International Patient Access
1.1.0 - STU1 International flag

International Patient Access, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-ipa/ and changes regularly. See the Directory of published versions

Resource Profile: IPA-Condition

Official URL: http://hl7.org/fhir/uv/ipa/StructureDefinition/ipa-condition Version: 1.1.0
Standards status: Trial-use Computable Name: IPACondition

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

Minimum expectations for a Condition resource when accessed via an International Patient Access API. This profile communicates information about a patient's condition or diagnosis, such as recording primary and secondary diagnoses for encounters or justification for past medications. For the use of the condition resource to get a list of the patient's current problem list, use the IPA-Problem-List-Item profile instead. The difference between this profile and the IPA Problem List Item profile is that this profile does not specify or require a category.

Mandatory and Must Support Data Elements

The following data elements must always be present (in other words, mandatory resource properties where the minimum cardinality is 1) or must be supported (Must Support definition). Servers cannot restrict access to mandatory elements when authorizing an application. However, servers may choose to provide additional information or may be required to do so by national or other profiles that apply to the server's context.

Each Condition SHALL have:

  • a code identifying the condition, problem, or diagnosis
  • a patient

Applications must also support:

  • a clinical status
  • a verification status
  • one or more category codes used to group conditions

Profile Specific Implementation Rules and Guidance

Accessing Condition Resources

Clients can access a Condition resources using:

GET [url]/Condition/[id]

where id is found in some other resource that refers to a Condition. The result of this read is a Condition resource, or an error if there is no resource the client can access for that id. Alternatively, the client may search for condition resources.

Condition Codes

All Condition resources are required to have a code, but the coding systems used around the world and even within jurisdictions very wildly. This specification does not fix any kind of value set that controls what kind of codes can be used - other national specifications etc will place their own restrictions on the codes.

Client Applications should be prepared to encounter codes they do not recognize and handle the records accordingly. Servers SHOULD populate Condition.code.coding.display and/or Condition.code.text so that clients can always at least display the condition even if they do not know the codes that are used.

Clients should be careful making use of the code search parameter given that the codes used vary so much.

Safety Issues

  • Clients SHALL not treat all conditions as if they are part of the patient's current problem list
    • Note that some Condition resources may not have these status codes - this is usually due to poor record keeping reflected in legacy data
    • Servers SHOULD avoid leaving these status codes missing
  • Clients SHALL pay attention to the clinicalStatus and verificationStatus and display and process them correctly
  • Clients SHALL still work safely when the server does not support all the search parameters listed in the IPA Server Capability Statement. (see also Search advice)

Usage:

Formal Views of Profile Content

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

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..* Condition Detailed information about conditions, problems or diagnoses
... clinicalStatus SO 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
ObligationsActor
SHALL:populate-if-known Server
SHALL:handle Client
... verificationStatus SO 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
ObligationsActor
SHALL:populate-if-known Server
SHALL:handle Client
... category SO 0..* CodeableConcept problem-list-item | encounter-diagnosis
ObligationsActor
SHALL:populate-if-known Server
... subject SO 1..1 Reference(IPA-Patient) Who has the condition?
ObligationsActor
SHALL:populate-if-known Server

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... clinicalStatus ?!SOΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

ObligationsActor
SHALL:populate-if-known Server
SHALL:handle Client
... category SO 0..* CodeableConcept problem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


ObligationsActor
SHALL:populate-if-known Server
... code SOΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

ObligationsActor
SHALL:populate-if-known Server
SHOULD:handle Client
... subject SOΣ 1..1 Reference(IPA-Patient) Who has the condition?
ObligationsActor
SHALL:populate-if-known Server

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... id Σ 0..1 id 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
... 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 ?!SOΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

ObligationsActor
SHALL:populate-if-known Server
SHALL:handle Client
... verificationStatus ?!SOΣC 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.

ObligationsActor
SHALL:populate-if-known Server
SHALL:handle Client
... category SO 0..* CodeableConcept problem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


ObligationsActor
SHALL:populate-if-known Server
... 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 SOΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

ObligationsActor
SHALL:populate-if-known Server
SHOULD:handle Client
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SOΣ 1..1 Reference(IPA-Patient) Who has the condition?
ObligationsActor
SHALL:populate-if-known Server
... 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] C 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 C 0..* BackboneElement Stage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... 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
con-2: evidence SHALL have code or details
.... 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

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severitypreferredCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryexampleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

This structure is derived from Condition

Summary

Mandatory: 1 element
Must-Support: 5 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..* Condition Detailed information about conditions, problems or diagnoses
... clinicalStatus SO 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
ObligationsActor
SHALL:populate-if-known Server
SHALL:handle Client
... verificationStatus SO 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
ObligationsActor
SHALL:populate-if-known Server
SHALL:handle Client
... category SO 0..* CodeableConcept problem-list-item | encounter-diagnosis
ObligationsActor
SHALL:populate-if-known Server
... subject SO 1..1 Reference(IPA-Patient) Who has the condition?
ObligationsActor
SHALL:populate-if-known Server

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... clinicalStatus ?!SOΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

ObligationsActor
SHALL:populate-if-known Server
SHALL:handle Client
... category SO 0..* CodeableConcept problem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


ObligationsActor
SHALL:populate-if-known Server
... code SOΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

ObligationsActor
SHALL:populate-if-known Server
SHOULD:handle Client
... subject SOΣ 1..1 Reference(IPA-Patient) Who has the condition?
ObligationsActor
SHALL:populate-if-known Server

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... id Σ 0..1 id 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
... 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 ?!SOΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

ObligationsActor
SHALL:populate-if-known Server
SHALL:handle Client
... verificationStatus ?!SOΣC 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.

ObligationsActor
SHALL:populate-if-known Server
SHALL:handle Client
... category SO 0..* CodeableConcept problem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


ObligationsActor
SHALL:populate-if-known Server
... 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 SOΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.

ObligationsActor
SHALL:populate-if-known Server
SHOULD:handle Client
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SOΣ 1..1 Reference(IPA-Patient) Who has the condition?
ObligationsActor
SHALL:populate-if-known Server
... 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] C 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 C 0..* BackboneElement Stage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... 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
con-2: evidence SHALL have code or details
.... 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

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severitypreferredCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryexampleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

This structure is derived from Condition

Summary

Mandatory: 1 element
Must-Support: 5 elements

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron