DSTU2 QA Preview

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

F.??.4 StructureDefinition: QICore-Condition - Detailed Descriptions

Definitions for the qicore-condition Profile.

Condition(QICore-Condition)
Definition

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.

Control0..*
TypeCondition
Condition.id
Definition

The logical id of the resource, as used in the url for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.

Condition.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
Condition.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.

Condition.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language
The codes SHALL be taken from http://tools.ietf.org/html/bcp47
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Condition.text
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

Condition.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

Condition.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: url
Condition.extension (http://hl7.org/fhir/StructureDefinition/condition-criticality)
Definition

Characterizes potential impact of the condition on life, durable physiological function, or quality of life. May include concepts such as self-resolving, life-threatening, requires hospitalization, or potential loss of function or capacity. Different from severity in that a moderate subarachnoid hemorrhage is likely to be highly critical, whereas a moderate headache is not as important.

Control0..1
TypeExtension (Extension Type: CodeableConcept)
Comments

What is the value set for this?

Condition.extension(bodySiteInstance)
Definition

An Extension

Control0..*
TypeReference(QICore-BodySite)
Must Supporttrue
Condition.extension (http://hl7.org/fhir/StructureDefinition/condition-dueTo)
Definition

Further conditions, problems, diagnoses, procedures or events or the substance that caused/triggered this Condition.

Control0..*
TypeExtension (Extension Type: Choice of: boolean, integer, decimal, base64Binary, instant, string, uri, date, dateTime, time, code, oid, id, unsignedInt, positiveInt, markdown, Annotation, Attachment, Identifier, CodeableConcept, Coding, Quantity, Range, Period, Ratio, SampledData, Signature, HumanName, Address, ContactPoint, Timing, Reference, Meta)
Comments

Although a condition may be caused by a substance, this is not intended to be used to record allergies/adverse reactions to substances.

Condition.extension.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Condition.extension.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: url
Condition.extension.extension (http://hl7.org/fhir/StructureDefinition/condition-dueTo#code)
Definition

Further conditions, problems, diagnoses, procedures or events or the substance that caused/triggered this Condition.

Control0..*
TypeExtension (Extension Type: Choice of: boolean, integer, decimal, base64Binary, instant, string, uri, date, dateTime, time, code, oid, id, unsignedInt, positiveInt, markdown, Annotation, Attachment, Identifier, CodeableConcept, Coding, Quantity, Range, Period, Ratio, SampledData, Signature, HumanName, Address, ContactPoint, Timing, Reference, Meta)
Comments

Although a condition may be caused by a substance, this is not intended to be used to record allergies/adverse reactions to substances.

Condition.extension.extension(dueTo.detail)
Definition

An Extension

Control0..*
TypeChoice of: Reference(QICore-Condition), Reference(QICore-Procedure), Reference(QICore-MedicationAdministration), Reference(QICore-MedicationStatement), Reference(QICore-Immunization)
Condition.extension.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition should be version specific. This will ideally be the URI for the Resource Profile defining the extension, with the code for the extension after a #.

Condition.extension.value[x]
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control0..1
TypeChoice of: boolean, integer, decimal, base64Binary, instant, string, uri, date, dateTime, time, code, oid, id, unsignedInt, positiveInt, markdown, Annotation, Attachment, Identifier, CodeableConcept, Coding, Quantity, Range, Period, Ratio, SampledData, Signature, HumanName, Address, ContactPoint, Timing, Reference, Meta
[x] NoteSee Choice of Data Types for further information about how to use [x]
Condition.extension (http://hl7.org/fhir/StructureDefinition/condition-occurredFollowing)
Definition

Further conditions, problems, diagnoses, procedures or events or the substance that preceded this Condition.

Control0..*
TypeExtension (Extension Type: Choice of: boolean, integer, decimal, base64Binary, instant, string, uri, date, dateTime, time, code, oid, id, unsignedInt, positiveInt, markdown, Annotation, Attachment, Identifier, CodeableConcept, Coding, Quantity, Range, Period, Ratio, SampledData, Signature, HumanName, Address, ContactPoint, Timing, Reference, Meta)
Condition.extension.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Condition.extension.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: url
Condition.extension.extension (http://hl7.org/fhir/StructureDefinition/condition-occurredFollowing#code)
Definition

Further conditions, problems, diagnoses, procedures or events or the substance that preceded this Condition.

Control0..*
TypeExtension (Extension Type: Choice of: boolean, integer, decimal, base64Binary, instant, string, uri, date, dateTime, time, code, oid, id, unsignedInt, positiveInt, markdown, Annotation, Attachment, Identifier, CodeableConcept, Coding, Quantity, Range, Period, Ratio, SampledData, Signature, HumanName, Address, ContactPoint, Timing, Reference, Meta)
Condition.extension.extension(occurredFollowing.detail)
Definition

An Extension

Control0..*
TypeChoice of: Reference(QICore-Condition), Reference(QICore-Procedure), Reference(QICore-MedicationAdministration), Reference(QICore-MedicationStatement), Reference(QICore-Immunization)
Condition.extension.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition should be version specific. This will ideally be the URI for the Resource Profile defining the extension, with the code for the extension after a #.

