Resumen Clínico del Paciente de Chile
0.4.0 - STU2 Chile flag

Resumen Clínico del Paciente de Chile, published by HL7 Chile. This guide is not an authorized publication; it is the continuous build for version 0.4.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7Chile/IPS-CL/ and changes regularly. See the Directory of published versions

Resource Profile: ConditionClIps - Detailed Descriptions

Page standards status: Draft Maturity Level: 1

Definitions for the Condition-cl-ips resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Condition
Definition

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

ShortDetailed information about conditions, problems or diagnoses
Control0..*
Is Modifierfalse
Summaryfalse
Invariantscon-3: 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($this='problem-list-item').empty())
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists())
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error (verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty())
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item (clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty())
con-4: 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: 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())
2. Condition.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. Condition.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. Condition.clinicalStatus
Definition

El estatus en el cual se encuentra la condición de un Paciente


The clinical status of the condition.

ShortConcepto que referencia a una terminología o un texto acordeactive | recurrence | relapse | inactive | remission | resolved
Comments

The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

Control0..1
This element is affected by the following invariants: con-3, con-4, con-5
BindingThe codes SHALL be taken from ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
(required to http://hl7.org/fhir/ValueSet/condition-clinical)

Códigos definidos por estándar


The clinical status of the condition or diagnosis.

TypeCodeableConcept(Codeable Concept (IPS))
Is Modifiertrue because This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Condition.verificationStatus
Definition

Estado de verificación de la condición o Diagnóstico


The verification status to support the clinical status of the condition.

ShortConcepto que referencia a una terminología o un texto acordeunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Comments

verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

Control0..1
This element is affected by the following invariants: con-3, con-5
BindingThe codes SHALL be taken from ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/condition-ver-status)

Códigos definidos por estándar


The verification status to support or decline the clinical status of the condition or diagnosis.

TypeCodeableConcept(Codeable Concept (IPS))
Is Modifiertrue because This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Condition.category
Definition

A category assigned to the condition.

ShortConcepto que referencia a una terminología o un texto acordeproblem-list-item | encounter-diagnosis
Comments

The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.

Control0..*
BindingUnless not suitable, these codes SHALL be taken from Problem Type - IPShttp://hl7.org/fhir/ValueSet/condition-category
(extensible to http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips)
TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Condition.severity
Definition

A subjective assessment of the severity of the condition as evaluated by the clinician.

ShortGrado de severidad del problemaSubjective severity of condition
Comments

Coding of the severity with a terminology is preferred, where possible.

Control0..1
BindingThe codes SHOULD be taken from Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity
(preferred to http://hl7.org/fhir/ValueSet/condition-severity)
TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. Condition.code
Definition

Identificación de la condición, el problema o el diagnóstico o registro del "problema ausente" o de los "problemas desconocidos".


Identification of the condition, problem or diagnosis.

ShortCódigo del problema clínicoIdentification of the condition, problem or diagnosis
Comments

Se agregan los códigos no conocido o no presente

Control10..1
BindingThe codes SHOULD be taken from For example codes, see Problems - IPShttp://hl7.org/fhir/ValueSet/condition-code
(preferred to http://hl7.org/fhir/uv/ips/ValueSet/problems-uv-ips)

Código para un problema clínico (o problema ausente/desconocido) que se selecciona de SNOMED CT.


Identification of the condition or diagnosis.

TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

0..1 to account for primarily narrative only resources.

Alternate Namestype
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. Condition.bodySite
Definition

The anatomical location where this condition manifests itself.

ShortUbicación del cuerpo donde se presenta el problemaAnatomical location, if relevant
Comments

Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension bodySite. May be a summary code, or a reference to a very precise definition of the location, or both.

Control0..*
BindingFor example codes, see SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site
(example to http://hl7.org/fhir/ValueSet/body-site)
TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. Condition.subject
Definition

Paciente sobre al que corresponde la condición.


Indicates the patient or group who the condition record is associated with.

ShortPaciente sobre al que corresponde la condición.Who has the condition?
Control1..1
TypeReference(Paciente, Patient, Group)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Group is typically used for veterinary or public health use cases.

Alternate Namespatient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Condition.subject.reference
Definition

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

ShortReferencia al recurso del Paciente al cual se indica el diagnóstico o condiciónLiteral reference, Relative, internal or absolute URL
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Control10..1
This element is affected by the following invariants: ref-1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. Condition.onset[x]
Definition

Fecha o rango de fechas en que se definió el diagnóstico o se determinó la condición


Estimated or actual date or date-time the condition began, in the opinion of the clinician.

ShortFecha, fecha y hora estimada o real.Estimated or actual date, date-time, or age
Comments

Age is generally used when the patient reports an age at which the Condition began to occur.

Control0..1
TypeChoice of: dateTime, Period, string, Range, Age
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesdateTime
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))