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 
StructureDefinition for The Condition(s) referenced in USRealm laboratory test and reporting in ambulatory care setting.
{
"resourceType": "StructureDefinition",
"id": "uslab-cond",
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"url": "http://hl7.org/fhir/StructureDefinition/uslab-cond",
"name": "US Laboratory Condition Profile",
"status": "draft",
"publisher": "Health Level Seven International (Orders and Observations - US Lab)",
"contact": [
{
"telecom": [
{
"system": "other",
"value": "http://hl7.org"
}
]
}
],
"date": "2014-11-17",
"description": "The Condition(s) referenced in USRealm laboratory test and reporting in ambulatory care setting.",
"kind": "resource",
"constrainedType": "Condition",
"abstract": false,
"base": "http://hl7.org/fhir/StructureDefinition/Condition",
"snapshot": {
"element": [
{
"path": "Condition",
"name": "USlab-Cond",
"short": "Detailed information about conditions, problems or diagnoses",
"definition": "Reason for Study or Additional Clinical Information for Laboratorian or Pathologist.",
"comments": "For supplying ICD9 -CM and ICD_10 CM codes to demonstrate medical necessity for ordering lab tests use USLabReasonForStudy.",
"alias": [
"Reason for Study"
],
"min": 0,
"max": "*",
"base": {
"path": "Condition",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Condition"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "PPR message"
},
{
"identity": "rim",
"map": "Observation[classCode=OBS, moodCode=EVN, code=ASSERTION, value<Diagnosis]"
},
{
"identity": "w5",
"map": "clinical.general"
}
]
},
{
"path": "Condition.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the url for the resource. Once assigned, this value never changes.",
"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.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"path": "Condition.meta",
"short": "Metadata about the resource",
"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.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.meta",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"path": "Condition.implicitRules",
"short": "A set of rules under which this content was created",
"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.",
"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.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.implicitRules",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"path": "Condition.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"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).",
"min": 0,
"max": "1",
"base": {
"path": "Condition.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"binding": {
"strength": "required",
"description": "A human language",
"valueSetUri": "http://tools.ietf.org/html/bcp47"
}
},
{
"path": "Condition.text",
"short": "Text summary of the resource, for human interpretation",
"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.",
"comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "Condition.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"path": "Condition.contained",
"short": "Contained, inline Resources",
"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.",
"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.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "Condition.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Condition.extension",
"short": "Additional Content defined by implementations",
"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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Condition.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Condition.modifierExtension",
"short": "Extensions that cannot be ignored",
"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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Condition.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Condition.identifier",
"short": "External Ids for this condition",
"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).",
"requirements": "Need to allow connection to a wider workflow.",
"min": 0,
"max": "*",
"base": {
"path": "Condition.identifier",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".id"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"path": "Condition.patient",
"short": "Patient",
"definition": "Patient.",
"alias": [
"Patient"
],
"min": 1,
"max": "1",
"base": {
"path": "Condition.patient",
"min": 1,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/uslab-patient"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/uslab-phpatient"
]
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "PID-3"
},
{
"identity": "rim",
"map": ".participation[typeCode=SBJ].role[classCode=PAT]"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"path": "Condition.encounter",
"short": "Encounter when condition first asserted",
"definition": "Encounter during which the condition was first asserted.",
"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\".",
"min": 0,
"max": "1",
"base": {
"path": "Condition.encounter",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Encounter"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "PV1-19 (+PV1-54)"
},
{
"identity": "rim",
"map": ".inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]"
},
{
"identity": "w5",
"map": "context"
}
]
},
{
"path": "Condition.asserter",
"short": "Person who asserts this condition",
"definition": "Individual who is making the condition statement.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.asserter",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "REL-7.1 identifier + REL-7.12 type code"
