Health eData 1 Sandbox
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Health eData 1 Sandbox, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/argonautproject/USCDIV7/ and changes regularly. See the Directory of published versions

Resource Profile: US Core Condition Encounter Diagnosis Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis Version: 0.1.0
Active as of 2023-10-17 Maturity Level: 4 Computable Name: USCoreConditionEncounterDiagnosisProfile
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.17

The US Core Condition Encounter Diagnosis Profile inherits from the FHIR Condition resource; refer to it for scope and usage definitions. US Core version 5.0.0 split the US Core Condition Profile into this profile and the US Core Condition Problems and Health Concerns Profile. This profile meets the requirements of the U.S. Core Data for Interoperability (USCDI) Encounter Diagnosis Data Element. It sets minimum expectations for the Condition resource to record, search, and fetch information about an encounter diagnosis. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... clinicalStatus ?!ΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by value:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... category:us-core S 1..1 CodeableConcept encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
... subject SΣ 1..1 Reference(US Core Patient Profile(9.0.0) S | Group) Who has the condition?
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Encounter created as part of
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder Σ 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile(9.0.0) | PractitionerRole | US Core RelatedPerson Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... detail ΣC 0..* Reference(US Core Simple Observation Profile) Supporting information found elsewhere

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.category:us-core Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📦9.0.0 US Core v9.0

Constraints

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

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition 0..* Condition Detailed information about conditions, problems or diagnoses
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by value:$this
.... category:us-core S 1..1 CodeableConcept encounter-diagnosis
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
... code S 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
... subject S 1..1 Reference(US Core Patient Profile(9.0.0) S | Group) Who has the condition?
... recordedDate S 0..1 dateTime Date record was first recorded
... recorder 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile(9.0.0) | PractitionerRole | US Core RelatedPerson Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
... evidence 0..* BackboneElement Supporting evidence
.... detail 0..* Reference(US Core Simple Observation Profile) Supporting information found elsewhere

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Condition.code Base extensible US Core Condition Codes 📦9.0.0 US Core v9.0
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... 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 ?!ΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!ΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by value:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... category:us-core S 1..1 CodeableConcept encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... severity 0..1 CodeableConcept Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... subject SΣ 1..1 Reference(US Core Patient Profile(9.0.0) S | Group) Who has the condition?
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Encounter created as part of
... onset[x] Σ 0..1 Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] C 0..1 When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder Σ 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile(9.0.0) | PractitionerRole | US Core RelatedPerson Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition
... stage C 0..* BackboneElement Stage/grade, usually assessed formally
Constraints: con-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 CodeableConcept Kind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code ΣC 0..* CodeableConcept Manifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(US Core Simple Observation Profile) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Condition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.category:us-core Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📦9.0.0 US Core v9.0
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Condition.stage.summary Base example Condition Stage 📍4.0.1 FHIR Std.
Condition.stage.type Base example Condition Stage Type 📍4.0.1 FHIR Std.
Condition.evidence.code Base example Manifestation and Symptom Codes 📍4.0.1 FHIR Std.

Constraints

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

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... clinicalStatus ?!ΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by value:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... category:us-core S 1..1 CodeableConcept encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
... subject SΣ 1..1 Reference(US Core Patient Profile(9.0.0) S | Group) Who has the condition?
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Encounter created as part of
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder Σ 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile(9.0.0) | PractitionerRole | US Core RelatedPerson Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... detail ΣC 0..* Reference(US Core Simple Observation Profile) Supporting information found elsewhere

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.category:us-core Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📦9.0.0 US Core v9.0

Constraints

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

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition 0..* Condition Detailed information about conditions, problems or diagnoses
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by value:$this
.... category:us-core S 1..1 CodeableConcept encounter-diagnosis
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
... code S 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
... subject S 1..1 Reference(US Core Patient Profile(9.0.0) S | Group) Who has the condition?
... recordedDate S 0..1 dateTime Date record was first recorded
... recorder 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile(9.0.0) | PractitionerRole | US Core RelatedPerson Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
... evidence 0..* BackboneElement Supporting evidence
.... detail 0..* Reference(US Core Simple Observation Profile) Supporting information found elsewhere

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Condition.code Base extensible US Core Condition Codes 📦9.0.0 US Core v9.0

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... 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 ?!ΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!ΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by value:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
.... category:us-core S 1..1 CodeableConcept encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... severity 0..1 CodeableConcept Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... subject SΣ 1..1 Reference(US Core Patient Profile(9.0.0) S | Group) Who has the condition?
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Encounter created as part of
... onset[x] Σ 0..1 Estimated or actual date, date-time, or age
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
... abatement[x] C 0..1 When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder Σ 0..1 Reference(US Core Practitioner Profile | US Core Patient Profile(9.0.0) | PractitionerRole | US Core RelatedPerson Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition
... stage C 0..* BackboneElement Stage/grade, usually assessed formally
Constraints: con-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 CodeableConcept Kind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code ΣC 0..* CodeableConcept Manifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(US Core Simple Observation Profile) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Condition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.category:us-core Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 FHIR Std.
Condition.code Base extensible US Core Condition Codes 📦9.0.0 US Core v9.0
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Condition.stage.summary Base example Condition Stage 📍4.0.1 FHIR Std.
Condition.stage.type Base example Condition Stage Type 📍4.0.1 FHIR Std.
Condition.evidence.code Base example Manifestation and Symptom Codes 📍4.0.1 FHIR Std.

Constraints

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

 

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