STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

9.2 Resource Condition - Content

Patient Care Work GroupMaturity Level: 2Compartments: Encounter, Patient, Practitioner, RelatedPerson

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.

9.2.1 Scope and Usage

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:

  • recording a problem, diagnosis, health concern or health issue during an encounter
  • the use of such information to populate a problem list of a summary statement such as a discharge summary

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 be used to record a condition following a procedure, such as the condition of Amputee-BKA following an amputation procedure.

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.

9.2.2 Boundaries and Relationships

The condition resource may be referenced by other resources as "reasons" for an action (e.g. MedicationRequest, Procedure, DiagnosticRequest, 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.

Use the Observation resource when a symptom is resolved without long term management, tracking, or when a symptom contributes to the establishment of a condition.

Use Condition when a symptom requires long term management, tracking, or is used as a proxy for a diagnosis or problem that is not yet determined.

The condition resource also specifically excludes AllergyIntolerance as those are handled with their own resource.

STU Note: The Condition.category element is a CodeableConcept data type with a preferred (not required) binding to four category codes: complaint | symptom | finding | diagnosis from the FHIR-defined condition-category code system and value set. In GFORGE # 10091 , the conformance requirements for code vs. CodeableConcept (4a) note that a CodeableConcept should use a standard terminology such as SNOMED CT. The Patient Care WG has recommended that Condition.category be changed to a code data type with a required binding to the condition-category value set (containing the four codes: complaint | symptom | finding | diagnosis as noted above).

Feedback is sought particularly on these questions:

  1. Is CodeableConcept needed for Condition.category? If so, what are the concepts that could be used from SNOMED CT for this constrained value set? How would this impact searching by category?
  2. If Condition.category is changed to a code data type, is the use of the current four codes adequate for condition classification, or are additional codes needed? If so, what would these be? Note the recommendation to make this a required, not a preferred binding. Please comment on the impact of high level categories vs. more granular categories.

PLANNED CHANGE:

Condition is one of the Event resources in the FHIR Workflow specification. As such, it is expected to be adjusted to align with the Event workflow pattern which will involve adding a number of additional data elements and potentially renaming a few elements. Any concerns about performing such alignment are welcome as ballot comments and/or tracker items.

This resource is referenced by CarePlan, Claim, ClinicalImpression, DiagnosticRequest, Encounter, EpisodeOfCare, ExplanationOfBenefit, Goal, MedicationAdministration, MedicationRequest, MedicationStatement, Procedure, ProcedureRequest, RiskAssessment and VisionPrescription

9.2.3 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition IDomainResourceDetailed information about conditions, problems or diagnoses
If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!Σ0..1codeactive | recurrence | inactive | remission | resolved
Condition Clinical Status Codes (Required)
... verificationStatus ?!Σ0..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
ConditionVerificationStatus (Required)
... category 0..*CodeableConceptproblem-list-item | encounter-diagnosis
Condition Category Codes (Example)
... severity 0..1CodeableConceptSubjective severity of condition
Condition/Diagnosis Severity (Preferred)
... code Σ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Condition/Problem/Diagnosis Codes (Example)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
SNOMED CT Body Structures (Example)
... subject Σ1..1Reference(Patient | Group)Who has the condition?
... context 0..1Reference(Encounter | EpisodeOfCare)Encounter when condition first asserted
... onset[x] Σ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] 0..1If/when in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementBooleanboolean
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... assertedDate 0..1dateDate record was believed accurate
... asserter Σ0..1Reference(Practitioner | Patient | RelatedPerson)Person who asserts this condition
... stage I0..1BackboneElementStage/grade, usually assessed formally
Stage SHALL have summary or assessment
.... summary I0..1CodeableConceptSimple summary (disease specific)
Condition Stage (Example)
.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
evidence SHALL have code or details
.... code I0..1CodeableConceptManifestation/symptom
Manifestation and Symptom Codes (Example)
.... detail I0..*Reference(Any)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

UML Diagram (Legend)

