ImplementationGuide for Malaysia Core (MY Core)
0.0.1 - CI Build
ImplementationGuide for Malaysia Core (MY Core), published by Malaysia Healthcare Nexus (MHN). This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/nhphong245/my-core-ig-r4/ and changes regularly. See the Directory of published versions
Official URL: http://fhir.hie.moh.gov.my/StructureDefinition/Condition-my-core | Version: 0.0.1 | |||
Active as of 2024-03-13 | Responsible: Malaysia Healthcare Nexus (MHN) | Realm: | Computable Name: ConditionMyCore |
This profile represents the constraints applied to the Condition resource by MY Core FHIR Implementation Guide and describes the minimum expectations for the Patient resource when used in the MY Core composition or in one of the referred resources.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Condition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | Condition | Detailed information about conditions, problems or diagnoses | |
Slices for extension | Content/Rules for all slices | |||
audit | 0..1 | (Complex) | Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core | |
category | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required) | |
code | ||||
coding | ||||
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
text | 1..1 | string | Plain text representation of the concept | |
note | ||||
author[x] | 0..1 | Individual responsible for the annotation | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization | http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner) | |||
authorString | string | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.category | required | ValueSetConditionCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core from this IG |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | Condition | Detailed information about conditions, problems or diagnoses 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 |
Slices for extension | Content/Rules for all slices | |||
audit | 0..1 | (Complex) | Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core | |
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. |
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. |
category | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required) | |
subject | Σ | 1..1 | Reference(Patient | Group) | Who has the 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 | required | ValueSetConditionCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core 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..* | Condition | Detailed information about conditions, problems or diagnoses 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 | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
audit | 0..1 | (Complex) | Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core | |||||
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. | ||||
category | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required) | |||||
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 | Σ | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 0..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 1..1 | string | Plain text representation of the concept | ||||
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
subject | Σ | 1..1 | Reference(Patient | Group) | Who has the condition? | ||||
encounter | Σ | 0..1 | Reference(Encounter) | 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 | Σ | 0..1 | dateTime | Date record was first recorded | ||||
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | 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 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 | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
author[x] | Σ | 0..1 | Individual responsible for the annotation | |||||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization | http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner) | |||||||
authorString | string | |||||||
time | Σ | 0..1 | dateTime | When the annotation was made | ||||
text | Σ | 1..1 | markdown | The annotation - text content (as markdown) | ||||
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 | required | ValueSetConditionCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core from this IG | ||||
Condition.severity | preferred | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site 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 Condition
Differential View
This structure is derived from Condition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | Condition | Detailed information about conditions, problems or diagnoses | |
Slices for extension | Content/Rules for all slices | |||
audit | 0..1 | (Complex) | Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core | |
category | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required) | |
code | ||||
coding | ||||
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
text | 1..1 | string | Plain text representation of the concept | |
note | ||||
author[x] | 0..1 | Individual responsible for the annotation | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization | http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner) | |||
authorString | string | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.category | required | ValueSetConditionCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core from this IG |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | Condition | Detailed information about conditions, problems or diagnoses 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 |
Slices for extension | Content/Rules for all slices | |||
audit | 0..1 | (Complex) | Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core | |
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. |
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. |
category | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required) | |
subject | Σ | 1..1 | Reference(Patient | Group) | Who has the 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 | required | ValueSetConditionCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core 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..* | Condition | Detailed information about conditions, problems or diagnoses 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 | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
audit | 0..1 | (Complex) | Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core | |||||
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. | ||||
category | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required) | |||||
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 | Σ | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 0..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 1..1 | string | Plain text representation of the concept | ||||
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
subject | Σ | 1..1 | Reference(Patient | Group) | Who has the condition? | ||||
encounter | Σ | 0..1 | Reference(Encounter) | 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 | Σ | 0..1 | dateTime | Date record was first recorded | ||||
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | 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 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 | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
author[x] | Σ | 0..1 | Individual responsible for the annotation | |||||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization | http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner) | |||||||
authorString | string | |||||||
time | Σ | 0..1 | dateTime | When the annotation was made | ||||
text | Σ | 1..1 | markdown | The annotation - text content (as markdown) | ||||
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 | required | ValueSetConditionCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core from this IG | ||||
Condition.severity | preferred | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Condition.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site 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 Condition
Other representations of profile: CSV, Excel, Schematron