STU 2 Ballot

This page is part of the Data Access Framework (v1.6.0: STU 2 Ballot 1) based on FHIR v1.6.0. . For a full list of available versions, see the Directory of published versions

D.4.1 StructureDefinition: DAF-core-condition

This profile sets minimum expectations for the Condition resource to record, search and fetch a list of problems and health concerns associated with a patient. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile.

Example Usage Scenarios:

The following are example usage scenarios for the DAF-Condition profile:

  • Query for a Patient’s problems
  • Query for all patients who have had a specific condition,problem or finding
Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and an example are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Condition must have:

  1. a status of the problem
  2. a verification status
  3. a code that identifies the problem
  4. a patient

Profile specific implementation guidance:

  • The DAF Condition Category Codes support the separate concepts of problems and health concerns so API consumers can separate health concerns and problems. However this is not mandatory for 2015 certification
Example: Condition Example: example

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is:

http://hl7.org/fhir/us/daf/StructureDefinition/daf-core-condition

This profile was published on Thu Aug 21 00:00:00 AEST 2014 as a draft by Health Level Seven International (Infrastructure and Messaging - Data Access Framework).

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

This structure is derived from Condition

Complete Summary of the Mandatory Requirements

  1. Conditionally One clinical status in Condition.clinicalStatus
    • Invariants
      • required if Condition.verificationStatus != ‘entered-in-error‘
      • not present if Condition.verificationStatus = ‘entered-in-error‘
    • Condition.clinicalStatus is bound to Condition Clinical Status Codes value set
  2. One code in Condition.verificationStatus
  3. One Identification of the problem or health concern in Condition.codewhich has an extensible binding to:
  4. One patient reference in Condition.patient

problems and health concerns category codes

The DAF Condition Category Codes supports the separate concepts of problems and health concerns in Condition.category in order for API consumers to be able to separate health concerns and problems. However this is not mandatory for 2015 certification.

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*daf-1: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... clinicalStatus SI0..1codeBinding: Condition Clinical Status Codes (required)
... verificationStatus S1..1codeBinding: ConditionVerificationStatus (required)
... code S1..1CodeableConceptBinding: Problem Value Set (extensible)
... subject S1..1Reference(Profile daf-core-patient)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*Detailed information about conditions, problems or diagnoses
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
daf-1: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... id 0..1idLogical id of this artifact
... meta 0..1MetaMetadata about the resource
... implicitRules ?!0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!S0..1codeactive | relapse | remission | resolved
Binding: Condition Clinical Status Codes (required)
... verificationStatus ?!S1..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding: ConditionVerificationStatus (required)
... category 0..1CodeableConceptcomplaint | symptom | finding | diagnosis
Binding: Condition Category Codes (preferred)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (preferred)
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (extensible)
... bodySite 0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (example)
... subject S1..1Reference(Profile daf-core-patient)Who has the condition?
... context 0..1Reference(Encounter | EpisodeOfCare)Encounter when condition first asserted
... onset[x] 0..1dateTime, Age, Period, Range, stringEstimated or actual date, date-time, or age
... abatement[x] 0..1dateTime, Age, boolean, Period, Range, stringIf/when in resolution/remission
... dateRecorded 0..1dateWhen first entered
... asserter 0..1Reference(Practitioner | Patient)Person who asserts this condition
... stage I0..1BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... code I0..1CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example)
.... detail I0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

yet to be done: Xml template

yet to be done: Json template

This structure is derived from Condition

Summary

Mandatory: 3 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*daf-1: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... clinicalStatus SI0..1codeBinding: Condition Clinical Status Codes (required)
... verificationStatus S1..1codeBinding: ConditionVerificationStatus (required)
... code S1..1CodeableConceptBinding: Problem Value Set (extensible)
... subject S1..1Reference(Profile daf-core-patient)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*Detailed information about conditions, problems or diagnoses
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
daf-1: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... id 0..1idLogical id of this artifact
... meta 0..1MetaMetadata about the resource
... implicitRules ?!0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!S0..1codeactive | relapse | remission | resolved
Binding: Condition Clinical Status Codes (required)
... verificationStatus ?!S1..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding: ConditionVerificationStatus (required)
... category 0..1CodeableConceptcomplaint | symptom | finding | diagnosis
Binding: Condition Category Codes (preferred)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (preferred)
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (extensible)
... bodySite 0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (example)
... subject S1..1Reference(Profile daf-core-patient)Who has the condition?
... context 0..1Reference(Encounter | EpisodeOfCare)Encounter when condition first asserted
... onset[x] 0..1dateTime, Age, Period, Range, stringEstimated or actual date, date-time, or age
... abatement[x] 0..1dateTime, Age, boolean, Period, Range, stringIf/when in resolution/remission
... dateRecorded 0..1dateWhen first entered
... asserter 0..1Reference(Practitioner | Patient)Person who asserts this condition
... stage I0..1BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... code I0..1CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example)
.... detail I0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

XML Template

yet to be done: Xml template

JSON Template

yet to be done: Json template

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathNameConformanceValueSet
Condition.languageCommon LanguagesextensibleCommon Languages
Condition.clinicalStatusCondition Clinical Status CodesrequiredCondition Clinical Status Codes
Condition.verificationStatusConditionVerificationStatusrequiredConditionVerificationStatus
Condition.categoryCondition Category CodespreferredCondition Category Codes
Condition.severityCondition/Diagnosis SeveritypreferredCondition/Diagnosis Severity
Condition.codeProblem Value SetextensibleProblem Value Set
Condition.bodySiteSNOMED CT Body StructuresexampleSNOMED CT Body Structures
Condition.stage.summaryCondition StageexampleCondition Stage
Condition.evidence.codeManifestation and Symptom CodesexampleManifestation and Symptom Codes

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2ConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
XPath: not(parent::f:contained and f:contained)
dom-1ConditionIf the resource is contained in another resource, it SHALL NOT contain any narrative
XPath: not(parent::f:contained and f:text)
dom-4ConditionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
XPath: not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
dom-3ConditionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
XPath: not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))
daf-1ConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
XPath: exists(f:clinicalStatus)=(f:verificationStatus/@value!='entered-in-error')
con-1Condition.stageStage SHALL have summary or assessment
XPath: exists(f:summary) or exists(f:assessment)
con-2Condition.evidenceevidence SHALL have code or details
XPath: exists(f:code) or exists(f:detail)
.