Condition (DomainResource)This records identifiers associated with this condition that are defined by business processes 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)identifier : Identifier [0..*]The clinical status of the condition (this element modifies the meaning of other elements)clinicalStatus : code [0..1] « The clinical status of the condition or diagnosis. (Strength=Required)Condition Clinical Status ! »The verification status to support the clinical status of the condition (this element modifies the meaning of other elements)verificationStatus : code [0..1] « The verification status to support or decline the clinical status of the condition or diagnosis. (Strength=Required)ConditionVerificationStatus! »A category assigned to the conditioncategory : CodeableConcept [0..*] « A category assigned to the condition. (Strength=Example)Condition Category ?? »A subjective assessment of the severity of the condition as evaluated by the clinicianseverity : CodeableConcept [0..1] « A subjective assessment of the severity of the condition as evaluated by the clinician. (Strength=Preferred)Condition/Diagnosis Severity? »Identification of the condition, problem or diagnosiscode : CodeableConcept [1..1] « Identification of the condition or diagnosis. (Strength=Example)Condition/Problem/Diagnosis ?? »The anatomical location where this condition manifests itselfbodySite : CodeableConcept [0..*] « Codes describing anatomical locations. May include laterality. (Strength=Example)SNOMED CT Body Structures?? »Indicates the patient or group who the condition record is associated withsubject : Reference [1..1] « Patient|Group »Encounter during which the condition was first assertedcontext : Reference [0..1] « Encounter|EpisodeOfCare »Estimated or actual date or date-time the condition began, in the opinion of the clinicianonset[x] : Type [0..1] « dateTime|Age|Period|Range|string »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 abateabatement[x] : Type [0..1] « dateTime|Age|boolean|Period|Range| string »The date on which the existance of the Condition was first asserted or acknowledgedassertedDate : date [0..1]Individual who is making the condition statementasserter : Reference [0..1] « Practitioner|Patient|RelatedPerson »Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosisnote : Annotation [0..*]StageA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specificsummary : CodeableConcept [0..1] « Codes describing condition stages (e.g. Cancer stages). (Strength=Example)Condition Stage?? »Reference to a formal record of the evidence on which the staging assessment is basedassessment : Reference [0..*] « ClinicalImpression|DiagnosticReport| Observation »EvidenceA manifestation or symptom that led to the recording of this conditioncode : CodeableConcept [0..1] « Codes that describe the manifestation or symptoms of a condition. (Strength=Example)Manifestation and Symptom ?? »Links to other relevant information, including pathology reportsdetail : Reference [0..*] « Any »Clinical stage or grade of a condition. May include formal severity assessmentsstage[0..1]Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmedevidence[0..*]

XML Template

<Condition xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <clinicalStatus value="[code]"/><!-- 0..1 active | recurrence | inactive | remission | resolved -->
 <verificationStatus value="[code]"/><!-- 0..1 provisional | differential | confirmed | refuted | entered-in-error | unknown -->
 <category><!-- 0..* CodeableConcept problem-list-item | encounter-diagnosis --></category>
 <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity>
 <code><!-- 1..1 CodeableConcept Identification of the condition, problem or diagnosis --></code>
 <bodySite><!-- 0..* CodeableConcept Anatomical location, if relevant --></bodySite>
 <subject><!-- 1..1 Reference(Patient|Group) Who has the condition? --></subject>
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter when condition first asserted --></context>
 <onset[x]><!-- 0..1 dateTime|Age|Period|Range|string Estimated or actual date,  date-time, or age --></onset[x]>
 <abatement[x]><!-- 0..1 dateTime|Age|boolean|Period|Range|string If/when in resolution/remission --></abatement[x]>
 <assertedDate value="[date]"/><!-- 0..1 Date record was believed accurate -->
 <asserter><!-- 0..1 Reference(Practitioner|Patient|RelatedPerson) Person who asserts this condition --></asserter>
 <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>
 <note><!-- 0..* Annotation Additional information about the Condition --></note>
</Condition>

