to the providers may be generated using programs and tools from the data present within the resource. For e.g a Condition resource text element may contain information such as the visit date, onset date. This type of information will enable identification of the individuals. In order to avoid inadvertent revealing of PII/PHI, text elements cannot be included in the De-identified FHIR resource and the submission will be rejected when text elements are present by the validation process.

Ids and References

The original Condition resource id should not be included in the De-identified condition instance. Instead a new id should be created and provided as part of the FHIR resource. This Data Submitter should be capable of using the generated id to relink the data to the original Condition. All resource references to the Condition submitted as part of the UDS+ report should refer to newly generated id.

Resource references cannot contain text element as it may contain PHI/PII. The text element for following references are not allowed

  • subject
  • encounter

Date Truncation

The Data Submitter has to truncate the following dates to only have a precision of year

  • onsetDate
  • abatementDate
  • recordedDate

Examples

Examples of identifiable data and its corresponding de-identifiable data is present in Reporting Guidance.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition De-Identified UDS Plus Diagnosis
Constraints: con-3, con-4, con-5
... id SΣ 0..1 id The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... extension:assertedDate S 0..1 dateTime Date the allergy, intolerance, condition, problem, or diagnosis or other event, situation, issue, or clinical concept was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... clinicalStatus ?!SΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!SΣC 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.
... category S 1..1 CodeableConcept problem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who has the condition?
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
... Slices for onset[x] Σ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Estimated or actual date, date-time, or age
... Slices for abatement[x] C 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
.... abatement[x]:abatementDateTime SC 0..1 dateTime When in resolution/remission
... recordedDate SΣ 0..1 dateTime Date record was first recorded

doco 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.code Base extensible US Core Condition Codes 📦8.0.1 US Core v8.0

Constraints

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

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition 0..* Condition De-Identified UDS Plus Diagnosis
... id S 0..1 id The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver
... text 0..0 Cannot include any text in the resource as part of the de-identified data.
... contained 0..0 Cannot include any contained resources in the resource as part of the de-identified data.
.... extension:assertedDate S 0..1 dateTime Date the allergy, intolerance, condition, problem, or diagnosis or other event, situation, issue, or clinical concept was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... clinicalStatus S 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
.... text 0..0 Plain text representation of the concept
... verificationStatus S 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
.... text 0..0 Plain text representation of the concept
... category S 1..1 CodeableConcept problem-list-item | encounter-diagnosis
.... text 0..0 Plain text representation of the concept
... code S 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis
.... text 0..0 Plain text representation of the concept
... subject S 1..1 Reference(De-Identified UDS Plus Patient) Who has the condition?
.... display 0..0 Text alternative for the resource
... encounter S 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
.... display 0..0 Text alternative for the resource
... onsetDateTime S 0..1 dateTime Estimated or actual date, date-time, or age
... abatementDateTime S 0..1 dateTime When in resolution/remission
... recordedDate S 0..1 dateTime Date record was first recorded

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Condition.code Base extensible US Core Condition Codes 📦8.0.1 US Core v8.0
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition De-Identified UDS Plus Diagnosis
Constraints: con-3, con-4, con-5
... id SΣ 0..1 id The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:assertedDate S 0..1 dateTime Date the allergy, intolerance, condition, problem, or diagnosis or other event, situation, issue, or clinical concept was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Ids for this condition
... clinicalStatus ?!SΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... verificationStatus ?!SΣC 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.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... category S 1..1 CodeableConcept problem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... severity 0..1 CodeableConcept Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who has the condition?
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... Slices for onset[x] Σ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Estimated or actual date, date-time, or age
... Slices for abatement[x] C 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
.... abatement[x]:abatementDateTime SC 0..1 dateTime When in resolution/remission
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition
... stage C 0..* BackboneElement Stage/grade, usually assessed formally
Constraints: con-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 CodeableConcept Kind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code ΣC 0..* CodeableConcept Manifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco 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.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📦8.0.1 US Core v8.0
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Condition.subject.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Condition.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Condition.stage.summary Base example Condition Stage 📍4.0.1 FHIR Std.
Condition.stage.type Base example Condition Stage Type 📍4.0.1 FHIR Std.
Condition.evidence.code Base example Manifestation and Symptom Codes 📍4.0.1 FHIR Std.

