This page is part of the FHIR Specification (v3.3.0: R4 Ballot 2). 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 Group

Maturity Level: 3

Trial Use

Compartments: Encounter, Patient, Practitioner, RelatedPerson

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

9.2.1 Scope and Usage

Condition is one of the event resources in the FHIR workflow specification.

This resource is used to record detailed information about a condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. The condition could be a point in time diagnosis in context of an encounter, it could be an item on the practitioner’s Problem List, or it could be a concern that doesn’t exist on the practitioner’s Problem List. Often times, a condition is about a clinician's assessment and assertion of a particular aspect of a patient's state of health. It can be used 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 a practitioner considers harmful, potentially harmful and may be investigated and managed (problem), or other health issue/situation that may require ongoing monitoring and/or management (health issue/concern).

The condition resource may be used to record a certain health state of a patient which does not normally present a negative outcome, e.g. pregnancy. The condition resource may be used to record a condition following a procedure, such as the condition of Amputee-BKA following an amputation procedure.

While conditions are frequently a result of a clinician's assessment and assertion of a particular aspect of a patient's state of health, conditions can also be expressed by the patient, related person, or any care team member. A clinician may have a concern about a patient condition (e.g. anorexia) that the patient is not concerned about. Likewise, the patient may have a condition (e.g. hair loss) that does not rise to the level of importance such that it belongs on a practitioner’s Problem List.

For example, each of the following conditions could rise to the level of importance such that it belongs on a problem or concern list due to its direct or indirect impact on the patient’s health. These examples may also be represented using other resources, such as FamilyMemberHistory, Observation, or Procedure.

Unemployed
Without transportation (or other barriers)
Susceptibility to falls
Exposure to communicable disease
Family History of cardiovascular disease
Fear of cancer
Cardiac pacemaker
Amputee-BKA
Risk of Zika virus following travel to a country
Former smoker
Travel to a country planned (that warrants immunizations)
Motor Vehicle Accident
Patient has had coronary bypass graft

9.2.2 Boundaries and Relationships

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

This resource is not typically used to record information about subjective and objective information that might lead to the recording of a Condition resource. Such signs and symptoms 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.

When the diagnosis is related to an allergy or intolerance, the Condition and AllergyIntolerance resources can both be used. However, to be actionable for decision support, using Condition alone is not sufficient as the allergy or intolerance condition needs to be represented as an AllergyIntolerance.

This resource is referenced by AdverseEvent, Appointment, CarePlan, CareTeam, Claim, ClinicalImpression, Communication, CommunicationRequest, DeviceRequest, DeviceUseStatement, EligibilityRequest, Encounter, EpisodeOfCare, ExplanationOfBenefit, FamilyMemberHistory, Goal, GuidanceResponse, ImagingStudy, Immunization, MedicationAdministration, MedicationRequest, MedicationStatement, Procedure, RequestGroup, ResearchStudy, RiskAssessment, ServiceRequest, SupplyRequest and VisionPrescription

Structure

Name	Flags	Card.	Type	Description & Constraints
Condition	I TU		DomainResource	Detailed information about conditions, problems or diagnoses + Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error + 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 Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!Σ I	0..1	code	active \| recurrence \| relapse \| well-controlled \| poorly-controlled \| inactive \| remission \| resolved Condition Clinical Status Codes (Required)
verificationStatus	?!Σ I	0..1	code	unconfirmed \| provisional \| differential \| confirmed \| refuted \| entered-in-error ConditionVerificationStatus (Required)
category		0..*	CodeableConcept	problem-list-item \| encounter-diagnosis Condition Category Codes (Example)
severity		0..1	CodeableConcept	Subjective severity of condition Condition/Diagnosis Severity (Preferred)
code	Σ	0..1	CodeableConcept	Identification of the condition, problem or diagnosis Condition/Problem/Diagnosis Codes (Example)
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant SNOMED CT Body Structures (Example)
subject	Σ	1..1	Reference(Patient \| Group)	Who has the condition?
context	Σ	0..1	Reference(Encounter \| EpisodeOfCare)	Encounter or episode when condition first asserted
onset[x]	Σ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	I	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
assertedDate	Σ	0..1	dateTime	Date record was believed accurate
recorder	Σ	0..1	Reference(Practitioner \| Patient \| RelatedPerson)	Who recorded the condition
asserter	Σ	0..1	Reference(Practitioner \| PractitionerRole \| Patient \| RelatedPerson)	Person who asserts this condition
stage	I	0..*	BackboneElement	Stage/grade, usually assessed formally + Stage SHALL have summary or assessment
summary	I	0..1	CodeableConcept	Simple summary (disease specific) Condition Stage (Example)
assessment	I	0..*	Reference(ClinicalImpression \| DiagnosticReport \| Observation)	Formal record of assessment
type		0..1	CodeableConcept	Kind of staging Condition Stage Type (Example)
evidence	I	0..*	BackboneElement	Supporting evidence + evidence SHALL have code or details
code	Σ I	0..*	CodeableConcept	Manifestation/symptom Manifestation and Symptom Codes (Example)
detail	Σ I	0..*	Reference(Any)	Supporting information found elsewhere
note		0..*	Annotation	Additional information about the Condition
Documentation for this format

