This page is part of the FHIR Specification (v1.0.0: DSTU 2 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2
Patient Care Work Group | Maturity Level: 0 | Compartments: Encounter, Patient, Practitioner |
Use to record detailed information about conditions, problems or diagnoses recognized by a clinician. There are many uses including: recording a Diagnosis during an Encounter; populating a problem List or a Summary Statement, such as a Discharge Summary.
Used to record detailed information pertinent to a clinician's assessment and assertion of a particular aspect of a person's state of health. Examples of condition include problems, diagnoses, concerns, issues. There are many uses of condition which include:
This resource is used to record detailed information about a clinician's assessment and assertion of a particular aspect of a patient's state of health. It is intended for use to record information about a disease/illness identified from application of clinical reasoning over the pathologic and pathophysiologic findings (diagnosis), or identification of health issues/situations that require ongoing monitoring and/or management (health issue/concern), or identification of health issues/situations considered harmful, potentially harmful and required to be investigated and managed (problems).
The condition resource may also be used to record certain health state of a patient which does not normally present negative outcome (until complications are predicted or detected), e.g. pregnancy. Examples of complications of pregnancy include: hyperemesis gravidarum, preeclampsia, eclampsia, which are captured as problems/diagnoses.
The condition resource may be referenced by other resources as "reasons" for an action (e.g. MedicationOrder, Procedure, DiagnosticOrder, etc.)
This resource is not to be used to record information about subjective and objective information that might lead to the recording of a Condition. Such signs and symptoms that are typically captured using the Observation resource; although in some cases a persistent symptom, e.g. fever, headache may be captured as a condition before a definitive diagnosis can be discerned by a clinician.
The condition resource also specifically excludes AllergyIntoelrance as those are handled with their own resource.
This resource is referenced by CarePlan, ClinicalImpression, DiagnosticOrder, Encounter, EpisodeOfCare, Goal, MedicationOrder, MedicationStatement, Procedure, ProcedureRequest, RiskAssessment and VisionPrescription
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | Σ | DomainResource | Detailed information about conditions, problems or diagnoses | |
identifier | Σ | 0..* | Identifier | External Ids for this condition |
patient | Σ | 1..1 | Reference(Patient) | Who has the condition? |
encounter | Σ | 0..1 | Reference(Encounter) | Encounter when condition first asserted |
asserter | Σ | 0..1 | Reference(Practitioner | Patient) | Person who asserts this condition |
dateRecorded | Σ | 0..1 | date | When first entered |
code | Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Condition/Problem/Diagnosis Codes (Example) |
category | Σ | 0..1 | CodeableConcept | complaint | symptom | finding | diagnosis Condition Category Codes (Preferred) |
clinicalStatus | ?! Σ | 0..1 | code | active | relapse | remission | resolved Condition Clinical Status Codes (Preferred) |
verificationStatus | ?! Σ | 1..1 | code | provisional | differential | confirmed | refuted | entered-in-error | unknown ConditionVerificationStatus (Required) |
severity | Σ | 0..1 | CodeableConcept | Subjective severity of condition Condition/Diagnosis Severity (Preferred) |
onset[x] | Σ | 0..1 | Estimated or actual date, date-time, or age | |
onsetDateTime | dateTime | |||
onsetQuantity | Age | |||
onsetPeriod | Period | |||
onsetRange | Range | |||
onsetString | string | |||
abatement[x] | Σ | 0..1 | If/when in resolution/remission | |
abatementDateTime | dateTime | |||
abatementQuantity | Age | |||
abatementBoolean | boolean | |||
abatementPeriod | Period | |||
abatementRange | Range | |||
abatementString | string | |||
stage | Σ I | 0..1 | BackboneElement | Stage/grade, usually assessed formally Stage SHALL have summary or assessment |
summary | Σ I | 0..1 | CodeableConcept | Simple summary (disease specific) Condition Stage (Example) |
assessment | Σ I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment |
evidence | Σ I | 0..* | BackboneElement | Supporting evidence evidence SHALL have code or details |
code | Σ I | 0..1 | CodeableConcept | Manifestation/symptom Manifestation and Symptom Codes (Example) |
