Generated Narrative: StructureDefinition ProblemDiagnosis Name Flags Card. Type Description & Constraints ProblemDiagnosis S 0..* Base Problem Diagnosis #xD; Protocol S 0..1 BackboneElement Protocol #xD; Lastupdated S 0..1 dateTime Last updated #xD; Extension S 0..* Reference() Extension #xD; Data S 0..1 BackboneElement Data #xD; ProblemDiagnosisname S 1..1 CodeableConcept Problem Diagnosis name #xD; Variant S 0..* string Variant #xD; Clinicaldescription S 0..1 string Clinical description #xD; Bodysite S 0..* CodeableConcept Body site #xD; Structuredbodysite S 0..* Reference() Structured body site #xD; Cause S 0..* string Cause #xD; Datetimeofonset S 0..1 dateTime Datetime of onset #xD; Datetimeclinicallyrecognised S 0..1 dateTime Datetime clinically recognised #xD; Severity S 0..1 CodeableConcept Severity #xD; Specificdetails S 0..* Reference() Specific details #xD; Coursedescription S 0..1 string Course description #xD; Datetimeofresolution S 0..1 dateTime Datetime of resolution #xD; Status S 0..* Coding Status #xD; Diagnosticcertainty S 0..1 CodeableConcept Diagnostic certainty #xD; Comment S 0..1 string Comment #xD; Documentation for this format
The Problem Diagnosis Logical Model Mindmap is shown below. Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. **Purpose** For recording details about a single, identified health problem or diagnosis. The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional. **Misuse** Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. Not to be used to record procedures - use the ACTION.procedure archetype. Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis. **Considerations** Use for recording details about a single, identified health problem or diagnosis. Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.
Use for recording details about a single, identified health problem or diagnosis. Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.
Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. Not to be used to record procedures - use the ACTION.procedure archetype. Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.
For recording details about a single, identified health problem or diagnosis. The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.
Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.
**Purpose** For recording details about a single, identified health problem or diagnosis. The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional. **Misuse** Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. Not to be used to record procedures - use the ACTION.procedure archetype. Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis. **Considerations** Use for recording details about a single, identified health problem or diagnosis. Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
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.
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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
Extensions that cannot be ignored even if unrecognized
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).
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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
The date this problem or diagnosis was last updated.
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Additional information required to capture local content or to align with other reference models/formalisms.
**Considerations** For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Identification of the problem or diagnosis, by name.
**Considerations** Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible.
Specific variant or subtype of the Diagnosis, if relevant.
**Considerations** For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible.
Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
Narrative description about the problem or diagnosis.
**Considerations** Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.
Identification of a simple body site for the location of the problem or diagnosis.
**Considerations** Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.
Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.
A structured anatomical location for the problem or diagnosis.
**Considerations** Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.
Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
A cause, set of causes, or manner of causation of the problem or diagnosis.
**Considerations** Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.
**Considerations** Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.
Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.
**Considerations** Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.
If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.
An assessment of the overall severity of the problem or diagnosis.
**Considerations** If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.
May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.
Details that are additionally required to record as unique attributes of this problem or diagnosis.
**Considerations** May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.
Narrative description about the course of the problem or diagnosis since onset.
Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.
Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.
**Considerations** Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.
Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.
Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.
**Considerations** Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.
If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.
The level of confidence in the identification of the diagnosis.
**Considerations** If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.
Additional narrative about the problem or diagnosis not captured in other fields.