PACIO Personal Functioning and Engagement Implementation Guide
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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 3.0.0-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 Problems and Health Concerns Profile

Official URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/pfe-condition-problems-health-concerns Version: 3.0.0-ballot
Standards status: Trial-use Maturity Level: 3 Computable Name: PFEConditionProblemsHealthConcerns
Other Identifiers: OID:2.16.840.1.113883.4.642.40.67.42.6

An exchange of post-acute care condition, problem, or health concern for a patient. This profile is used for exchanging a problem list item or a health concern.

Scope and Usage

Purpose of the resource

The purpose of the Personal Functioning and Engagement Condition Problems and Health Concerns Profile is to facilitate exchange between post-acute care and other health care settings of a personal functioning and engagement related to a patient’s problem list item or condition, problem, or health concern. For this profile, post-acute care is defined as “care that is provided to individuals who need additional help recuperating from an acute illness or serious medical procedure” cite; personal functioning and engagement relates to a person’s functioning in terms of body functions, activities, and participation cite.

What is in this resource

The Personal Functioning and Engagement Condition Problems and Health Concerns Profile includes data elements regarding:

  • A description of the condition/problem/concern, its anatomical location (if relevant), the date it emerged and (if resolved) abated, and its current clinical status (e.g., active, recurrence, resolved) and verification status (e.g., confirmed, provisional, refuted),
  • The categorization of the condition/problem/concern
  • The categorization of an assessment or health status of the condition/problem/concern using US Core Screening Assessment Condition codes.

Intended audience and setting for the resource

This resource has been developed for anyone involved with identifying personal functioning and engagement conditions, problems, or health concerns of a post-acute care patients, such as healthcare providers (e.g., physicians, nurse practitioners, physical therapists), the patient themselves, or a patient's family member. It accommodates various types of healthcare providers and non-providers (e.g., the patient). It was also developed for EHR implementers. The profile was developed for post-acute care settings, such as skilled nursing facilities and home health, and can also be used in acute care settings.

What the resource can be used for

This resource can be used by post-acute care facilities, as well as acute care hospitals, to support documentation of information regarding a post-acute care patient's condition, problem, or health concern related to their personal functioning and engagement.

Example of the Problems/Concerns resource supporting documentation of a physical therapist’s concern about the gait of a patient they are supporting in a rehabilitation facility which has implemented the resource into their electronic health record (EHR):

During a routine session, a physical therapist supporting a patient receiving post-stroke rehabilitation notices that the patient’s gait is unsteady compared to the previous session. The physical therapist completes a gait assessment and finds, when reviewing the results from a previous assessment 2 weeks prior, that the patient’s gait is unsteady. The physical therapist uses the EHR, which has fields for entering data elements for Problems/Concerns, to document this problem and their concerns about the patient’s fall risk so that the patient’s care team is alerted to this change in status.

How this resource was developed

The Personal Functioning and Engagement Condition Problems and Health Concerns Profile was developed by the Personal Functioning and Engagement subgroup of the Post-Acute Care InterOperability (PACIO) project. The subgroup contained experts in: supporting patients’ nutrition and diet (e.g., physical therapists, speech language pathologists), EHR implementation and interoperability, HL7 FHIR, and user-centered design. PACIO is sponsored by the US Centers for Medicare and Medicaid Services (CMS) and by the MITRE Corporation.

Boundaries and Relationships

Within boundaries/scope of the resource

The scope of the Personal Functioning and Engagement Condition Problems and Health Concerns Profile encompasses a post-acute care patient's condition, problem, or health concern related to their personal functioning and engagement.

Other resources that address related content outside the boundaries/scope of this resource

Beginning in U.S. Core version 5.0.0, The US Core Condition Profile has been split into the US Core Condition Encounter Diagnosis profile and US Core Condition Problems and Health Concerns profile. The Personal Functioning and Engagement implementation guide includes PFE-specific profiles of both of these U.S. Core Condition-based profiles.

Relationship to other resources

This profile is derived from the US Core Condition Problems and Health Concerns. Within the Personal Functioning and Engagement Condition Problems and Health Concerns Profile, the asserter data element has been elevated to must support. This data element is a reference to an instance of Practitioner, PractitionerRole, Patient, or RelatedPerson. In addition, the US Core Encounter profile may reference a Personal Functioning and Engagement Condition Problems and Health Concerns Profile via its diagnosis data element.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* USCoreConditionProblemsHealthConcernsProfile(9.0.0) Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... meta SΣ 0..1 Meta Metadata about the resource
.... lastUpdated SΣ 0..1 instant When the resource last changed
... 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 condition 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)
... verificationStatus ?!SΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by value:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... category:us-core S 1..* CodeableConcept problem-list-item | health-concern
Binding: USCoreProblemOrHealthConcern (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
.... category:screening-assessment S 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: USCDI Health Status/Assessments Data Class
Binding: USCoreSimpleObservationCategory (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
Additional BindingsPurposeDocumentation
USCoreScreeningAssessmentConditionCategory (9.0.0) Min Binding
Certifying Systems must support a category of "sdoh".

... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: USCoreConditionCodes (9.0.0) (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(9.0.0) S | Group) Who has the condition?
... onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] SC 0..1 When in resolution/remission
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate SΣ 0..1 dateTime 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

Path Status Usage ValueSet Version Source
Condition.clinicalStatus Base required Condition Clinical Status Codes 📦4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📦4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.category:us-core Base required US Core Problem or Health Concern 📍9.0.0 US Core v9.0
Condition.category:screening-assessment Base required US Core Simple Observation Category 📍9.0.0 US Core v9.0
Condition.code Base extensible US Core Condition Codes 📍9.0.0 US Core v9.0
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition 0..* USCoreConditionProblemsHealthConcernsProfile(9.0.0) Detailed information about conditions, problems or diagnoses
... Slices for category Content/Rules for all slices
.... category:screening-assessment S 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: USCDI Health Status/Assessments Data Class
... 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 & Constraints    Filter: Filtersdoco
.. Condition C 0..* USCoreConditionProblemsHealthConcernsProfile(9.0.0) Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 0..1 instant When the resource last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:assertedDate S 0..1 dateTime 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 active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by value:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... category:us-core S 1..* CodeableConcept problem-list-item | health-concern
Binding: USCoreProblemOrHealthConcern (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
.... category:screening-assessment S 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: USCDI Health Status/Assessments Data Class
Binding: USCoreSimpleObservationCategory (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
Additional BindingsPurposeDocumentation
USCoreScreeningAssessmentConditionCategory (9.0.0) Min Binding
Certifying Systems must support a category of "sdoh".

... 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: USCoreConditionCodes (9.0.0) (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(9.0.0) S | Group) Who has the condition?
... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
... onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] SC 0..1 When in resolution/remission
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder Σ 0..1 Reference(US Core Practitioner Profile(9.0.0) | US Core Patient Profile(9.0.0) | PractitionerRole | US Core RelatedPerson Profile(9.0.0)) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: 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
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.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Condition.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Condition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Condition.clinicalStatus Base required Condition Clinical Status Codes 📦4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📦4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.category:us-core Base required US Core Problem or Health Concern 📍9.0.0 US Core v9.0
Condition.category:screening-assessment Base required US Core Simple Observation Category 📍9.0.0 US Core v9.0
Condition.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📍9.0.0 US Core v9.0
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Condition.stage.summary Base example Condition Stage 📍4.0.1 FHIR Std.
Condition.stage.type Base example Condition Stage Type 📍4.0.1 FHIR Std.
Condition.evidence.code Base example Manifestation and Symptom Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression

Summary

Must-Support: 3 elements

Maturity: 3

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* USCoreConditionProblemsHealthConcernsProfile(9.0.0) Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... meta SΣ 0..1 Meta Metadata about the resource
.... lastUpdated SΣ 0..1 instant When the resource last changed
... 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 condition 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)
... verificationStatus ?!SΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by value:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... category:us-core S 1..* CodeableConcept problem-list-item | health-concern
Binding: USCoreProblemOrHealthConcern (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
.... category:screening-assessment S 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: USCDI Health Status/Assessments Data Class
Binding: USCoreSimpleObservationCategory (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
Additional BindingsPurposeDocumentation
USCoreScreeningAssessmentConditionCategory (9.0.0) Min Binding
Certifying Systems must support a category of "sdoh".

... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: USCoreConditionCodes (9.0.0) (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(9.0.0) S | Group) Who has the condition?
... onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] SC 0..1 When in resolution/remission
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate SΣ 0..1 dateTime 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

Path Status Usage ValueSet Version Source
Condition.clinicalStatus Base required Condition Clinical Status Codes 📦4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📦4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.category:us-core Base required US Core Problem or Health Concern 📍9.0.0 US Core v9.0
Condition.category:screening-assessment Base required US Core Simple Observation Category 📍9.0.0 US Core v9.0
Condition.code Base extensible US Core Condition Codes 📍9.0.0 US Core v9.0
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition 0..* USCoreConditionProblemsHealthConcernsProfile(9.0.0) Detailed information about conditions, problems or diagnoses
... Slices for category Content/Rules for all slices
.... category:screening-assessment S 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: USCDI Health Status/Assessments Data Class
... 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

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* USCoreConditionProblemsHealthConcernsProfile(9.0.0) Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 0..1 instant When the resource last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:assertedDate S 0..1 dateTime 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 active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by value:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... category:us-core S 1..* CodeableConcept problem-list-item | health-concern
Binding: USCoreProblemOrHealthConcern (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
.... category:screening-assessment S 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: USCDI Health Status/Assessments Data Class
Binding: USCoreSimpleObservationCategory (9.0.0) (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
Additional BindingsPurposeDocumentation
USCoreScreeningAssessmentConditionCategory (9.0.0) Min Binding
Certifying Systems must support a category of "sdoh".

... 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: USCoreConditionCodes (9.0.0) (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(9.0.0) S | Group) Who has the condition?
... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
... onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] SC 0..1 When in resolution/remission
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder Σ 0..1 Reference(US Core Practitioner Profile(9.0.0) | US Core Patient Profile(9.0.0) | PractitionerRole | US Core RelatedPerson Profile(9.0.0)) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: 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
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.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Condition.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Condition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Condition.clinicalStatus Base required Condition Clinical Status Codes 📦4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📦4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.category:us-core Base required US Core Problem or Health Concern 📍9.0.0 US Core v9.0
Condition.category:screening-assessment Base required US Core Simple Observation Category 📍9.0.0 US Core v9.0
Condition.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📍9.0.0 US Core v9.0
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Condition.stage.summary Base example Condition Stage 📍4.0.1 FHIR Std.
Condition.stage.type Base example Condition Stage Type 📍4.0.1 FHIR Std.
Condition.evidence.code Base example Manifestation and Symptom Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression

Summary

Must-Support: 3 elements

Maturity: 3

 

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