LK NEHR Sri Lanka Patient Summary (IPS based) Implementation Guide
0.1.0 - STU1
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 2024-09-22 | 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 | VSMedicalConditions
http://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditionsfrom 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|4.0.1from the FHIR Standard | ||||||
| Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1from the FHIR Standard | ||||||
| Condition.category | preferred | ProblemTypeUvIps
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips | ||||||
| Condition.severity | preferred | Condition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severityfrom the FHIR Standard | ||||||
| Condition.code | extensible | VSMedicalConditions
http://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditionsfrom 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/languagesfrom the FHIR Standard | ||||||
| Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1from the FHIR Standard | ||||||
| Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1from the FHIR Standard | ||||||
| Condition.category | preferred | ProblemTypeUvIps
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips | ||||||
| Condition.severity | preferred | Condition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severityfrom the FHIR Standard | ||||||
| Condition.code | extensible | VSMedicalConditions
http://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditionsfrom this IG | ||||||
| Condition.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||||
| Condition.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||||
| Condition.stage.summary | example | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stagefrom the FHIR Standard | ||||||
| Condition.stage.type | example | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-typefrom the FHIR Standard | ||||||
| Condition.evidence.code | example | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptomfrom 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 | VSMedicalConditions
http://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditionsfrom 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|4.0.1from the FHIR Standard | ||||||
| Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1from the FHIR Standard | ||||||
| Condition.category | preferred | ProblemTypeUvIps
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips | ||||||
| Condition.severity | preferred | Condition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severityfrom the FHIR Standard | ||||||
| Condition.code | extensible | VSMedicalConditions
http://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditionsfrom 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/languagesfrom the FHIR Standard | ||||||
| Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1from the FHIR Standard | ||||||
| Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1from the FHIR Standard | ||||||
| Condition.category | preferred | ProblemTypeUvIps
http://hl7.org/fhir/uv/ips/ValueSet/problem-type-uv-ips | ||||||
| Condition.severity | preferred | Condition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severityfrom the FHIR Standard | ||||||
| Condition.code | extensible | VSMedicalConditions
http://fhir.health.gov.lk/ips/ValueSet/vs-medical-conditionsfrom this IG | ||||||
| Condition.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||||
| Condition.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||||
| Condition.stage.summary | example | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stagefrom the FHIR Standard | ||||||
| Condition.stage.type | example | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-typefrom the FHIR Standard | ||||||
| Condition.evidence.code | example | ManifestationAndSymptomCodeshttp://hl7.org/fhir/ValueSet/manifestation-or-symptomfrom 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