UV_Vital Records Birth and Fetal Death Reporting
1.1.0 - STU 1.1 International flag

UV_Vital Records Birth and Fetal Death Reporting, published by IHE International. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/fhir-bfdr/ and changes regularly. See the Directory of published versions

Resource Profile: ConditionPerinealLaceration - Detailed Descriptions

Active as of 2024-07-09

Definitions for the Condition-perineal-laceration resource profile.

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

0. Condition
ShortThis Condition profile indicates a maternal morbidity of perineal laceration.
2. Condition.code
ShortPerineal laceration during delivery (disorder)
Pattern Value{
  "coding" : [{
    "system" : "http://snomed.info/sct",
    "code" : "398019008"
  }]
}
4. Condition.subject
TypeReference(Patient - Mother - Vital Records)

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.

ShortThis Condition profile indicates a maternal morbidity of perineal laceration.Detailed information about conditions, problems or diagnoses
Comments

-

Control0..*
Is Modifierfalse
Must Supportfalse
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.extension:assertedDate
Slice NameassertedDate
Definition

The date on which the existence of the Condition was first asserted or acknowledged.

ShortDate the condition was first asserted
Comments

The assertedDate is in the context of the recording practitioner and might not be the same as the recordedDate.

Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(Condition Asserted Date) (Extension Type: dateTime)
Is Modifierfalse
Must Supporttrue
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())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. 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())
8. Condition.clinicalStatus
Definition

The clinical status of the condition.

Shortactive | 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)
TypeCodeableConcept
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()))
10. Condition.verificationStatus
Definition

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

Shortunconfirmed | 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)
TypeCodeableConcept
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()))
12. Condition.category
Definition

A category assigned to the condition.

Shortcategory codesproblem-list-item | encounter-diagnosis
Comments

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

Control10..*
BindingUnless not suitable, these codes SHALL be taken from ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category
(extensible to http://hl7.org/fhir/ValueSet/condition-category)

A category assigned to the condition.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Condition.category. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
  • 14. Condition.category:us-core
    Slice Nameus-core
    Definition

    A category assigned to the condition.

    Shortproblem-list-item | health-concernproblem-list-item | encounter-diagnosis
    Comments

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

    Control10..*
    BindingThe codes SHALL be taken from Unless not suitable, these codes SHALL be taken from US Core Problem or Health Concernhttp://hl7.org/fhir/ValueSet/condition-category
    (required to http://hl7.org/fhir/us/core/ValueSet/us-core-problem-or-health-concern)
    TypeCodeableConcept
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    16. Condition.category:sdoh
    Slice Namesdoh
    Definition

    A category assigned to the condition.

    Shortproblem-list-item | encounter-diagnosis
    Comments

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

    Control0..1*
    BindingUnless not suitable, these codes SHALL be taken from ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category
    (extensible to http://hl7.org/fhir/ValueSet/condition-category)

    A category assigned to the condition.

    TypeCodeableConcept
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Pattern Value{
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-tags",
        "code" : "sdoh"
      }]
    }
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    18. Condition.code
    Definition

    Identification of the condition, problem or diagnosis.

    ShortPerineal laceration during delivery (disorder)Identification of the condition, problem or diagnosis
    Control10..1
    BindingUnless not suitable, these codes SHALL be taken from For example codes, see US Core Condition Codeshttp://hl7.org/fhir/ValueSet/condition-code
    (extensible to http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code)

    Valueset to describe the actual problem experienced by the patient


    Identification of the condition or diagnosis.

    TypeCodeableConcept
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

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

    Alternate Namestype
    Pattern Value{
      "coding" : [{
        "system" : "http://snomed.info/sct",
        "code" : "398019008"
      }]
    }
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    20. Condition.subject
    Definition

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

    ShortWho has the condition?
    Control1..1
    TypeReference(Patient - Mother - Vital Records, 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()))
    22. Condition.onset[x]
    Definition

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

    ShortEstimated 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, Age, Period, Range, string
    [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()))
    24. Condition.abatement[x]
    Definition

    The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate.

    ShortWhen in resolution/remission
    Comments

    There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.

    Control0..1
    This element is affected by the following invariants: con-4
    TypeChoice of: dateTime, Age, Period, Range, string
    [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
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    26. Condition.recordedDate
    Definition

    The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.

    ShortDate record was first recorded
    Control0..1
    TypedateTime
    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()))

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

    0. Condition
    Definition

    -

    ShortThis Condition profile indicates a maternal morbidity of perineal laceration.
    Comments

    -

    Control0..*
    Is Modifierfalse
    Must Supportfalse
    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())
    2. Condition.id
    Definition

    The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

    ShortLogical id of this artifact
    Comments

    The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

    Control0..1
    Typeid
    Is Modifierfalse
    Summarytrue
    4. Condition.meta
    Definition

    The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

    ShortMetadata about the resource
    Control0..1
    TypeMeta
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    6. 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()))
    8. Condition.language
    Definition

    The base language in which the resource is written.