detail | Σ I | 0..* | Reference(Any) | Supporting information found elsewhere |
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant SNOMED CT Body Structures (Example) |
notes | Σ | 0..1 | string | Additional information about the Condition |
Documentation for this format |
UML Diagram
XML Template
<Condition xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier External Ids for this condition --></identifier> <patient><!-- 1..1 Reference(Patient) Who has the condition? --></patient> <encounter><!-- 0..1 Reference(Encounter) Encounter when condition first asserted --></encounter> <asserter><!-- 0..1 Reference(Practitioner|Patient) Person who asserts this condition --></asserter> <dateRecorded value="[date]"/><!-- 0..1 When first entered --> <code><!-- 1..1 CodeableConcept Identification of the condition, problem or diagnosis --></code> <category><!-- 0..1 CodeableConcept complaint | symptom | finding | diagnosis --></category> <clinicalStatus value="[code]"/><!-- 0..1 active | relapse | remission | resolved --> <verificationStatus value="[code]"/><!-- 1..1 provisional | differential | confirmed | refuted | entered-in-error | unknown --> <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity> <onset[x]><!-- 0..1 dateTime|Quantity(Age)|Period|Range|string Estimated or actual date, date-time, or age --></onset[x]> <abatement[x]><!-- 0..1 dateTime|Quantity(Age)|boolean|Period|Range|string If/when in resolution/remission --></abatement[x]> <stage> <!-- 0..1 Stage/grade, usually assessed formally --> <summary><!-- 0..1 CodeableConcept Simple summary (disease specific) --></summary> <assessment><!-- 0..* Reference(ClinicalImpression|DiagnosticReport|Observation) Formal record of assessment --></assessment> </stage> <evidence> <!-- 0..* Supporting evidence --> <code><!-- 0..1 CodeableConcept Manifestation/symptom --></code> <detail><!-- 0..* Reference(Any) Supporting information found elsewhere --></detail> </evidence> <bodySite><!-- 0..* CodeableConcept Anatomical location, if relevant --></bodySite> <notes value="[string]"/><!-- 0..1 Additional information about the Condition --> </Condition>
JSON Template
{ "resourceType" : "Condition", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // External Ids for this condition "patient" : { Reference(Patient) }, // R! Who has the condition? "encounter" : { Reference(Encounter) }, // Encounter when condition first asserted "asserter" : { Reference(Practitioner|Patient) }, // Person who asserts this condition "dateRecorded" : "<date>", // When first entered "code" : { CodeableConcept }, // R! Identification of the condition, problem or diagnosis "category" : { CodeableConcept }, // complaint | symptom | finding | diagnosis "clinicalStatus" : "<code>", // active | relapse | remission | resolved "verificationStatus" : "<code>", // R! provisional | differential | confirmed | refuted | entered-in-error | unknown "severity" : { CodeableConcept }, // Subjective severity of condition // onset[x]: Estimated or actual date, date-time, or age. One of these 5: "onsetDateTime" : "<dateTime>", "onsetQuantity" : { Quantity(Age) }, "onsetPeriod" : { Period }, "onsetRange" : { Range }, "onsetString" : "<string>", // abatement[x]: If/when in resolution/remission. One of these 6: "abatementDateTime" : "<dateTime>", "abatementQuantity" : { Quantity(Age) }, "abatementBoolean" : <boolean>, "abatementPeriod" : { Period }, "abatementRange" : { Range }, "abatementString" : "<string>", "stage" : { // Stage/grade, usually assessed formally "summary" : { CodeableConcept }, // C? Simple summary (disease specific) "assessment" : [{ Reference(ClinicalImpression|DiagnosticReport|Observation) }] // C? Formal record of assessment }, "evidence" : [{ // Supporting evidence "code" : { CodeableConcept }, // C? Manifestation/symptom "detail" : [{ Reference(Any) }] // C? Supporting information found elsewhere }], "bodySite" : [{ CodeableConcept }], // Anatomical location, if relevant "notes" : "<string>" // Additional information about the Condition }
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | Σ | DomainResource | Detailed information about conditions, problems or diagnoses | |
identifier | Σ | 0..* | Identifier | External Ids for this condition |
patient | Σ | 1..1 | Reference(Patient) | Who has the condition? |
encounter | Σ | 0..1 | Reference(Encounter) | Encounter when condition first asserted |
asserter | Σ | 0..1 | Reference(Practitioner | Patient) | Person who asserts this condition |
dateRecorded | Σ | 0..1 | date | When first entered |
code | Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Condition/Problem/Diagnosis Codes (Example) |