JSON Template

{doco
  "resourceType" : "Condition",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this condition
  "clinicalStatus" : "<code>", // active | recurrence | inactive | remission | resolved
  "verificationStatus" : "<code>", // provisional | differential | confirmed | refuted | entered-in-error | unknown
  "category" : [{ CodeableConcept }], // problem-list-item | encounter-diagnosis
  "severity" : { CodeableConcept }, // Subjective severity of condition
  "code" : { CodeableConcept }, // R!  Identification of the condition, problem or diagnosis
  "bodySite" : [{ CodeableConcept }], // Anatomical location, if relevant
  "subject" : { Reference(Patient|Group) }, // R!  Who has the condition?
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter when condition first asserted
  // onset[x]: Estimated or actual date,  date-time, or age. One of these 5:
  "onsetDateTime" : "<dateTime>",
  "onsetAge" : { Age },
  "onsetPeriod" : { Period },
  "onsetRange" : { Range },
  "onsetString" : "<string>",
  // abatement[x]: If/when in resolution/remission. One of these 6:
  "abatementDateTime" : "<dateTime>",
  "abatementAge" : { Age },
  "abatementBoolean" : <boolean>,
  "abatementPeriod" : { Period },
  "abatementRange" : { Range },
  "abatementString" : "<string>",
  "assertedDate" : "<date>", // Date record was believed accurate
  "asserter" : { Reference(Practitioner|Patient|RelatedPerson) }, // Person who asserts this condition
  "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
  }],
  "note" : [{ Annotation }] // Additional information about the Condition
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:Condition;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Condition.identifier [ Identifier ], ... ; # 0..* External Ids for this condition
  fhir:Condition.clinicalStatus [ code ]; # 0..1 active | recurrence | inactive | remission | resolved
  fhir:Condition.verificationStatus [ code ]; # 0..1 provisional | differential | confirmed | refuted | entered-in-error | unknown
  fhir:Condition.category [ CodeableConcept ], ... ; # 0..* problem-list-item | encounter-diagnosis
  fhir:Condition.severity [ CodeableConcept ]; # 0..1 Subjective severity of condition
  fhir:Condition.code [ CodeableConcept ]; # 1..1 Identification of the condition, problem or diagnosis
  fhir:Condition.bodySite [ CodeableConcept ], ... ; # 0..* Anatomical location, if relevant
  fhir:Condition.subject [ Reference(Patient|Group) ]; # 1..1 Who has the condition?
  fhir:Condition.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Encounter when condition first asserted
  # Condition.onset[x] : 0..1 Estimated or actual date,  date-time, or age. One of these 5
    fhir:Condition.onsetDateTime [ dateTime ]
    fhir:Condition.onsetAge [ Age ]
    fhir:Condition.onsetPeriod [ Period ]
    fhir:Condition.onsetRange [ Range ]
    fhir:Condition.onsetString [ string ]
  # Condition.abatement[x] : 0..1 If/when in resolution/remission. One of these 6
    fhir:Condition.abatementDateTime [ dateTime ]
    fhir:Condition.abatementAge [ Age ]
    fhir:Condition.abatementBoolean [ boolean ]
    fhir:Condition.abatementPeriod [ Period ]
    fhir:Condition.abatementRange [ Range ]
    fhir:Condition.abatementString [ string ]
  fhir:Condition.assertedDate [ date ]; # 0..1 Date record was believed accurate
  fhir:Condition.asserter [ Reference(Practitioner|Patient|RelatedPerson) ]; # 0..1 Person who asserts this condition
  fhir:Condition.stage [ # 0..1 Stage/grade, usually assessed formally
    fhir:Condition.stage.summary [ CodeableConcept ]; # 0..1 Simple summary (disease specific)
    fhir:Condition.stage.assessment [ Reference(ClinicalImpression|DiagnosticReport|Observation) ], ... ; # 0..* Formal record of assessment
  ];
  fhir:Condition.evidence [ # 0..* Supporting evidence
    fhir:Condition.evidence.code [ CodeableConcept ]; # 0..1 Manifestation/symptom
    fhir:Condition.evidence.detail [ Reference(Any) ], ... ; # 0..* Supporting information found elsewhere
  ], ...;
  fhir:Condition.note [ Annotation ], ... ; # 0..* Additional information about the Condition
]

