2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Profile: cqf-condition-refuted

The official URL for this profile is: 

http://hl7.org/fhir/Profile/cqf-condition-refuted-cqf-condition-refuted

. Profile of condition refuted/nonoccurrence for decision support/quality metrics. Indicates which elements must be supported by CQF rules and measure engines. Removes modifying attributes. : Clinical Quality Framework (CQF) Condition Refuted Profile

This profile was published on Tue, Oct 28, 2014 00:00+1100 as a draft by Health Level Seven, Inc. - CQI WG.

Summary

Terminology Bindings

  • Condition.certainty must come from Value set for Condition certainty for a condition nonoccurrence

Required/Prohibited Elements

  • The element Condition is required
  • The element Condition.subject is required
  • The element Condition.code is required
  • The element Condition.status is required

Fixed Values

  • The element Condition.status value has been fixed to refuted

Formal Views of Profile Content

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

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 1..1A condition that is known not to be present in a patient.
... id 0..1idLogical id of this artefact
... meta 0..1MetaMetadata about the resource
... implicitRules M0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required, not 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
... subject S1..1PatientWho has the condition?
... encounter S0..1EncounterEncounter when condition first asserted
... asserter S0..1Practitioner, PatientPerson who asserts this condition
... dateAsserted S0..1dateWhen first detected/suspected/entered
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: ConditionKind (example, extensible)
... category S0..1CodeableConceptE.g. complaint | symptom | finding | diagnosis
Binding: ConditionCategory (preferred, extensible)
... status M1..1codeprovisional | working | confirmed | refuted
Binding: ConditionStatus (required, not extensible)
Fixed Value: refuted
... certainty M S0..1CodeableConceptDegree of confidence
Binding: ValuesetConditionCertaintyAbsent (required, not extensible)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: ConditionSeverity (example, extensible)
... onset[x] 0..1dateTime, AgeEstimated or actual date, date-time, or age
... abatement[x] 0..1date, Age, booleanIf/when in resolution/remission
... stage S I0..1Stage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... summary S I0..1CodeableConceptSimple summary (disease specific)
.... assessment I0..*AnyFormal record of assessment
... evidence I0..*Supporting evidence
con-2: evidence SHALL have code or details
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code I0..1CodeableConceptManifestation/symptom
.... detail I0..*AnySupporting information found elsewhere
... location S I0..*Anatomical location, if relevant
con-3: location SHALL have code or details
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code S I0..1CodeableConceptLocation - may include laterality
.... detail I0..1stringPrecise location details
... dueTo I0..*Causes for this Condition
con-4: Relationship SHALL have either a code or a target
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... codeableConcept I0..1CodeableConceptRelationship target by means of a predefined code
Binding: ConditionKind (example, extensible)
.... target I0..1Condition, Procedure, MedicationAdministration, Immunization, MedicationStatementRelationship target resource
... occurredFollowing I0..*Precedent for this Condition
con-5: Relationship SHALL have either a code or a target
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... codeableConcept I0..1CodeableConceptRelationship target by means of a predefined code
Binding: ConditionKind (example, extensible)
.... target I0..1Condition, Procedure, MedicationAdministration, Immunization, MedicationStatementRelationship target resource
... notes 0..1stringAdditional information about the Condition

XML Template

JSON Template

todo

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 1..1A condition that is known not to be present in a patient.
... id 0..1idLogical id of this artefact
... meta 0..1MetaMetadata about the resource
... implicitRules M0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required, not 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
... subject S1..1PatientWho has the condition?
... encounter S0..1EncounterEncounter when condition first asserted
... asserter S0..1Practitioner, PatientPerson who asserts this condition
... dateAsserted S0..1dateWhen first detected/suspected/entered
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: ConditionKind (example, extensible)
... category S0..1CodeableConceptE.g. complaint | symptom | finding | diagnosis
Binding: ConditionCategory (preferred, extensible)
... status M1..1codeprovisional | working | confirmed | refuted
Binding: ConditionStatus (required, not extensible)
Fixed Value: refuted
... certainty M S0..1CodeableConceptDegree of confidence
Binding: ValuesetConditionCertaintyAbsent (required, not extensible)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: ConditionSeverity (example, extensible)
... onset[x] 0..1dateTime, AgeEstimated or actual date, date-time, or age
... abatement[x] 0..1date, Age, booleanIf/when in resolution/remission
... stage S I0..1Stage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... summary S I0..1CodeableConceptSimple summary (disease specific)
.... assessment I0..*AnyFormal record of assessment
... evidence I0..*Supporting evidence
con-2: evidence SHALL have code or details
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code I0..1CodeableConceptManifestation/symptom
.... detail I0..*AnySupporting information found elsewhere
... location S I0..*Anatomical location, if relevant
con-3: location SHALL have code or details
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code S I0..1CodeableConceptLocation - may include laterality
.... detail I0..1stringPrecise location details
... dueTo I0..*Causes for this Condition
con-4: Relationship SHALL have either a code or a target
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... codeableConcept I0..1CodeableConceptRelationship target by means of a predefined code
Binding: ConditionKind (example, extensible)
.... target I0..1Condition, Procedure, MedicationAdministration, Immunization, MedicationStatementRelationship target resource
... occurredFollowing I0..*Precedent for this Condition
con-5: Relationship SHALL have either a code or a target
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... codeableConcept I0..1CodeableConceptRelationship target by means of a predefined code
Binding: ConditionKind (example, extensible)
.... target I0..1Condition, Procedure, MedicationAdministration, Immunization, MedicationStatementRelationship target resource
... notes 0..1stringAdditional information about the Condition

XML Template

JSON Template

todo

 

Other definitions: (todo)

Terminology Bindings

PathNameConformanceValueSet
Condition.languageLanguagerequiredhttp://tools.ietf.org/html/bcp47
Condition.codeConditionKindexample (extensible)Condition/Problem/Diagnosis Codes
Condition.categoryConditionCategorypreferred (extensible)Condition/Problem/Diagnosis Codes
Condition.statusConditionStatusrequiredConditionStatus
Condition.certaintyValuesetConditionCertaintyAbsentrequiredCondition/Diagnosis Certainty
Condition.severityConditionSeverityexample (extensible)Condition/Diagnosis Severity
Condition.dueTo.codeableConceptConditionKindexample (extensible)Condition/Problem/Diagnosis Codes
Condition.occurredFollowing.codeableConceptConditionKindexample (extensible)Condition/Problem/Diagnosis Codes

Constraints

IdPathNameDetails
con-1Condition.stageStage ruleStage SHALL have summary or assessment
XPath: exists(f:summary) or exists(f:assessment)
con-2Condition.evidenceEvidenceevidence SHALL have code or details
XPath: exists(f:code) or exists(f:detail)
con-3Condition.locationLocationlocation SHALL have code or details
XPath: exists(f:code) or exists(f:detail)
con-4Condition.dueToRelationship1Relationship SHALL have either a code or a target
XPath: exists(f:code) != exists(f:target)
con-5Condition.occurredFollowingRelationship2Relationship SHALL have either a code or a target
XPath: exists(f:code) != exists(f:target)
.