},
{
"identity": "rim",
"map": ".participation[typeCode=AUT].role"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"path": "Condition.dateRecorded",
"short": "When first entered",
"definition": "A date, when the Condition statement was documented.",
"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.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.dateRecorded",
"min": 0,
"max": "1"
},
"type": [
{
"code": "date"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "REL-11"
},
{
"identity": "rim",
"map": ".participation[typeCode=AUT].time"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"path": "Condition.code",
"short": "Identification of the condition, problem or diagnosis",
"definition": "Identification of the condition, problem or diagnosis.",
"min": 1,
"max": "1",
"base": {
"path": "Condition.code",
"min": 1,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"mustSupport": true,
"isSummary": true,
"binding": {
"strength": "example",
"description": "Identification of the Condition or diagnosis.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
},
"mapping": [
{
"identity": "v2",
"map": "PRB-3"
},
{
"identity": "rim",
"map": ".value"
},
{
"identity": "w5",
"map": "what"
}
]
},
{
"path": "Condition.code.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "CodeableConcept.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.code.extension",
"short": "Additional Content defined by implementations",
"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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "CodeableConcept.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.code.coding",
"short": "Code defined by a terminology system",
"definition": "A reference to a code defined by a terminology system.",
"comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the V3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.",
"requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.",
"min": 0,
"max": "1",
"base": {
"path": "CodeableConcept.coding",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Coding"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding"
},
{
"identity": "v2",
"map": "C*E.1-8, C*E.10-22"
},
{
"identity": "rim",
"map": "union(., ./translation)"
}
]
},
{
"path": "Condition.code.coding.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "Coding.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.code.coding.extension",
"short": "Additional Content defined by implementations",
"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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Coding.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.code.coding.system",
"short": "Identity of the terminology system",
"definition": "The identification of the code system that defines the meaning of the symbol in the code.",
"comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.",
"requirements": "Need to be unambiguous about the source of the definition of the symbol.",
"min": 1,
"max": "1",
"base": {
"path": "Coding.system",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem"
},
{
"identity": "v2",
"map": "C*E.3"
},
{
"identity": "rim",
"map": "./codeSystem"
}
]
},
{
"path": "Condition.code.coding.version",
"short": "Version of the system - if relevant",
"definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.",
"comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.",
"min": 0,
"max": "1",
"base": {
"path": "Coding.version",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion"
},
{
"identity": "v2",
"map": "C*E.7"
},
{
"identity": "rim",
"map": "./codeSystemVersion"
}
]
},
{
"path": "Condition.code.coding.code",
"short": "Symbol in syntax defined by the system",
"definition": "A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).",
"requirements": "Need to refer to a particular code in the system.",
"min": 1,
"max": "1",
"base": {
"path": "Coding.code",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code"
},
{
"identity": "v2",
"map": "C*E.1"
},
{
"identity": "rim",
"map": "./code"
}
]
},
{
"path": "Condition.code.coding.display",
"short": "Representation defined by the system",
"definition": "A representation of the meaning of the code in the system, following the rules of the system.",
"requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.",
"min": 0,
"max": "1",
"base": {
"path": "Coding.display",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName"
},
{
"identity": "v2",
"map": "C*E.2 - but note this is not well followed"
},
{
"identity": "rim",
"map": "CV.displayName"
}
]
},
{
"path": "Condition.code.coding.userSelected",
"short": "If this coding was chosen directly by the user",
"definition": "Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).",
"comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.",
"requirements": "This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.",
"min": 0,
"max": "1",
"base": {
"path": "Coding.userSelected",
"min": 0,
"max": "1"
},
"type": [
{
"code": "boolean"
}
],
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]"
},
{
"identity": "v2",
"map": "Sometimes implied by being first"
},
{
"identity": "rim",
"map": "CD.codingRationale"
}
]
},
{
"path": "Condition.code.text",
"short": "Plain text representation of the concept",
"definition": "A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.",
"comments": "Very often the text is the same as a displayName of one of the codings.",
"requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.",
"min": 0,
"max": "1",
"base": {
