LK NEHR Sri Lanka Patient Summary (IPS based) Implementation Guide
0.1.0 - STU1
LK NEHR Sri Lanka Patient Summary (IPS based) Implementation Guide, published by Ministry of Health, Sri Lanka. 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/lk-gov-health-hiu/lk-nehr-fhir-ips/ and changes regularly. See the Directory of published versions
Official URL: http://fhir.health.gov.lk/ips/StructureDefinition/medical-history | Version: 0.1.0 | |||
Active as of 2024-11-14 | Computable Name: MedicalHistory |
Represents previous, pre-existing and new conditions for the patient.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ConditionUvIps
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | ConditionUvIps | |||||||
verificationStatus | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text | ||||
category | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text | |||||
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Conditions (extensible)
| |||||
subject | 1..1 | Reference(Patient) | Who has the condition? | |||||
encounter | 1..1 | Reference(Target Facility Encounter) | Encounter created as part of | |||||
recordedDate | 1..1 | dateTime | Date record was first recorded | |||||
recorder | S | 0..1 | Reference(Practitioner | Patient) | Who recorded the condition | ||||
asserter | S | 0..1 | Reference(Practitioner | Patient) | Person who asserts this condition | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.code | extensible | VSMedicalConditionshttp://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditions from this IG |
Name | Flags | Card. | Type | Description & Constraints | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | ConditionUvIps | Documentation of a health problem of the patient con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | ||||||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
clinicalStatus | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||||||
verificationStatus | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | ||||||||
category | S | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problem Type - IPS (preferred)
| ||||||||
severity | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Condition/DiagnosisSeverity (preferred)
| ||||||||
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Conditions (extensible)
| ||||||||
subject | SΣ | 1..1 | Reference(Patient) | Who has the condition? | ||||||||
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||||
encounter | Σ | 1..1 | Reference(Target Facility Encounter) | Encounter created as part of | ||||||||
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||||||
onsetDateTime | dateTime | |||||||||||
recordedDate | Σ | 1..1 | dateTime | Date record was first recorded | ||||||||
recorder | SΣ | 0..1 | Reference(Practitioner | Patient) | Who recorded the condition | ||||||||
asserter | SΣ | 0..1 | Reference(Practitioner | Patient) | Person who asserts this condition | ||||||||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | |
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | |
Condition.category | preferred | ProblemTypeUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips | |
Condition.severity | preferred | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | |
Condition.code | extensible | VSMedicalConditionshttp://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditions from this IG |
Id | Grade | Path(s) | Details | Requirements |
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() |
Name | Flags | Card. | Type | Description & Constraints | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | ConditionUvIps | Documentation of a health problem of the patient con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | ||||||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||
contained | 0..* | Resource | Contained, inline Resources | |||||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||||||
clinicalStatus | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||||||
verificationStatus | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | ||||||||
category | S | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problem Type - IPS (preferred)
| ||||||||
severity | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Condition/DiagnosisSeverity (preferred)
| ||||||||
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Conditions (extensible)
| ||||||||
bodySite | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example) | |||||||||
subject | SΣ | 1..1 | Reference(Patient) | Who has the condition? | ||||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||||||
encounter | Σ | 1..1 | Reference(Target Facility Encounter) | Encounter created as part of | ||||||||
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||||||
onsetDateTime | dateTime S | |||||||||||
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 | Σ | 1..1 | dateTime | Date record was first recorded | ||||||||
recorder | SΣ | 0..1 | Reference(Practitioner | Patient) | Who recorded the condition | ||||||||
asserter | SΣ | 0..1 | Reference(Practitioner | Patient) | Person who asserts this condition | ||||||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment | ||||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||||||
evidence | C | 0..* | BackboneElement | Supporting evidence con-2: evidence SHALL have code or details | ||||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||||||
detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||||||
note | 0..* | Annotation | Additional information about the Condition | |||||||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | preferred | ProblemTypeUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips | ||||
Condition.severity | preferred | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | extensible | VSMedicalConditionshttp://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditions from this IG | ||||
Condition.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Condition.stage.summary | example | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | example | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | example | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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() |
This structure is derived from ConditionUvIps
Differential View
This structure is derived from ConditionUvIps
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | ConditionUvIps | |||||||
verificationStatus | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text | ||||
category | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text | |||||
code | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Conditions (extensible)
| |||||
subject | 1..1 | Reference(Patient) | Who has the condition? | |||||
encounter | 1..1 | Reference(Target Facility Encounter) | Encounter created as part of | |||||
recordedDate | 1..1 | dateTime | Date record was first recorded | |||||
recorder | S | 0..1 | Reference(Practitioner | Patient) | Who recorded the condition | ||||
asserter | S | 0..1 | Reference(Practitioner | Patient) | Person who asserts this condition | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.code | extensible | VSMedicalConditionshttp://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditions from this IG |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | ConditionUvIps | Documentation of a health problem of the patient con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | ||||||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
clinicalStatus | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||||||
verificationStatus | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | ||||||||
category | S | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problem Type - IPS (preferred)
| ||||||||
severity | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Condition/DiagnosisSeverity (preferred)
| ||||||||
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Conditions (extensible)
| ||||||||
subject | SΣ | 1..1 | Reference(Patient) | Who has the condition? | ||||||||
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||||
encounter | Σ | 1..1 | Reference(Target Facility Encounter) | Encounter created as part of | ||||||||
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||||||
onsetDateTime | dateTime | |||||||||||
recordedDate | Σ | 1..1 | dateTime | Date record was first recorded | ||||||||
recorder | SΣ | 0..1 | Reference(Practitioner | Patient) | Who recorded the condition | ||||||||
asserter | SΣ | 0..1 | Reference(Practitioner | Patient) | Person who asserts this condition | ||||||||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | |
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | |
Condition.category | preferred | ProblemTypeUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips | |
Condition.severity | preferred | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | |
Condition.code | extensible | VSMedicalConditionshttp://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditions from this IG |
Id | Grade | Path(s) | Details | Requirements |
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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | ConditionUvIps | Documentation of a health problem of the patient con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | ||||||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||
contained | 0..* | Resource | Contained, inline Resources | |||||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||||||
clinicalStatus | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||||||
verificationStatus | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | ||||||||
category | S | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problem Type - IPS (preferred)
| ||||||||
severity | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Condition/DiagnosisSeverity (preferred)
| ||||||||
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Conditions (extensible)
| ||||||||
bodySite | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example) | |||||||||
subject | SΣ | 1..1 | Reference(Patient) | Who has the condition? | ||||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||||||
encounter | Σ | 1..1 | Reference(Target Facility Encounter) | Encounter created as part of | ||||||||
onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||||||
onsetDateTime | dateTime S | |||||||||||
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 | Σ | 1..1 | dateTime | Date record was first recorded | ||||||||
recorder | SΣ | 0..1 | Reference(Practitioner | Patient) | Who recorded the condition | ||||||||
asserter | SΣ | 0..1 | Reference(Practitioner | Patient) | Person who asserts this condition | ||||||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment | ||||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||||||
evidence | C | 0..* | BackboneElement | Supporting evidence con-2: evidence SHALL have code or details | ||||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||
code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||||||
detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||||||
note | 0..* | Annotation | Additional information about the Condition | |||||||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | preferred | ProblemTypeUvIpshttp://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips | ||||
Condition.severity | preferred | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | extensible | VSMedicalConditionshttp://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditions from this IG | ||||
Condition.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Condition.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Condition.stage.summary | example | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | example | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | example | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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() |
This structure is derived from ConditionUvIps
Other representations of profile: CSV, Excel, Schematron