    ShortLanguage of the resource content
    Comments

    Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

    Control0..1
    BindingThe codes SHOULD be taken from CommonLanguages
    (preferred to http://hl7.org/fhir/ValueSet/languages)

    A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    Typecode
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    10. Condition.text
    Definition

    A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

    ShortText summary of the resource, for human interpretation
    Comments

    Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

    Control0..1
    TypeNarrative
    Is Modifierfalse
    Summaryfalse
    Alternate Namesnarrative, html, xhtml, display
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    12. Condition.contained
    Definition

    These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

    ShortContained, inline Resources
    Comments

    This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

    Control0..*
    TypeResource
    Is Modifierfalse
    Summaryfalse
    Alternate Namesinline resources, anonymous resources, contained resources
    14. Condition.extension
    Definition

    An Extension

    ShortExtension
    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    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())
    SlicingThis element introduces a set of slices on Condition.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 16. Condition.extension:assertedDate
      Slice NameassertedDate
      Definition

      The date on which the existence of the Condition was first asserted or acknowledged.

      ShortDate the condition was first asserted
      Comments

      The assertedDate is in the context of the recording practitioner and might not be the same as the recordedDate.

      Control0..1
      This element is affected by the following invariants: ele-1
      TypeExtension(Condition Asserted Date) (Extension Type: dateTime)
      Is Modifierfalse
      Must Supporttrue
      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())
      18. 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())
      20. Condition.identifier
      Definition

      Business identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

      ShortExternal Ids for this condition
      Comments

      This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

      NoteThis is a business identifier, not a resource identifier (see discussion)
      Control0..*
      TypeIdentifier
      Is Modifierfalse
      Summarytrue
      Requirements

      Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      22. Condition.clinicalStatus
      Definition

      The clinical status of the condition.

      Shortactive | 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 ConditionClinicalStatusCodes
      (required to http://hl7.org/fhir/ValueSet/condition-clinical)
      TypeCodeableConcept
      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()))
      24. Condition.verificationStatus
      Definition

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

      Shortunconfirmed | 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 ConditionVerificationStatus
      (required to http://hl7.org/fhir/ValueSet/condition-ver-status)
      TypeCodeableConcept
      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()))
      26. Condition.category
      Definition

      A category assigned to the condition.

      Shortcategory codes
      Comments

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

      Control1..*
      BindingUnless not suitable, these codes SHALL be taken from ConditionCategoryCodes
      (extensible to http://hl7.org/fhir/ValueSet/condition-category)

      A category assigned to the condition.

      TypeCodeableConcept
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      SlicingThis element introduces a set of slices on Condition.category. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • pattern @ $this
      • 28. Condition.category:us-core
        Slice Nameus-core
        Definition

        A category assigned to the condition.

        Shortproblem-list-item | health-concern
        Comments

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

        Control1..*
        BindingThe codes SHALL be taken from US Core Problem or Health Concern
        (required to http://hl7.org/fhir/us/core/ValueSet/us-core-problem-or-health-concern)
        TypeCodeableConcept
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        30. Condition.category:sdoh
        Slice Namesdoh
        Definition

        A category assigned to the condition.

        Shortproblem-list-item | encounter-diagnosis
        Comments

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

        Control0..1
        BindingUnless not suitable, these codes SHALL be taken from ConditionCategoryCodes
        (extensible to http://hl7.org/fhir/ValueSet/condition-category)

        A category assigned to the condition.

        TypeCodeableConcept
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Pattern Value{
          "coding" : [{
            "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-tags",
            "code" : "sdoh"
          }]
        }
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        32. Condition.severity
        Definition

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

        ShortSubjective severity of condition
        Comments

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

        Control0..1
        BindingThe codes SHOULD be taken from Condition/DiagnosisSeverity
        (preferred to http://hl7.org/fhir/ValueSet/condition-severity)

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

        TypeCodeableConcept
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        34. Condition.code
        Definition

        Identification of the condition, problem or diagnosis.

        ShortPerineal laceration during delivery (disorder)
        Control1..1
        BindingUnless not suitable, these codes SHALL be taken from US Core Condition Codes
        (extensible to http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code)

        Valueset to describe the actual problem experienced by the patient

        TypeCodeableConcept
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Requirements

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

        Alternate Namestype
        Pattern Value{
          "coding" : [{
            "system" : "http://snomed.info/sct",
            "code" : "398019008"
          }]
        }
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        36. Condition.bodySite
        Definition

        The anatomical location where this condition manifests itself.

        ShortAnatomical 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 SNOMEDCTBodyStructures
        (example to http://hl7.org/fhir/ValueSet/body-site)

        Codes describing anatomical locations. May include laterality.

