HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1
0.1.0 - STU 1 Ballot

HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1, published by HL7 International - Patient Care WG. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/fhir-eyecare-ig/ and changes regularly. See the Directory of published versions

## Resource Profile: Ophthalmic Diagnoses

Defining URL: | http://hl7.org/fhir/uv/eyecare/StructureDefinition/condition-base
Version: | 0.1.0
Name: | ConditionBase
Title: | Ophthalmic Diagnoses
Status: | Draft as of 2022-06-24 01:58:09+0000
Definition: | A profile to describe the formal past/present clinical diagnosis of a specific non-ophthalmic pathological Condition. As noted above, although the Condition Resource is also referenced in the non-ophthalmic findings profile, this profile is a modification of the base Condition Resource (as opposed to a base Obervation Resource modification, referencing Condition).
Publisher: | HL7 International - Patient Care WG
Source Resource: | XML / JSON / Turtle

The official URL for this profile is:

    http://hl7.org/fhir/uv/eyecare/StructureDefinition/condition-base

### Formal Views of Profile Content

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

- Text Summary
- Differential Table
- Snapshot Table
- Snapshot Table (Must Support)
- All

This structure is derived from Condition

Summary

Mandatory: 1 element
Must-Support: 5 elements

Structures

This structure refers to these other structures:

- Ocular anatomical location (http://hl7.org/fhir/uv/eyecare/StructureDefinition/body-structure-eye)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/bodySite

This structure is derived from Condition

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Condition |  | 0..* | Condition | Detailed information about conditions, problems or diagnoses
code | S | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Ophthalmology Condition ICD10 and SNOMED codes ValueSet (preferred)
bodySite | S | 0..* | CodeableConcept | Anatomical location, if relevant
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
bodySite | S | 0..* | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
value[x] | S | 1..1 | Reference(BodyStructure | Ocular anatomical location) | Value of extension
subject | S | 1..1 | Reference(Patient | Group) | Who has the condition?
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Condition | I | 0..* | Condition | Detailed information about conditions, problems or diagnoses
id | Σ | 0..1 | string | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | External Ids for this condition
clinicalStatus | ?!Σ I | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!Σ I | 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 |  | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the 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.
code | S Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Ophthalmology Condition ICD10 and SNOMED codes ValueSet (preferred)
bodySite | S Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
bodySite | S | 0..* | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/bodySite"
value[x] | S | 1..1 | Reference(BodyStructure | Ocular anatomical location) | Value of extension
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
subject | S Σ | 1..1 | Reference(Patient | Group) | Who has the condition?
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of
onset[x] | Σ | 0..1 |  | Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
onsetString |  |  | string |
abatement[x] | I | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
abatementString |  |  | string |
recordedDate | Σ | 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 | I | 0..* | BackboneElement | Stage/grade, usually assessed formally
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 | I | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment | I | 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 | I | 0..* | BackboneElement | Supporting evidence
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 | Σ I | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ I | 0..* | Reference(Resource) | Supporting information found elsewhere
note |  | 0..* | Annotation | Additional information about the Condition
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Condition | I | 0..* | Condition | Detailed information about conditions, problems or diagnoses
code | Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Ophthalmology Condition ICD10 and SNOMED codes ValueSet (preferred)
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
bodySite |  | 0..* | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
value[x] |  | 1..1 | Reference(BodyStructure | Ocular anatomical location) | Value of extension
subject | Σ | 1..1 | Reference(Patient | Group) | Who has the condition?
Documentation for this format

This structure is derived from Condition

Summary

Mandatory: 1 element
Must-Support: 5 elements

Structures

This structure refers to these other structures:

- Ocular anatomical location (http://hl7.org/fhir/uv/eyecare/StructureDefinition/body-structure-eye)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/bodySite

Differential View

This structure is derived from Condition

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Condition |  | 0..* | Condition | Detailed information about conditions, problems or diagnoses
code | S | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Ophthalmology Condition ICD10 and SNOMED codes ValueSet (preferred)
bodySite | S | 0..* | CodeableConcept | Anatomical location, if relevant
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
bodySite | S | 0..* | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
value[x] | S | 1..1 | Reference(BodyStructure | Ocular anatomical location) | Value of extension
subject | S | 1..1 | Reference(Patient | Group) | Who has the condition?
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Condition | I | 0..* | Condition | Detailed information about conditions, problems or diagnoses
id | Σ | 0..1 | string | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | External Ids for this condition
clinicalStatus | ?!Σ I | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!Σ I | 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 |  | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the 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.
code | S Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Ophthalmology Condition ICD10 and SNOMED codes ValueSet (preferred)
bodySite | S Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
bodySite | S | 0..* | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/bodySite"
value[x] | S | 1..1 | Reference(BodyStructure | Ocular anatomical location) | Value of extension
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
subject | S Σ | 1..1 | Reference(Patient | Group) | Who has the condition?
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of
onset[x] | Σ | 0..1 |  | Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
onsetString |  |  | string |
abatement[x] | I | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
abatementString |  |  | string |
recordedDate | Σ | 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 | I | 0..* | BackboneElement | Stage/grade, usually assessed formally
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 | I | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment | I | 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 | I | 0..* | BackboneElement | Supporting evidence
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 | Σ I | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail | Σ I | 0..* | Reference(Resource) | Supporting information found elsewhere
note |  | 0..* | Annotation | Additional information about the Condition
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

#### Terminology Bindings

Path | Conformance | ValueSet
Condition.language | preferred | CommonLanguages Max Binding: AllLanguages
Condition.clinicalStatus | required | ConditionClinicalStatusCodes
Condition.verificationStatus | required | ConditionVerificationStatus
Condition.category | extensible | ConditionCategoryCodes
Condition.severity | preferred | Condition/DiagnosisSeverity
Condition.code | preferred | OphthalmologyConditionCodesValueSet
Condition.bodySite | example | SNOMEDCTBodyStructures
Condition.stage.summary | example | ConditionStage
Condition.stage.type | example | ConditionStageType
Condition.evidence.code | example | ManifestationAndSymptomCodes

#### Constraints

Id | Grade | Path | Details | Requirements
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 | Condition.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Condition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Condition.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Condition.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Condition.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.clinicalStatus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.verificationStatus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.severity | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.bodySite | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.bodySite.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Condition.bodySite.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Condition.bodySite.extension:bodySiteEye | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Condition.bodySite.extension:bodySiteEye | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Condition.bodySite.extension:bodySiteEye.value[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.bodySite.coding | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.bodySite.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.onset[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.abatement[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.recordedDate | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.recorder | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.asserter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() |
ele-1 | error | Condition.stage | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.stage.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Condition.stage.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Condition.stage.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Condition.stage.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Condition.stage.summary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.stage.assessment | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.stage.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() |
ele-1 | error | Condition.evidence | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.evidence.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Condition.evidence.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Condition.evidence.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Condition.evidence.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Condition.evidence.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.evidence.detail | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Condition.note | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |