US Quality Core Implementation Guide
1.0.0-ballot - STU 1 - ballot United States of America flag

US Quality Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-quality-core/ and changes regularly. See the Directory of published versions

Resource Profile: US Quality Core Condition Encounter Diagnosis

Official URL: http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-condition-encounter-diagnosis Version: 1.0.0-ballot
Standards status: Trial-use Maturity Level: 4 Computable Name: USQualityCoreConditionEncounterDiagnosis
Other Identifiers: OID:2.16.840.1.113883.4.642.40.78.42.8

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

The US Quality Core Condition Encounter Diagnosis Profile is based upon the US Core Condition Encounter Diagnosis Profile. In version 5.0.0, the US Quality Core Condition Profile has been split into the US Quality Core Condition Encounter Diagnosis Profile and US Quality Core Condition Problems and Health Concerns Profile. To promote interoperability and adoption through consistent implementation, this profile defines constraints and extensions on the Condition resource for the minimal set of data to record, search, and retrieve information about an encounter diagnosis. It defines the core set of elements and extensions for quality rule and measure authors.

USCDI+ Quality Element Support Expectations

Systems are expected to support this profile as part of implementing USCDI+ Quality V2 in FHIR and meeting the conformance requirements of this guide.

The following elements are specifically relevant to USCDI+ Quality V2 data classes and elements. Systems are expected to support these elements as applicable to their role in US Quality Core data exchange. See the Must Support section of this guide for more information. These elements are flagged as (USCDI+ Quality) in the formal profile views.

USCDI+ Quality Elements:

Profile element Description USCDI+ Quality Data Element(s)
abatement[x] When in resolution/remission Problems: Date of Resolution
code Identification of the condition, problem or diagnosis Encounter Information: Encounter Diagnosis
encounter Encounter created as part of Encounter Information: Encounter Diagnosis
onset[x] Estimated or actual date, date-time, or age Problems: Date of Onset
recordedDate Date record was first recorded Problems: Date of Diagnosis
recorder Who recorded the condition Provenance: Author

Because this profile is derived directly or indirectly from US Core, systems are also expected to support the Must Support and Additional USCDI requirements specified by the US Core profile this profile inherits from. For more information about those requirements, refer to the US Core Condition Encounter Diagnosis Profile. The Formal Views section also provides the formal summary, definitions, terminology requirements, and mandatory element requirements.

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..* USCoreConditionEncounterDiagnosisProfile(9.0.0) Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:assertedDate S 0..1 dateTime Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... verificationStatus ?!ΣC 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.
... 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..1 CodeableConcept 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
... code SΣ 1..1 CodeableConcept (USCDI+ Quality) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
... subject SΣ 1..1 Reference(US Quality Core Patient S | Group) Who has the condition?
... encounter SΣ 0..1 Reference(US Quality Core Encounter) (USCDI+ Quality) Encounter created as part of
... onset[x] Σ 0..1 (USCDI+ Quality) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] C 0..1 (USCDI+ Quality) When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
... recordedDate SΣ 0..1 dateTime (USCDI+ Quality) Date record was first recorded
... recorder Σ 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile) (USCDI+ Quality) Who recorded the 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 extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📦9.0.0 US Core v9.0

Constraints

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition 0..* USCoreConditionEncounterDiagnosisProfile(9.0.0) Detailed information about conditions, problems or diagnoses
... 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
... category 1..* CodeableConcept category codes
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
... code 1..1 CodeableConcept (USCDI+ Quality) Identification of the condition, problem or diagnosis
... encounter 0..1 Reference(US Quality Core Encounter) (USCDI+ Quality) Encounter created as part of
... onset[x] 0..1 (USCDI+ Quality) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] 0..1 (USCDI+ Quality) When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
... recordedDate 0..1 dateTime (USCDI+ Quality) Date record was first recorded
... recorder 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile) (USCDI+ Quality) Who recorded the condition

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Condition.category Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile(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 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
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 ?!ΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!ΣC 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.
... 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..1 CodeableConcept 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+ Quality) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... subject SΣ 1..1 Reference(US Quality Core Patient S | Group) Who has the condition?
... encounter SΣ 0..1 Reference(US Quality Core Encounter) (USCDI+ Quality) Encounter created as part of
... onset[x] Σ 0..1 (USCDI+ Quality) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] C 0..1 (USCDI+ Quality) When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
... recordedDate SΣ 0..1 dateTime (USCDI+ Quality) Date record was first recorded
... recorder Σ 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile) (USCDI+ Quality) Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition
... stage C 0..* BackboneElement Stage/grade, usually assessed formally
Constraints: con-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 CodeableConcept Kind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code ΣC 0..* CodeableConcept Manifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Condition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
Condition.category:us-core Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📦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
con-1 error Condition.stage Stage SHALL have summary or assessment summary.exists() or assessment.exists()
con-2 error Condition.evidence evidence SHALL have code or details code.exists() or detail.exists()
con-3 best practice Condition Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4 error Condition If condition is abated, then clinicalStatus must be either inactive, resolved, or remission abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5 error Condition Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2 error Condition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Condition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Condition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Condition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Condition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile(9.0.0) Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:assertedDate S 0..1 dateTime Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... verificationStatus ?!ΣC 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.
... 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..1 CodeableConcept 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
... code SΣ 1..1 CodeableConcept (USCDI+ Quality) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
... subject SΣ 1..1 Reference(US Quality Core Patient S | Group) Who has the condition?
... encounter SΣ 0..1 Reference(US Quality Core Encounter) (USCDI+ Quality) Encounter created as part of
... onset[x] Σ 0..1 (USCDI+ Quality) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] C 0..1 (USCDI+ Quality) When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
... recordedDate SΣ 0..1 dateTime (USCDI+ Quality) Date record was first recorded
... recorder Σ 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile) (USCDI+ Quality) Who recorded the 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 extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📦9.0.0 US Core v9.0

Constraints

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

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition 0..* USCoreConditionEncounterDiagnosisProfile(9.0.0) Detailed information about conditions, problems or diagnoses
... 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
... category 1..* CodeableConcept category codes
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
... code 1..1 CodeableConcept (USCDI+ Quality) Identification of the condition, problem or diagnosis
... encounter 0..1 Reference(US Quality Core Encounter) (USCDI+ Quality) Encounter created as part of
... onset[x] 0..1 (USCDI+ Quality) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] 0..1 (USCDI+ Quality) When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
... recordedDate 0..1 dateTime (USCDI+ Quality) Date record was first recorded
... recorder 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile) (USCDI+ Quality) Who recorded the condition

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Condition.category Base extensible Condition Category Codes 📦4.0.1 FHIR Std.

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile(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 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
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 ?!ΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!ΣC 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.
... 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..1 CodeableConcept 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+ Quality) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... subject SΣ 1..1 Reference(US Quality Core Patient S | Group) Who has the condition?
... encounter SΣ 0..1 Reference(US Quality Core Encounter) (USCDI+ Quality) Encounter created as part of
... onset[x] Σ 0..1 (USCDI+ Quality) Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] C 0..1 (USCDI+ Quality) When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
... recordedDate SΣ 0..1 dateTime (USCDI+ Quality) Date record was first recorded
... recorder Σ 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile) (USCDI+ Quality) Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition
... stage C 0..* BackboneElement Stage/grade, usually assessed formally
Constraints: con-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 CodeableConcept Kind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code ΣC 0..* CodeableConcept Manifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Condition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
Condition.category:us-core Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📦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
con-1 error Condition.stage Stage SHALL have summary or assessment summary.exists() or assessment.exists()
con-2 error Condition.evidence evidence SHALL have code or details code.exists() or detail.exists()
con-3 best practice Condition Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4 error Condition If condition is abated, then clinicalStatus must be either inactive, resolved, or remission abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5 error Condition Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2 error Condition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Condition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Condition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Condition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Condition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Element Conformance Indicators by Profile Layer

Badges identify the profile layer where each conformance indicator is first introduced. Indicators introduced in an earlier layer remain applicable in later derived profiles.

Element conformance indicators organized by the profile layer where they are first introduced
Profile element FHIR US Core US Quality Core
extension:assertedDate Must Support
category Mandatory Must Support
category:us-core Mandatory Must Support
code Mandatory Must Support USCDI+ Quality
subject Mandatory Must Support
encounter Must Support USCDI+ Quality
onset[x] USCDI+ Quality
abatement[x] USCDI+ Quality
recordedDate Must Support USCDI+ Quality
recorder Additional USCDI USCDI+ Quality

Cardinality note: “Mandatory” means the element has a minimum cardinality greater than zero. For nested elements, the cardinality indicator applies when the containing element is present.

Mandatory US Quality Core Server Search Parameters

The searches below are the focused set identified by US Quality Core as needed to retrieve USCDI+ Quality data for quality measurement and reporting. See the US Core FHIR RESTful Search API Requirements for detailed information on requirements by search parameter type.

Because this profile derives directly or indirectly from US Core, servers SHALL also support all mandatory searches described in the US Core Server CapabilityStatement requirements for Condition. When possible, this guide reuses mandatory searches from US Core and notes them with the EXISTING US CORE REQUIREMENT flag. While US Quality Core may restate US Core requirements to highlight searches directly relevant to USCDI+ Quality data access, US Core requirements not restated here remain applicable.

See the US Quality Core Server CapabilityStatement for complete requirements for the underlying Condition resource and Search Requirement Selection for how this focused set was selected.

Servers supporting this profile SHALL support the following search parameters and search parameter combinations:

  1. SHALL support searching for all Condition resources for a patient using the patient search parameter. EXISTING US CORE REQUIREMENT

    GET [base]/Condition?patient={Patient/}[id]

    Example:

    GET [base]/Condition?patient=Patient/example

    Implementation Notes: Fetches a bundle of US Quality Core Condition Encounter Diagnosis resources matching the specified search criteria. See how to search by reference.

    Rationale for inclusion: Supports patient-scoped retrieval of Condition resources for USCDI+ Quality workflows.

  2. SHALL support searching for all Condition resources for a patient using the combination of the patient and category search parameters. EXISTING US CORE REQUIREMENT

    • Including optional support for OR search on category (e.g.category={system|}[search_code],{system|}[search_code],...).

    GET [base]/Condition?patient={Patient/}[id]&category={system|}[search_code]

    Example:

    GET [base]/Condition?patient=Patient/example&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis

    Implementation Notes: Fetches a bundle of US Quality Core Condition Encounter Diagnosis resources matching the specified search criteria. See how to search by reference and how to search by token.

    Rationale for inclusion: Supports patient-scoped retrieval of Condition resources filtered by category for USCDI+ Quality workflows.

  3. SHALL support searching for all Condition resources for a patient using the combination of the patient and code search parameters.

    • Including optional support for OR search on code (e.g.code={system|}[search_code],{system|}[search_code],...).

    GET [base]/Condition?patient={Patient/}[id]&code={system|}[search_code]

    Example:

    GET [base]/Condition?patient=Patient/example&code=http://snomed.info/sct|74400008

    Implementation Notes: Fetches a bundle of US Quality Core Condition Encounter Diagnosis resources matching the specified search criteria. See how to search by reference and how to search by token.

    Rationale for inclusion: Supports patient-scoped retrieval of Condition resources filtered by code for USCDI+ Quality workflows.