category | Σ | 0..1 | CodeableConcept | complaint | symptom | finding | diagnosis Condition Category Codes (Preferred) |
clinicalStatus | ?! Σ | 0..1 | code | active | relapse | remission | resolved Condition Clinical Status Codes (Preferred) |
verificationStatus | ?! Σ | 1..1 | code | provisional | differential | confirmed | refuted | entered-in-error | unknown ConditionVerificationStatus (Required) |
severity | Σ | 0..1 | CodeableConcept | Subjective severity of condition Condition/Diagnosis Severity (Preferred) |
onset[x] | Σ | 0..1 | Estimated or actual date, date-time, or age | |
onsetDateTime | dateTime | |||
onsetQuantity | Age | |||
onsetPeriod | Period | |||
onsetRange | Range | |||
onsetString | string | |||
abatement[x] | Σ | 0..1 | If/when in resolution/remission | |
abatementDateTime | dateTime | |||
abatementQuantity | Age | |||
abatementBoolean | boolean | |||
abatementPeriod | Period | |||
abatementRange | Range | |||
abatementString | string | |||
stage | Σ I | 0..1 | BackboneElement | Stage/grade, usually assessed formally Stage SHALL have summary or assessment |
summary | Σ I | 0..1 | CodeableConcept | Simple summary (disease specific) Condition Stage (Example) |
assessment | Σ I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment |
evidence | Σ I | 0..* | BackboneElement | Supporting evidence evidence SHALL have code or details |
code | Σ I | 0..1 | CodeableConcept | Manifestation/symptom Manifestation and Symptom Codes (Example) |
detail | Σ I | 0..* | Reference(Any) | Supporting information found elsewhere |
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant SNOMED CT Body Structures (Example) |
notes | Σ | 0..1 | string | Additional information about the Condition |
Documentation for this format |
XML Template
<Condition xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier External Ids for this condition --></identifier> <patient><!-- 1..1 Reference(Patient) Who has the condition? --></patient> <encounter><!-- 0..1 Reference(Encounter) Encounter when condition first asserted --></encounter> <asserter><!-- 0..1 Reference(Practitioner|Patient) Person who asserts this condition --></asserter> <dateRecorded value="[date]"/><!-- 0..1 When first entered --> <code><!-- 1..1 CodeableConcept Identification of the condition, problem or diagnosis --></code> <category><!-- 0..1 CodeableConcept complaint | symptom | finding | diagnosis --></category> <clinicalStatus value="[code]"/><!-- 0..1 active | relapse | remission | resolved --> <verificationStatus value="[code]"/><!-- 1..1 provisional | differential | confirmed | refuted | entered-in-error | unknown --> <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity> <onset[x]><!-- 0..1 dateTime|Quantity(Age)|Period|Range|string Estimated or actual date, date-time, or age --></onset[x]> <abatement[x]><!-- 0..1 dateTime|Quantity(Age)|boolean|Period|Range|string If/when in resolution/remission --></abatement[x]> <stage> <!-- 0..1 Stage/grade, usually assessed formally --> <summary><!-- 0..1 CodeableConcept Simple summary (disease specific) --></summary> <assessment><!-- 0..* Reference(ClinicalImpression|DiagnosticReport|Observation) Formal record of assessment --></assessment> </stage> <evidence> <!-- 0..* Supporting evidence --> <code><!-- 0..1 CodeableConcept Manifestation/symptom --></code> <detail><!-- 0..* Reference(Any) Supporting information found elsewhere --></detail> </evidence> <bodySite><!-- 0..* CodeableConcept Anatomical location, if relevant --></bodySite> <notes value="[string]"/><!-- 0..1 Additional information about the Condition --> </Condition>
JSON Template
{ "resourceType" : "Condition", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // External Ids for this condition "patient" : { Reference(Patient) }, // R! Who has the condition? "encounter" : { Reference(Encounter) }, // Encounter when condition first asserted "asserter" : { Reference(Practitioner|Patient) }, // Person who asserts this condition "dateRecorded" : "<date>", // When first entered "code" : { CodeableConcept }, // R! Identification of the condition, problem or diagnosis "category" : { CodeableConcept }, // complaint | symptom | finding | diagnosis "clinicalStatus" : "<code>", // active | relapse | remission | resolved "verificationStatus" : "<code>", // R! provisional | differential | confirmed | refuted | entered-in-error | unknown "severity" : { CodeableConcept }, // Subjective severity of condition // onset[x]: Estimated or actual date, date-time, or age. One of these 5: "onsetDateTime" : "<dateTime>", "onsetQuantity" : { Quantity(Age) }, "onsetPeriod" : { Period }, "onsetRange" : { Range }, "onsetString" : "<string>", // abatement[x]: If/when in resolution/remission. One of these 6: "abatementDateTime" : "<dateTime>", "abatementQuantity" : { Quantity(Age) }, "abatementBoolean" : <boolean>, "abatementPeriod" : { Period }, "abatementRange" : { Range }, "abatementString" : "<string>", "stage" : { // Stage/grade, usually assessed formally "summary" : { CodeableConcept }, // C? Simple summary (disease specific) "assessment" : [{ Reference(ClinicalImpression|DiagnosticReport|Observation) }] // C? Formal record of assessment }, "evidence" : [{ // Supporting evidence "code" : { CodeableConcept }, // C? Manifestation/symptom "detail" : [{ Reference(Any) }] // C? Supporting information found elsewhere }], "bodySite" : [{ CodeableConcept }], // Anatomical location, if relevant "notes" : "<string>" // Additional information about the Condition }
Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire
Path | Definition | Type | Reference |
---|---|---|---|
Condition.code | Identification of the Condition or diagnosis. | Example | Condition/Problem/Diagnosis Codes |
Condition.category | A category assigned to the condition. | Preferred | Condition Category Codes |
Condition.clinicalStatus | The clinical status of the Condition or diagnosis | Preferred | Condition Clinical Status Codes |
Condition.verificationStatus | The verification status to support or decline the clinical status of the Condition or diagnosis. | Required | ConditionVerificationStatus |
Condition.severity | A subjective assessment of the severity of the condition as evaluated by the clinician. | Preferred | Condition/Diagnosis Severity |
Condition.stage.summary | Codes describing condition stages (e.g. Cancer stages) | Example | Condition Stage |
Condition.evidence.code | Codes that describe the manifestation or symptoms of a condition. | Example | Manifestation and Symptom Codes |
Condition.bodySite | Codes describing anatomical locations. May include laterality | Example | SNOMED CT Body Structures |
Many of the code systems used for coding conditions will provide codes that define not only the condition itself, but may also specify a particular stage, location, or causality as part of the code. This is particularly true if SNOMED-CT is used for the condition, and especially if expressions are allowed.
The Condition.code may also include such concepts as "history of X" and "good health", where it is useful or appropriate to make such assertions.. It can also be used to capture "risk of" and "fear of" in addition to physical conditions.
When the Condition.code specifies additional properties of the condition, the other properties are not given a value - instead, the value must be understood from the Condition.code.
The Condition.evidence provides the basis for whatever is present in Condition.code.
A range is used to communicate age period of subject at time of abatement.
If the data enterer is different from the asserter and needs to be known, this could be captured using a Provenance instance pointing to the Condition. For example, it is possible that a nurse records the condition on behalf of a physician. The physician is taking responsibility, despite the nurse entering it into the medical record.
The Condition.stage and Condition.clinicalStatus may have interdependencies. For example, some "stages" of cancer, etc. will be different for a remission than for the initial occurrence.
Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
Name | Type | Description | Paths |
asserter | reference | Person who asserts this condition | Condition.asserter (Patient, Practitioner) |
body-site | token | Anatomical location, if relevant | Condition.bodySite |
category | token | The category of the condition | Condition.category |
clinicalstatus | token | The clinical status of the condition | Condition.clinicalStatus |
code | token | Code for the condition | Condition.code |
date-recorded | date | A date, when the Condition statement was documented | Condition.dateRecorded |
encounter | reference | Encounter when condition first asserted | Condition.encounter (Encounter) |
evidence | token | Manifestation/symptom | Condition.evidence.code |
identifier | token | A unique identifier of the condition record | Condition.identifier |
onset | date | Date related onsets (dateTime and Period) | Condition.onset[x] |
onset-info | string | Other onsets (boolean, age, range, string) | Condition.onset[x] |
patient | reference | Who has the condition? | Condition.patient (Patient) |
severity | token | The severity of the condition | Condition.severity |
stage | token | Simple summary (disease specific) | Condition.stage.summary |