Changes since DSTU2

Condition
Condition.clinicalStatus Add Binding http://hl7.org/fhir/ValueSet/condition-clinical (required)
Condition.verificationStatus Min Cardinality changed from 1 to 0
Default Value "unknown" added
Condition.category Max Cardinality changed from 1 to *
Condition.subject Renamed from patient to subject
Add Reference(Group)
Condition.context Renamed from encounter to context
Add Reference(EpisodeOfCare)
Condition.onset[x] Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Add Age
Condition.abatement[x] Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Add Age
Condition.assertedDate added Element
Condition.asserter Add Reference(RelatedPerson)
Condition.note Renamed from notes to note
Max Cardinality changed from 1 to *
Type changed from string to Annotation
Condition.dateRecorded deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition IDomainResourceDetailed information about conditions, problems or diagnoses
If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!Σ0..1codeactive | recurrence | inactive | remission | resolved
Condition Clinical Status Codes (Required)
... verificationStatus ?!Σ0..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
ConditionVerificationStatus (Required)
... category 0..*CodeableConceptproblem-list-item | encounter-diagnosis
Condition Category Codes (Example)
... severity 0..1CodeableConceptSubjective severity of condition
Condition/Diagnosis Severity (Preferred)
... code Σ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Condition/Problem/Diagnosis Codes (Example)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
SNOMED CT Body Structures (Example)
... subject Σ1..1Reference(Patient | Group)Who has the condition?
... context 0..1Reference(Encounter | EpisodeOfCare)Encounter when condition first asserted
... onset[x] Σ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] 0..1If/when in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementBooleanboolean
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... assertedDate 0..1dateDate record was believed accurate
... asserter Σ0..1Reference(Practitioner | Patient | RelatedPerson)Person who asserts this condition
... stage I0..1BackboneElementStage/grade, usually assessed formally
Stage SHALL have summary or assessment
.... summary I0..1CodeableConceptSimple summary (disease specific)
Condition Stage (Example)
.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
evidence SHALL have code or details
.... code I0..1CodeableConceptManifestation/symptom
Manifestation and Symptom Codes (Example)
.... detail I0..*Reference(Any)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

UML Diagram (Legend)

Condition (DomainResource)This records identifiers associated with this condition that are defined by business processes 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)identifier : Identifier [0..*]The clinical status of the condition (this element modifies the meaning of other elements)clinicalStatus : code [0..1] « The clinical status of the condition or diagnosis. (Strength=Required)Condition Clinical Status ! »The verification status to support the clinical status of the condition (this element modifies the meaning of other elements)verificationStatus : code [0..1] « The verification status to support or decline the clinical status of the condition or diagnosis. (Strength=Required)ConditionVerificationStatus! »A category assigned to the conditioncategory : CodeableConcept [0..*] « A category assigned to the condition. (Strength=Example)Condition Category ?? »A subjective assessment of the severity of the condition as evaluated by the clinicianseverity : CodeableConcept [0..1] « A subjective assessment of the severity of the condition as evaluated by the clinician. (Strength=Preferred)Condition/Diagnosis Severity? »Identification of the condition, problem or diagnosiscode : CodeableConcept [1..1] « Identification of the condition or diagnosis. (Strength=Example)Condition/Problem/Diagnosis ?? »The anatomical location where this condition manifests itselfbodySite : CodeableConcept [0..*] « Codes describing anatomical locations. May include laterality. (Strength=Example)SNOMED CT Body Structures?? »Indicates the patient or group who the condition record is associated withsubject : Reference [1..1] « Patient|Group »Encounter during which the condition was first assertedcontext : Reference [0..1] « Encounter|EpisodeOfCare »Estimated or actual date or date-time the condition began, in the opinion of the clinicianonset[x] : Type [0..1] « dateTime|Age|Period|Range|string »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 abateabatement[x] : Type [0..1] « dateTime|Age|boolean|Period|Range| string »The date on which the existance of the Condition was first asserted or acknowledgedassertedDate : date [0..1]Individual who is making the condition statementasserter : Reference [0..1] « Practitioner|Patient|RelatedPerson »Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosisnote : Annotation [0..*]StageA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specificsummary : CodeableConcept [0..1] « Codes describing condition stages (e.g. Cancer stages). (Strength=Example)Condition Stage?? »Reference to a formal record of the evidence on which the staging assessment is basedassessment : Reference [0..*] « ClinicalImpression|DiagnosticReport| Observation »EvidenceA manifestation or symptom that led to the recording of this conditioncode : CodeableConcept [0..1] « Codes that describe the manifestation or symptoms of a condition. (Strength=Example)Manifestation and Symptom ?? »Links to other relevant information, including pathology reportsdetail : Reference [0..*] « Any »Clinical stage or grade of a condition. May include formal severity assessmentsstage[0..1]Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmedevidence[0..*]