"path": "CodeableConcept.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText"
},
{
"identity": "v2",
"map": "C*E.9. But note many systems use C*E.2 for this"
},
{
"identity": "rim",
"map": "./originalText[mediaType/code=\"text/plain\"]/data"
}
]
},
{
"path": "Condition.category",
"short": "complaint | symptom | finding | diagnosis",
"definition": "A category assigned to the condition.",
"comments": "The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.",
"min": 1,
"max": "1",
"base": {
"path": "Condition.category",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"mustSupport": true,
"isSummary": true,
"binding": {
"strength": "preferred",
"description": "A category assigned to the condition.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-category"
}
},
"mapping": [
{
"identity": "v2",
"map": "'problem' if from PRB-3. 'diagnosis' if from DG1 segment in PV1 message"
},
{
"identity": "rim",
"map": ".code"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"path": "Condition.category.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "CodeableConcept.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.category.extension",
"short": "Additional Content defined by implementations",
"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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "CodeableConcept.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.category.coding",
"short": "Code defined by a terminology system",
"definition": "A reference to a code defined by a terminology system.",
"comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the V3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.",
"requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.",
"min": 0,
"max": "1",
"base": {
"path": "CodeableConcept.coding",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Coding"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding"
},
{
"identity": "v2",
"map": "C*E.1-8, C*E.10-22"
},
{
"identity": "rim",
"map": "union(., ./translation)"
}
]
},
{
"path": "Condition.category.coding.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "Coding.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.category.coding.extension",
"short": "Additional Content defined by implementations",
"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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Coding.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.category.coding.system",
"short": "Identity of the terminology system",
"definition": "The identification of the code system that defines the meaning of the symbol in the code.",
"comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.",
"requirements": "Need to be unambiguous about the source of the definition of the symbol.",
"min": 1,
"max": "1",
"base": {
"path": "Coding.system",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem"
},
{
"identity": "v2",
"map": "C*E.3"
},
{
"identity": "rim",
"map": "./codeSystem"
}
]
},
{
"path": "Condition.category.coding.version",
"short": "Version of the system - if relevant",
"definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.",
"comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.",
"min": 0,
"max": "1",
"base": {
"path": "Coding.version",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion"
},
{
"identity": "v2",
"map": "C*E.7"
},
{
"identity": "rim",
"map": "./codeSystemVersion"
}
]
},
{
"path": "Condition.category.coding.code",
"short": "Symbol in syntax defined by the system",
"definition": "A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).",
"requirements": "Need to refer to a particular code in the system.",
"min": 1,
"max": "1",
"base": {
"path": "Coding.code",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code"
},
{
"identity": "v2",
"map": "C*E.1"
},
{
"identity": "rim",
"map": "./code"
}
]
},
{
"path": "Condition.category.coding.display",
"short": "Representation defined by the system",
"definition": "A representation of the meaning of the code in the system, following the rules of the system.",
"requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.",
"min": 0,
"max": "1",
"base": {
"path": "Coding.display",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName"
},
{
"identity": "v2",
"map": "C*E.2 - but note this is not well followed"
},
{
"identity": "rim",
"map": "CV.displayName"
}
]
},
{
"path": "Condition.category.coding.userSelected",
"short": "If this coding was chosen directly by the user",
"definition": "Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).",
"comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.",
"requirements": "This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.",
"min": 0,
"max": "1",
"base": {
"path": "Coding.userSelected",
"min": 0,
"max": "1"
},
"type": [
{
"code": "boolean"
}
],
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]"
},
{
"identity": "v2",
"map": "Sometimes implied by being first"
},
{
"identity": "rim",
"map": "CD.codingRationale"
}
]
},
{
"path": "Condition.category.text",
"short": "Plain text representation of the concept",
"definition": "A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.",
"comments": "Very often the text is the same as a displayName of one of the codings.",
"requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.",
"min": 0,
"max": "1",
"base": {
"path": "CodeableConcept.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "orim",
"map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText"
},
{
"identity": "v2",
"map": "C*E.9. But note many systems use C*E.2 for this"
},
{
"identity": "rim",
"map": "./originalText[mediaType/code=\"text/plain\"]/data"