Condition.extension.value[x]
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control0..1
TypeChoice of: boolean, integer, decimal, base64Binary, instant, string, uri, date, dateTime, time, code, oid, id, unsignedInt, positiveInt, markdown, Annotation, Attachment, Identifier, CodeableConcept, Coding, Quantity, Range, Period, Ratio, SampledData, Signature, HumanName, Address, ContactPoint, Timing, Reference, Meta
[x] NoteSee Choice of Data Types for further information about how to use [x]
Condition.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.identifier
Definition

This records identifiers associated with this condition that are defined by business processed and/ or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

Control0..*
TypeIdentifier
Requirements

Need to allow connection to a wider workflow.

Condition.patient
Definition

Indicates the patient who the condition record is associated with.

Control1..1
TypeReference(QICore-Patient)
Must Supporttrue
Condition.encounter
Definition

Encounter during which the condition was first asserted.

Control0..1
TypeReference(QICore-Encounter)
Must Supporttrue
Comments

This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".

Condition.asserter
Definition

Individual who is making the condition statement.

Control0..1
TypeChoice of: Reference(QICore-Patient), Reference(QICore-Practitioner)
Condition.dateRecorded
Definition

A date, when the Condition statement was documented.

Control0..1
Typedate
Must Supporttrue
Comments

The Date Recorded represents the date when this particular Condition record was created in the EHR, not the date of the most recent update in terms of when severity, abatement, etc. were specified.  The date of the last record modification can be retrieved from the resource metadata.

Condition.code
Definition

Identification of the condition, problem or diagnosis.

Control1..1
BindingThe code for the condition
The codes SHOULD be taken from Problem Value Set
TypeCodeableConcept
Must Supporttrue
Condition.category
Definition

A category assigned to the condition.

Control0..1
BindingA category assigned to the condition.
The codes SHOULD be taken from Condition Category Codes
TypeCodeableConcept
Must Supporttrue
Comments

The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.

Condition.clinicalStatus
Definition

The clinical status of the condition.

Control0..1
BindingThe clinical status of the Condition or diagnosis
The codes SHOULD be taken from Condition Clinical Status Codes
Typecode
Is Modifiertrue
Must Supporttrue
Condition.verificationStatus
Definition

The verification status to support the clinical status of the condition.

Control1..1
BindingThe verification status to support or decline the clinical status of the Condition or diagnosis.
The codes SHALL be taken from ConditionVerificationStatus
Typecode
Is Modifiertrue
Condition.severity
Definition

A subjective assessment of the severity of the condition as evaluated by the clinician.

Control0..1
BindingA subjective assessment of the severity of the condition as evaluated by the clinician.
The codes SHOULD be taken from Condition/Diagnosis Severity
TypeCodeableConcept
Must Supporttrue
Comments

Coding of the severity with a terminology is preferred, where possible.

Condition.onset[x]
Definition

Estimated or actual date or date-time the condition began, in the opinion of the clinician.

Control0..1
TypeChoice of: dateTime, Quantity(Age), Period, Range, string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Comments

Age is generally used when the patient reports an age at which the Condition began to occur.

Condition.abatement[x]
Definition

The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate.

Control0..1
TypeChoice of: dateTime, Quantity(Age), boolean, Period, Range, string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Comments

There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid.

Condition.stage
Definition

Clinical stage or grade of a condition. May include formal severity assessments.

Control0..1
TypeBackboneElement
Must Supporttrue
InvariantsDefined on this element
con-1: Stage SHALL have summary or assessment (xpath: exists(f:summary) or exists(f:assessment))
Condition.stage.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Condition.stage.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.stage.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.stage.summary
Definition

A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.

Control0..1 This element is affected by the following invariants: con-1
BindingA period or phase in the course of a disease
The codes SHOULD be taken from Disease Stage Value Set
TypeCodeableConcept
Must Supporttrue
Condition.stage.assessment
Definition

Reference to a formal record of the evidence on which the staging assessment is based.

Control0..* This element is affected by the following invariants: con-1
TypeChoice of: Reference(ClinicalImpression), Reference(DiagnosticReport), Reference(Observation)
Condition.evidence
Definition

Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed.

Control0..*
TypeBackboneElement
Comments

The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.

InvariantsDefined on this element
con-2: evidence SHALL have code or details (xpath: exists(f:code) or exists(f:detail))
Condition.evidence.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Condition.evidence.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.evidence.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.evidence.code
Definition

A manifestation or symptom that led to the recording of this condition.

Control0..1 This element is affected by the following invariants: con-2
BindingCodes that describe the manifestation or symptoms of a condition.
For example codes, see Manifestation and Symptom Codes
TypeCodeableConcept
Condition.evidence.detail
Definition

Links to other relevant information, including pathology reports.

Control0..* This element is affected by the following invariants: con-2
TypeReference(Resource)
Condition.bodySite
Definition

The anatomical location where this condition manifests itself.

Control0..*
BindingCodes describing anatomical locations. May include laterality
For example codes, see SNOMED CT Body Structures
TypeCodeableConcept
Must Supporttrue
Comments

May be a summary code, or a reference to a very precise definition of the location, or both.

Condition.notes
Definition

Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.

Control0..1
Typestring