XML Template

<Condition xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <clinicalStatus value="[code]"/><!-- 0..1 active | recurrence | inactive | remission | resolved -->
 <verificationStatus value="[code]"/><!-- 0..1 provisional | differential | confirmed | refuted | entered-in-error | unknown -->
 <category><!-- 0..* CodeableConcept problem-list-item | encounter-diagnosis --></category>
 <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity>
 <code><!-- 1..1 CodeableConcept Identification of the condition, problem or diagnosis --></code>
 <bodySite><!-- 0..* CodeableConcept Anatomical location, if relevant --></bodySite>
 <subject><!-- 1..1 Reference(Patient|Group) Who has the condition? --></subject>
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter when condition first asserted --></context>
 <onset[x]><!-- 0..1 dateTime|Age|Period|Range|string Estimated or actual date,  date-time, or age --></onset[x]>
 <abatement[x]><!-- 0..1 dateTime|Age|boolean|Period|Range|string If/when in resolution/remission --></abatement[x]>
 <assertedDate value="[date]"/><!-- 0..1 Date record was believed accurate -->
 <asserter><!-- 0..1 Reference(Practitioner|Patient|RelatedPerson) Person who asserts this condition --></asserter>
 <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>
 <note><!-- 0..* Annotation Additional information about the Condition --></note>
</Condition>

JSON Template

{doco
  "resourceType" : "Condition",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this condition
  "clinicalStatus" : "<code>", // active | recurrence | inactive | remission | resolved
  "verificationStatus" : "<code>", // provisional | differential | confirmed | refuted | entered-in-error | unknown
  "category" : [{ CodeableConcept }], // problem-list-item | encounter-diagnosis
  "severity" : { CodeableConcept }, // Subjective severity of condition
  "code" : { CodeableConcept }, // R!  Identification of the condition, problem or diagnosis
  "bodySite" : [{ CodeableConcept }], // Anatomical location, if relevant
  "subject" : { Reference(Patient|Group) }, // R!  Who has the condition?
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter when condition first asserted
  // onset[x]: Estimated or actual date,  date-time, or age. One of these 5:
  "onsetDateTime" : "<dateTime>",
  "onsetAge" : { Age },
  "onsetPeriod" : { Period },
  "onsetRange" : { Range },
  "onsetString" : "<string>",
  // abatement[x]: If/when in resolution/remission. One of these 6:
  "abatementDateTime" : "<dateTime>",
  "abatementAge" : { Age },
  "abatementBoolean" : <boolean>,
  "abatementPeriod" : { Period },
  "abatementRange" : { Range },
  "abatementString" : "<string>",
  "assertedDate" : "<date>", // Date record was believed accurate
  "asserter" : { Reference(Practitioner|Patient|RelatedPerson) }, // Person who asserts this condition
  "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
  }],
  "note" : [{ Annotation }] // Additional information about the Condition
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:Condition;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Condition.identifier [ Identifier ], ... ; # 0..* External Ids for this condition
  fhir:Condition.clinicalStatus [ code ]; # 0..1 active | recurrence | inactive | remission | resolved
  fhir:Condition.verificationStatus [ code ]; # 0..1 provisional | differential | confirmed | refuted | entered-in-error | unknown
  fhir:Condition.category [ CodeableConcept ], ... ; # 0..* problem-list-item | encounter-diagnosis
  fhir:Condition.severity [ CodeableConcept ]; # 0..1 Subjective severity of condition
  fhir:Condition.code [ CodeableConcept ]; # 1..1 Identification of the condition, problem or diagnosis
  fhir:Condition.bodySite [ CodeableConcept ], ... ; # 0..* Anatomical location, if relevant
  fhir:Condition.subject [ Reference(Patient|Group) ]; # 1..1 Who has the condition?
  fhir:Condition.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Encounter when condition first asserted
  # Condition.onset[x] : 0..1 Estimated or actual date,  date-time, or age. One of these 5
    fhir:Condition.onsetDateTime [ dateTime ]
    fhir:Condition.onsetAge [ Age ]
    fhir:Condition.onsetPeriod [ Period ]
    fhir:Condition.onsetRange [ Range ]
    fhir:Condition.onsetString [ string ]
  # Condition.abatement[x] : 0..1 If/when in resolution/remission. One of these 6
    fhir:Condition.abatementDateTime [ dateTime ]
    fhir:Condition.abatementAge [ Age ]
    fhir:Condition.abatementBoolean [ boolean ]
    fhir:Condition.abatementPeriod [ Period ]
    fhir:Condition.abatementRange [ Range ]
    fhir:Condition.abatementString [ string ]
  fhir:Condition.assertedDate [ date ]; # 0..1 Date record was believed accurate
  fhir:Condition.asserter [ Reference(Practitioner|Patient|RelatedPerson) ]; # 0..1 Person who asserts this condition
  fhir:Condition.stage [ # 0..1 Stage/grade, usually assessed formally
    fhir:Condition.stage.summary [ CodeableConcept ]; # 0..1 Simple summary (disease specific)
    fhir:Condition.stage.assessment [ Reference(ClinicalImpression|DiagnosticReport|Observation) ], ... ; # 0..* Formal record of assessment
  ];
  fhir:Condition.evidence [ # 0..* Supporting evidence
    fhir:Condition.evidence.code [ CodeableConcept ]; # 0..1 Manifestation/symptom
    fhir:Condition.evidence.detail [ Reference(Any) ], ... ; # 0..* Supporting information found elsewhere
  ], ...;
  fhir:Condition.note [ Annotation ], ... ; # 0..* Additional information about the Condition
]