}
]
},
{
"path": "Condition.clinicalStatus",
"short": "active | relapse | remission | resolved",
"definition": "The clinical status of the condition.",
"min": 1,
"max": "1",
"base": {
"path": "Condition.clinicalStatus",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"mustSupport": true,
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "preferred",
"description": "The clinical status of the Condition or diagnosis",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-clinical"
}
},
"mapping": [
{
"identity": "v2",
"map": "PRB-14 / DG1-6"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"path": "Condition.verificationStatus",
"short": "provisional | differential | confirmed | refuted | entered-in-error | unknown",
"definition": "The verification status to support the clinical status of the condition.",
"min": 1,
"max": "1",
"base": {
"path": "Condition.verificationStatus",
"min": 1,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "required",
"description": "The verification status to support or decline the clinical status of the Condition or diagnosis.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-ver-status"
}
},
"mapping": [
{
"identity": "v2",
"map": "PRB-13"
},
{
"identity": "rim",
"map": ".code (pre or post-coordinated in) Can use valueNegationInd for refuted"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"path": "Condition.severity",
"short": "Subjective severity of condition",
"definition": "A subjective assessment of the severity of the condition as evaluated by the clinician.",
"comments": "Coding of the severity with a terminology is preferred, where possible.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.severity",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "preferred",
"description": "A subjective assessment of the severity of the condition as evaluated by the clinician.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-severity"
}
},
"mapping": [
{
"identity": "v2",
"map": "PRB-26 / ABS-3"
},
{
"identity": "rim",
"map": "Can be pre/post-coordinated into value. Or ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code=\"severity\"].value"
},
{
"identity": "w5",
"map": "grade"
}
]
},
{
"path": "Condition.onset[x]",
"short": "Estimated or actual date, date-time, or age",
"definition": "Estimated or actual date or date-time the condition began, in the opinion of the clinician.",
"comments": "Age is generally used when the patient reports an age at which the Condition began to occur.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.onset[x]",
"min": 0,
"max": "1"
},
"type": [
{
"code": "dateTime"
},
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Age"
]
},
{
"code": "Period"
},
{
"code": "Range"
},
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "PRB-16"
},
{
"identity": "rim",
"map": ".effectiveTime.low or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code=\"age at onset\"].value"
},
{
"identity": "w5",
"map": "when.init"
}
]
},
{
"path": "Condition.abatement[x]",
"short": "If/when in resolution/remission",
"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.",
"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.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.abatement[x]",
"min": 0,
"max": "1"
},
"type": [
{
"code": "dateTime"
},
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Age"
]
},
{
"code": "boolean"
},
{
"code": "Period"
},
{
"code": "Range"
},
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".effectiveTime.high or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code=\"age at remission\"].value or .inboundRelationship[typeCode=SUBJ]source[classCode=CONC, moodCode=EVN].status=completed"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"path": "Condition.stage",
"short": "Stage/grade, usually assessed formally",
"definition": "Clinical stage or grade of a condition. May include formal severity assessments.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.stage",
"min": 0,
"max": "1"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "con-1",
"severity": "error",
"human": "Stage SHALL have summary or assessment",
"xpath": "exists(f:summary) or exists(f:assessment)"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code=\"stage/grade\"]"
}
]
},
{
"path": "Condition.stage.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "Condition.stage.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.stage.extension",
"short": "Additional Content defined by implementations",
"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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Condition.stage.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.stage.modifierExtension",
"short": "Extensions that cannot be ignored",
"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.",
"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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "Condition.stage.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Condition.stage.summary",
"short": "Simple summary (disease specific)",
"definition": "A simple summary of the stage such as \"Stage 3\". The determination of the stage is disease-specific.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.stage.summary",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"condition": [
"con-1"
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Codes describing condition stages (e.g. Cancer stages)",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-stage"
}
},
"mapping": [
{
"identity": "rim",
"map": ".value"
}
]
},
{
"path": "Condition.stage.assessment",