        TypeCodeableConcept
        Is Modifierfalse
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        38. Condition.subject
        Definition

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

        ShortWho has the condition?
        Control1..1
        TypeReference(Patient - Mother - Vital Records)
        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()))
        40. Condition.encounter
        Definition

        The Encounter during which this Condition was created or to which the creation of this record is tightly associated.

        ShortEncounter created as part of
        Comments

        This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".

        Control0..1
        TypeReference(Encounter)
        Is Modifierfalse
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        42. Condition.onset[x]
        Definition

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

        ShortEstimated 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, Age, Period, Range, string
        [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()))
        44. Condition.abatement[x]
        Definition

        The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate.

        ShortWhen in resolution/remission
        Comments

        There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.

        Control0..1
        This element is affected by the following invariants: con-4
        TypeChoice of: dateTime, Age, Period, Range, string
        [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
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        46. Condition.recordedDate
        Definition

        The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.

        ShortDate record was first recorded
        Control0..1
        TypedateTime
        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()))
        48. Condition.recorder
        Definition

        Individual who recorded the record and takes responsibility for its content.

        ShortWho recorded the condition
        Control0..1
        TypeReference(Practitioner, PractitionerRole, Patient, RelatedPerson)
        Is Modifierfalse
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        50. Condition.asserter
        Definition

        Individual who is making the condition statement.

        ShortPerson who asserts this condition
        Control0..1
        TypeReference(Practitioner, PractitionerRole, Patient, RelatedPerson)
        Is Modifierfalse
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        52. Condition.stage
        Definition

        Clinical stage or grade of a condition. May include formal severity assessments.

        ShortStage/grade, usually assessed formally
        Control0..*
        TypeBackboneElement
        Is Modifierfalse
        Summaryfalse
        Invariantscon-1: Stage SHALL have summary or assessment (summary.exists() or assessment.exists())
        ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        54. Condition.stage.id
        Definition

        Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

        ShortUnique id for inter-element referencing
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        56. Condition.stage.extension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

        ShortAdditional content defined by implementations
        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 Modifierfalse
        Summaryfalse
        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())
        58. Condition.stage.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained 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 can 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 even if unrecognized
        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 element that contains them
        Summarytrue
        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, modifiers
        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())
        60. Condition.stage.summary
        Definition

        A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.

        ShortSimple summary (disease specific)
        Control0..1
        This element is affected by the following invariants: con-1
        BindingFor example codes, see ConditionStage
        (example to http://hl7.org/fhir/ValueSet/condition-stage)

        Codes describing condition stages (e.g. Cancer stages).

        TypeCodeableConcept
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        62. Condition.stage.assessment
        Definition

        Reference to a formal record of the evidence on which the staging assessment is based.

        ShortFormal record of assessment
        Control0..*
        This element is affected by the following invariants: con-1
        TypeReference(ClinicalImpression, DiagnosticReport, Observation)
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        64. Condition.stage.type
        Definition

        The kind of staging, such as pathological or clinical staging.

        ShortKind of staging
        Control0..1
        BindingFor example codes, see ConditionStageType
        (example to http://hl7.org/fhir/ValueSet/condition-stage-type)

        Codes describing the kind of condition staging (e.g. clinical or pathological).

        TypeCodeableConcept
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        66. Condition.evidence
        Definition

        Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition.

        ShortSupporting evidence
        Comments

        The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.

        Control0..*
        TypeBackboneElement
        Is Modifierfalse
        Summaryfalse
        Invariantscon-2: evidence SHALL have code or details (code.exists() or detail.exists())
        ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        68. Condition.evidence.id
        Definition

        Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

        ShortUnique id for inter-element referencing
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        70. Condition.evidence.extension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

        ShortAdditional content defined by implementations
        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 Modifierfalse
        Summaryfalse
        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())
        72. Condition.evidence.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained 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 can 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 even if unrecognized
        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 element that contains them
        Summarytrue
        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, modifiers
        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())
        74. Condition.evidence.code
        Definition

        A manifestation or symptom that led to the recording of this condition.

        ShortManifestation/symptom
        Control0..*
        This element is affected by the following invariants: con-2
        BindingFor example codes, see ManifestationAndSymptomCodes
        (example to http://hl7.org/fhir/ValueSet/manifestation-or-symptom)

        Codes that describe the manifestation or symptoms of a condition.

        TypeCodeableConcept
        Is Modifierfalse
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        76. Condition.evidence.detail
        Definition

        Links to other relevant information, including pathology reports.

        ShortSupporting information found elsewhere
        Control0..*
        This element is affected by the following invariants: con-2
        TypeReference(Resource)
        Is Modifierfalse
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        78. Condition.note
        Definition

        Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.

        ShortAdditional information about the Condition
        Control0..*
        TypeAnnotation
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))