Changes since DSTU2

Condition
Condition.clinicalStatus Add Binding http://hl7.org/fhir/ValueSet/condition-clinical (required)
Condition.verificationStatus Min Cardinality changed from 1 to 0
Default Value "unknown" added
Condition.category Max Cardinality changed from 1 to *
Condition.subject Renamed from patient to subject
Add Reference(Group)
Condition.context Renamed from encounter to context
Add Reference(EpisodeOfCare)
Condition.onset[x] Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Add Age
Condition.abatement[x] Remove Quantity{http://hl7.org/fhir/StructureDefinition/Age}, Add Age
Condition.assertedDate added Element
Condition.asserter Add Reference(RelatedPerson)
Condition.note Renamed from notes to note
Max Cardinality changed from 1 to *
Type changed from string to Annotation
Condition.dateRecorded deleted

See the Full Difference for further information

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle), JSON-LD (for RDF as JSON-LD),

9.2.3.1 Terminology Bindings

PathDefinitionTypeReference
Condition.clinicalStatus The clinical status of the condition or diagnosis.RequiredCondition Clinical Status Codes
Condition.verificationStatus The verification status to support or decline the clinical status of the condition or diagnosis.RequiredConditionVerificationStatus
Condition.category A category assigned to the condition.ExampleCondition Category Codes
Condition.severity A subjective assessment of the severity of the condition as evaluated by the clinician.PreferredCondition/Diagnosis Severity
Condition.code Identification of the condition or diagnosis.ExampleCondition/Problem/Diagnosis Codes
Condition.bodySite Codes describing anatomical locations. May include laterality.ExampleSNOMED CT Body Structures
Condition.stage.summary Codes describing condition stages (e.g. Cancer stages).ExampleCondition Stage
Condition.evidence.code Codes that describe the manifestation or symptoms of a condition.ExampleManifestation and Symptom Codes

9.2.3.2 Constraints

  • con-1: On Condition.stage: Stage SHALL have summary or assessment (expression on Condition.stage: summary.exists() or assessment.exists())
  • con-2: On Condition.evidence: evidence SHALL have code or details (expression on Condition.evidence: code.exists() or detail.exists())
  • con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error (expression : verificationStatus='entered-in-error' or clinicalStatus.exists())
  • con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (expression : abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive')

9.2.3.3 Use of Condition.code

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, as well as "no known problems" or "negated" conditions (e.g., "no X" or "no history of X" - see the following section for "No Known Problems" and Negated 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.