"short": "Formal record of assessment",
"definition": "Reference to a formal record of the evidence on which the staging assessment is based.",
"min": 0,
"max": "*",
"base": {
"path": "Condition.stage.assessment",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ClinicalImpression"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/DiagnosticReport"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Observation"
]
}
],
"condition": [
"con-1"
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".self"
}
]
},
{
"path": "Condition.evidence",
"short": "Supporting evidence",
"definition": "Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed.",
"comments": "The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.",
"min": 0,
"max": "*",
"base": {
"path": "Condition.evidence",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "con-2",
"severity": "error",
"human": "evidence SHALL have code or details",
"xpath": "exists(f:code) or exists(f:detail)"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".outboundRelationship[typeCode=SPRT].target[classCode=OBS, moodCode=EVN]"
}
]
},
{
"path": "Condition.evidence.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "Condition.evidence.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.evidence.extension",
"short": "Additional Content defined by implementations",
"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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Condition.evidence.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Condition.evidence.modifierExtension",
"short": "Extensions that cannot be ignored",
"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.",
"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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "Condition.evidence.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Condition.evidence.code",
"short": "Manifestation/symptom",
"definition": "A manifestation or symptom that led to the recording of this condition.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.evidence.code",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"condition": [
"con-2"
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Codes that describe the manifestation or symptoms of a condition.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/manifestation-or-symptom"
}
},
"mapping": [
{
"identity": "rim",
"map": "[code=\"diagnosis\"].value"
}
]
},
{
"path": "Condition.evidence.detail",
"short": "Supporting information found elsewhere",
"definition": "Links to other relevant information, including pathology reports.",
"min": 0,
"max": "*",
"base": {
"path": "Condition.evidence.detail",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Resource"
]
}
],
"condition": [
"con-2"
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".self"
}
]
},
{
"path": "Condition.bodySite",
"short": "Anatomical location, if relevant",
"definition": "The anatomical location where this condition manifests itself.",
"comments": "May be a summary code, or a reference to a very precise definition of the location, or both.",
"min": 0,
"max": "*",
"base": {
"path": "Condition.bodySite",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Codes describing anatomical locations. May include laterality",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/body-site"
}
},
"mapping": [
{
"identity": "rim",
"map": ".targetBodySiteCode"
}
]
},
{
"path": "Condition.notes",
"short": "Additional information about the Condition",
"definition": "Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.",
"min": 0,
"max": "1",
"base": {
"path": "Condition.notes",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "NTE child of PRB"
},
{
"identity": "rim",
"map": ".inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value"
}
]
}
]
},
"differential": {
"element": [
{
"path": "Condition",
"name": "USlab-Cond",
"definition": "Reason for Study or Additional Clinical Information for Laboratorian or Pathologist.",
"comments": "For supplying ICD9 -CM and ICD_10 CM codes to demonstrate medical necessity for ordering lab tests use USLabReasonForStudy.",
"alias": [
"Reason for Study"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Condition"
}
]
},
{
"path": "Condition.patient",
"short": "Patient",
"definition": "Patient.",
"alias": [
"Patient"
],
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/uslab-patient"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/uslab-phpatient"
]
}
],
"mustSupport": true
},
{
"path": "Condition.code",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.code.coding",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.code.coding.system",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.code.coding.code",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.code.coding.display",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.code.text",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.category",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.category.coding",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.category.coding.system",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.category.coding.code",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.category.coding.display",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.clinicalStatus",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "Condition.notes",
"min": 0,
"max": "1",
"mustSupport": true
}
]
}
}
© HL7.org 2011+. FHIR DSTU2 (v1.0.0-6850) generated on Tue, Sep 1, 2015 14:42+1000.
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