PACIO Personal Functioning and Engagement Implementation Guide
2.0.0-ballot - STU2 Ballot United States of America flag

PACIO Personal Functioning and Engagement Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-pfe/ and changes regularly. See the Directory of published versions

Resource Profile: Personal Functioning and Engagement Condition Encounter Diagnosis Profile

Official URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/pfe-condition-encounter-diagnosis Version: 2.0.0-ballot
Active as of 2024-08-13 Computable Name: PFEConditionEncounterDiagnosis

An exchange of post-acute care condition encounter diagnosis for a patient. This profile is used for exchanging a condition encounter diagnosis.

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreConditionEncounterDiagnosisProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..* USCoreConditionEncounterDiagnosisProfile Detailed information about conditions, problems or diagnoses
... bodySite S 0..* CodeableConcept Anatomical location, if relevant
... asserter S 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile 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
... Slices for extension Content/Rules for all slices
.... assertedDate S 0..1 dateTime (USCDI) Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... verificationStatus ?!SΣC 0..1 CodeableConcept (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept (USCDI) category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:us-core S 1..1 CodeableConcept (USCDI) encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
... code SΣ 1..1 CodeableConcept (USCDI) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

... bodySite SΣ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who has the condition?
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Encounter created as part of
... onset[x] SΣ 0..1 (USCDI) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
... abatement[x] SC 0..1 (USCDI) When in resolution/remission
.... abatementDateTime dateTime
... recordedDate SΣ 0..1 dateTime (USCDI) Date record was first recorded
... asserter SΣ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.codeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile 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
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... assertedDate S 0..1 dateTime (USCDI) Date the condition 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 (USCDI) active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC 0..1 CodeableConcept (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept (USCDI) category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:us-core S 1..1 CodeableConcept (USCDI) encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... 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 (USCDI) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

... bodySite SΣ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who has the condition?
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Encounter created as part of
... onset[x] SΣ 0..1 (USCDI) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] SC 0..1 (USCDI) When in resolution/remission
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate SΣ 0..1 dateTime (USCDI) Date record was first recorded
... recorder Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the condition
... asserter SΣ 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

PathConformanceValueSet / CodeURI
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
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
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.codeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
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 USCoreConditionEncounterDiagnosisProfile

Summary

Must-Support: 2 elements

Differential View

This structure is derived from USCoreConditionEncounterDiagnosisProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..* USCoreConditionEncounterDiagnosisProfile Detailed information about conditions, problems or diagnoses
... bodySite S 0..* CodeableConcept Anatomical location, if relevant
... asserter S 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile 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
... Slices for extension Content/Rules for all slices
.... assertedDate S 0..1 dateTime (USCDI) Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... verificationStatus ?!SΣC 0..1 CodeableConcept (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept (USCDI) category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:us-core S 1..1 CodeableConcept (USCDI) encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
... code SΣ 1..1 CodeableConcept (USCDI) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

... bodySite SΣ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who has the condition?
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Encounter created as part of
... onset[x] SΣ 0..1 (USCDI) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
... abatement[x] SC 0..1 (USCDI) When in resolution/remission
.... abatementDateTime dateTime
... recordedDate SΣ 0..1 dateTime (USCDI) Date record was first recorded
... asserter SΣ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.codeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile 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
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... assertedDate S 0..1 dateTime (USCDI) Date the condition 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 (USCDI) active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC 0..1 CodeableConcept (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept (USCDI) category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:us-core S 1..1 CodeableConcept (USCDI) encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... 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 (USCDI) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

... bodySite SΣ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) Who has the condition?
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Encounter created as part of
... onset[x] SΣ 0..1 (USCDI) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] SC 0..1 (USCDI) When in resolution/remission
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate SΣ 0..1 dateTime (USCDI) Date record was first recorded
... recorder Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the condition
... asserter SΣ 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

PathConformanceValueSet / CodeURI
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
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
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.codeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
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 USCoreConditionEncounterDiagnosisProfile

Summary

Must-Support: 2 elements

 

Other representations of profile: CSV, Excel, Schematron