9.2.3.4 "No Known Problems" and Negated Conditions

Conditions/Problems Not Reviewed, Not Asked

When a sending system does not have any information about conditions/problems being reviewed or the statement is about conditions/problems not yet being asked, then the List resource should be used to indicate the List.emptyReason.code="notasked".

Conditions/Problems Reviewed, None Identified

Systems may use the List.emptyReason when a statement is about the full scope of the list (i.e. the patient has no conditions/problems of any type). However, it may be preferred to use a code for "no known problems" (e.g., SNOMED CT: 160245001 |No current problems or disability (situation)|), so that all condition/problem data will be available and queryable from Condition resource instances.

Also note that care should be used when adding new Condition resources to a list to ensure that any negation statements that are voided by the addition of a new record are removed from the list. E.g. If the list contains a "no known problems" record and you add a "diabetes" condition record, then be sure that you remove the "no known problems" record.

STU Note:There are two primary ways of reporting "no known problems" in the current specification: using the CodeableConcept, as described above, or using the List resource with emptyReason. During the STU period, feedback is sought regarding the preferred approach.

9.2.3.5 Assertions of Condition Absence

Generally, electronic records do not contain assertions of conditions that a patient does not have. There are however two exceptions:

  • It is appropriate to capture a "refuted" Condition record if the patient or anyone else had reason to believe that a patient did have a condition for a period of time and subsequent evidence has demonstrated that belief was mistaken. In this case, a concrete statement acknowledging the belief as well as the refution of it is useful.
  • It is common as part of checklists prior to admission, surgery, enrollment in trials, etc. to ask questions such as "are you pregnant", "do you have a history of hypertension", etc. This information should NOT be captured using the Condition resource but should instead be captured using QuestionnaireResponse or Observation. In this case, the combination of the question and answer would convey that a particular condition was not present.

9.2.3.6 Use of Condition.evidence

The Condition.evidence provides the basis for whatever is present in Condition.code.

9.2.3.7 Use of Condition.abatementRange

A range is used to communicate age period of subject at time of abatement.

9.2.3.8 Use of Condition.asserter

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.

9.2.3.9 Use of Condition.clinicalStatus

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.

9.2.4 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPathsIn Common
abatement-agequantityAbatement as age or age rangeCondition.abatement[x]
abatement-booleantokenAbatement boolean (boolean is true or non-boolean values are present)Condition.abatement[x]
abatement-datedateDate-related abatements (dateTime and period)Condition.abatement[x]
abatement-stringstringAbatement as a stringCondition.abatement[x]
asserted-datedateDate record was believed accurateCondition.assertedDate
asserterreferencePerson who asserts this conditionCondition.asserter
(Practitioner, Patient, RelatedPerson)
body-sitetokenAnatomical location, if relevantCondition.bodySite
categorytokenThe category of the conditionCondition.category
clinicalstatustokenThe clinical status of the conditionCondition.clinicalStatus
codetokenCode for the conditionCondition.code8 Resources
contextreferenceEncounter when condition first assertedCondition.context
(EpisodeOfCare, Encounter)
evidencetokenManifestation/symptomCondition.evidence.code
identifiertokenA unique identifier of the condition recordCondition.identifier26 Resources
onset-agequantityOnsets as age or age rangeCondition.onset[x]
onset-datedateDate related onsets (dateTime and Period)Condition.onset[x]
onset-infostringOnsets as a stringCondition.onset[x]
patientreferenceWho has the condition?Condition.subject
(Patient)		31 Resources
severitytokenThe severity of the conditionCondition.severity
stagetokenSimple summary (disease specific)Condition.stage.summary
subjectreferenceWho has the condition?Condition.subject
(Group, Patient)