Guía de Implementación ''cl core'' FHIR R4, (Versión Evolutiva), published by HL7 Chile. This guide is not an authorized publication; it is the continuous build for version 1.9.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7Chile/clcore_ig/ and changes regularly. See the Directory of published versions

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Resource Profile: CL Condición-Diagnóstico

Condicion o Diagnósticos de Pacientes

Usage:

• Refer to this Resource Profile: CL Encuentro Clínico
• Examples for this Resource Profile: Condition/DiagnosticoEj and Condition/DiagnosticoEj2

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
clinicalStatus	S	0..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar
verificationStatus	S	0..1	CodeableConcept	Estado de verificación de la condición o diagnóstico: unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): Códigos definidos por estándar
code	S	0..1	CodeableConcept	Códigos de SOMED-CT y adicionales de ausente o desconocido Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido
subject	S	1..1	Reference(CL Paciente | Group)	Paciente sobre al que corresponde la condición.
reference	S	0..1	string	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
onset[x]	S	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime S
onsetPeriod			Period S
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status from the FHIR Standard
Condition.code	example	VSDiagnosticosSCT https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT from this IG

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
clinicalStatus	?!SΣC	0..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar
verificationStatus	?!SΣC	0..1	CodeableConcept	Estado de verificación de la condición o diagnóstico: unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): Códigos definidos por estándar
code	SΣ	0..1	CodeableConcept	Códigos de SOMED-CT y adicionales de ausente o desconocido Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido
subject	SΣ	1..1	Reference(CL Paciente | Group)	Paciente sobre al que corresponde la condición.
reference	SΣC	0..1	string	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
onset[x]	SΣ	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime
onsetPeriod			Period
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status from the FHIR Standard
Condition.code	example	VSDiagnosticosSCT https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT from this IG

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!SΣC	0..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar
verificationStatus	?!SΣC	0..1	CodeableConcept	Estado de verificación de la condición o diagnóstico: unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): Códigos definidos por estándar
category		0..*	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
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	0..1	CodeableConcept	Códigos de SOMED-CT y adicionales de ausente o desconocido Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	SΣ	1..1	Reference(CL Paciente | Group)	Paciente sobre al que corresponde la condición.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	0..1	string	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
onset[x]	SΣ	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime S
onsetPeriod			Period S
abatement[x]	C	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	Σ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Who recorded the condition
asserter	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Person who asserts this condition
stage	C	0..*	BackboneElement	Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
summary	C	0..1	CodeableConcept	Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment	C	0..*	Reference(ClinicalImpression | DiagnosticReport | Observation)	Formal record of assessment
type		0..1	CodeableConcept	Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
evidence	C	0..*	BackboneElement	Supporting evidence con-2: evidence SHALL have code or details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	ΣC	0..*	CodeableConcept	Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail	ΣC	0..*	Reference(Resource)	Supporting information found elsewhere
note		0..*	Annotation	Additional information about the Condition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status from the FHIR Standard
Condition.category	extensible	ConditionCategoryCodes http://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard
Condition.severity	preferred	Condition/DiagnosisSeverity http://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard
Condition.code	example	VSDiagnosticosSCT https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT from this IG
Condition.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Condition.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Condition.stage.summary	example	ConditionStage http://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard
Condition.stage.type	example	ConditionStageType http://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard
Condition.evidence.code	example	ManifestationAndSymptomCodes http://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard

This structure is derived from Condition

Summary

Must-Support: 6 elements

Structures

This structure refers to these other structures:

• CL Paciente (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CorePacienteCl)

Differential View

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
clinicalStatus	S	0..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar
verificationStatus	S	0..1	CodeableConcept	Estado de verificación de la condición o diagnóstico: unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): Códigos definidos por estándar
code	S	0..1	CodeableConcept	Códigos de SOMED-CT y adicionales de ausente o desconocido Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido
subject	S	1..1	Reference(CL Paciente | Group)	Paciente sobre al que corresponde la condición.
reference	S	0..1	string	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
onset[x]	S	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime S
onsetPeriod			Period S
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status from the FHIR Standard
Condition.code	example	VSDiagnosticosSCT https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
clinicalStatus	?!SΣC	0..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar
verificationStatus	?!SΣC	0..1	CodeableConcept	Estado de verificación de la condición o diagnóstico: unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): Códigos definidos por estándar
code	SΣ	0..1	CodeableConcept	Códigos de SOMED-CT y adicionales de ausente o desconocido Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido
subject	SΣ	1..1	Reference(CL Paciente | Group)	Paciente sobre al que corresponde la condición.
reference	SΣC	0..1	string	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
onset[x]	SΣ	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime
onsetPeriod			Period
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status from the FHIR Standard
Condition.code	example	VSDiagnosticosSCT https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!SΣC	0..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar
verificationStatus	?!SΣC	0..1	CodeableConcept	Estado de verificación de la condición o diagnóstico: unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): Códigos definidos por estándar
category		0..*	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
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	0..1	CodeableConcept	Códigos de SOMED-CT y adicionales de ausente o desconocido Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	SΣ	1..1	Reference(CL Paciente | Group)	Paciente sobre al que corresponde la condición.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	0..1	string	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
onset[x]	SΣ	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime S
onsetPeriod			Period S
abatement[x]	C	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	Σ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Who recorded the condition
asserter	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Person who asserts this condition
stage	C	0..*	BackboneElement	Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
summary	C	0..1	CodeableConcept	Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment	C	0..*	Reference(ClinicalImpression | DiagnosticReport | Observation)	Formal record of assessment
type		0..1	CodeableConcept	Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
evidence	C	0..*	BackboneElement	Supporting evidence con-2: evidence SHALL have code or details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	ΣC	0..*	CodeableConcept	Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail	ΣC	0..*	Reference(Resource)	Supporting information found elsewhere
note		0..*	Annotation	Additional information about the Condition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status from the FHIR Standard
Condition.category	extensible	ConditionCategoryCodes http://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard
Condition.severity	preferred	Condition/DiagnosisSeverity http://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard
Condition.code	example	VSDiagnosticosSCT https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT from this IG
Condition.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Condition.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Condition.stage.summary	example	ConditionStage http://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard
Condition.stage.type	example	ConditionStageType http://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard
Condition.evidence.code	example	ManifestationAndSymptomCodes http://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard

This structure is derived from Condition

Summary

Must-Support: 6 elements

Structures

This structure refers to these other structures:

• CL Paciente (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CorePacienteCl)

Other representations of profile: CSV, Excel, Schematron