Constraints

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

This structure is derived from Condition

Summary

Mandatory: 3 elements
Must-Support: 11 elements
Prohibited: 8 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Maturity: 1

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition De-Identified UDS Plus Diagnosis
Constraints: con-3, con-4, con-5
... id SΣ 0..1 id The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... extension:assertedDate S 0..1 dateTime Date the allergy, intolerance, condition, problem, or diagnosis or other event, situation, issue, or clinical concept was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... clinicalStatus ?!SΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!SΣC 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.
... category S 1..1 CodeableConcept problem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who has the condition?
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
... Slices for onset[x] Σ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Estimated or actual date, date-time, or age
... Slices for abatement[x] C 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
.... abatement[x]:abatementDateTime SC 0..1 dateTime When in resolution/remission
... recordedDate SΣ 0..1 dateTime Date record was first recorded

doco 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.code Base extensible US Core Condition Codes 📦8.0.1 US Core v8.0

Constraints

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

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition 0..* Condition De-Identified UDS Plus Diagnosis
... id S 0..1 id The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver
... text 0..0 Cannot include any text in the resource as part of the de-identified data.
... contained 0..0 Cannot include any contained resources in the resource as part of the de-identified data.
.... extension:assertedDate S 0..1 dateTime Date the allergy, intolerance, condition, problem, or diagnosis or other event, situation, issue, or clinical concept was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... clinicalStatus S 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
.... text 0..0 Plain text representation of the concept
... verificationStatus S 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
.... text 0..0 Plain text representation of the concept
... category S 1..1 CodeableConcept problem-list-item | encounter-diagnosis
.... text 0..0 Plain text representation of the concept
... code S 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis
.... text 0..0 Plain text representation of the concept
... subject S 1..1 Reference(De-Identified UDS Plus Patient) Who has the condition?
.... display 0..0 Text alternative for the resource
... encounter S 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
.... display 0..0 Text alternative for the resource
... onsetDateTime S 0..1 dateTime Estimated or actual date, date-time, or age
... abatementDateTime S 0..1 dateTime When in resolution/remission
... recordedDate S 0..1 dateTime Date record was first recorded

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Condition.code Base extensible US Core Condition Codes 📦8.0.1 US Core v8.0

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition De-Identified UDS Plus Diagnosis
Constraints: con-3, con-4, con-5
... id SΣ 0..1 id The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:assertedDate S 0..1 dateTime Date the allergy, intolerance, condition, problem, or diagnosis or other event, situation, issue, or clinical concept was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Ids for this condition
... clinicalStatus ?!SΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... verificationStatus ?!SΣC 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.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... category S 1..1 CodeableConcept problem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... severity 0..1 CodeableConcept Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who has the condition?
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... Slices for onset[x] Σ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Estimated or actual date, date-time, or age
... Slices for abatement[x] C 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
.... abatement[x]:abatementDateTime SC 0..1 dateTime When in resolution/remission
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition
... stage C 0..* BackboneElement Stage/grade, usually assessed formally
Constraints: con-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 CodeableConcept Kind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code ΣC 0..* CodeableConcept Manifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco 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.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📦8.0.1 US Core v8.0
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Condition.subject.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Condition.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Condition.stage.summary Base example Condition Stage 📍4.0.1 FHIR Std.
Condition.stage.type Base example Condition Stage Type 📍4.0.1 FHIR Std.
Condition.evidence.code Base example Manifestation and Symptom Codes 📍4.0.1 FHIR Std.

Constraints

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

This structure is derived from Condition

Summary

Mandatory: 3 elements
Must-Support: 11 elements
Prohibited: 8 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Maturity: 1

 

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