UML Diagram (Legend)

XML Template

<Condition xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <clinicalStatus value="[code]"/><!--  0..1 active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved -->
 <verificationStatus value="[code]"/><!--  0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error -->
 <category><!-- 0..* CodeableConcept problem-list-item | encounter-diagnosis --></category>
 <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity>
 <code><!-- 0..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 or episode 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|Period|Range|string When in resolution/remission --></abatement[x]>
 <assertedDate value="[dateTime]"/><!-- 0..1 Date record was believed accurate -->
 <recorder><!-- 0..1 Reference(Practitioner|Patient|RelatedPerson) Who recorded the condition --></recorder>
 <asserter><!-- 0..1 Reference(Practitioner|PractitionerRole|Patient|
   RelatedPerson) Person who asserts this condition --></asserter>
 <stage>  <!-- 0..* 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>
  <type><!-- 0..1 CodeableConcept Kind of staging --></type>
 </stage>
 <evidence>  <!-- 0..* Supporting evidence -->
  <code><!--  0..* 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

{
  "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>", // C? active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  "verificationStatus" : "<code>", // C? unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
  "category" : [{ CodeableConcept }], // problem-list-item | encounter-diagnosis
  "severity" : { CodeableConcept }, // Subjective severity of condition
  "code" : { CodeableConcept }, // 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 or episode 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]: When in resolution/remission. One of these 5:
  "abatementDateTime" : "<dateTime>",
  "abatementAge" : { Age },
  "abatementPeriod" : { Period },
  "abatementRange" : { Range },
  "abatementString" : "<string>",
  "assertedDate" : "<dateTime>", // Date record was believed accurate
  "recorder" : { Reference(Practitioner|Patient|RelatedPerson) }, // Who recorded the condition
  "asserter" : { Reference(Practitioner|PractitionerRole|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
    "type" : { CodeableConcept } // Kind of staging
  }],
  "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/> .


[ 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 | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  fhir:Condition.verificationStatus [ code ]; # 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
  fhir:Condition.category [ CodeableConcept ], ... ; # 0..* problem-list-item | encounter-diagnosis
  fhir:Condition.severity [ CodeableConcept ]; # 0..1 Subjective severity of condition
  fhir:Condition.code [ CodeableConcept ]; # 0..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 or episode 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 When in resolution/remission. One of these 5
    fhir:Condition.abatementDateTime [ dateTime ]
    fhir:Condition.abatementAge [ Age ]
    fhir:Condition.abatementPeriod [ Period ]
    fhir:Condition.abatementRange [ Range ]
    fhir:Condition.abatementString [ string ]
  fhir:Condition.assertedDate [ dateTime ]; # 0..1 Date record was believed accurate
  fhir:Condition.recorder [ Reference(Practitioner|Patient|RelatedPerson) ]; # 0..1 Who recorded the condition
  fhir:Condition.asserter [ Reference(Practitioner|PractitionerRole|Patient|RelatedPerson) ]; # 0..1 Person who asserts this condition
  fhir:Condition.stage [ # 0..* 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.stage.type [ CodeableConcept ]; # 0..1 Kind of staging
  ], ...;
  fhir:Condition.evidence [ # 0..* Supporting evidence
    fhir:Condition.evidence.code [ CodeableConcept ], ... ; # 0..* 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 R3

Condition

Condition.verificationStatus

Default Value "unknown" removed

Condition.abatement[x]

Remove boolean

Condition.recorder

Added Element

Condition.asserter

Type changed from Reference(Practitioner|Patient|RelatedPerson) to Reference(Practitioner|PractitionerRole|Patient|RelatedPerson)

Condition.stage

Max Cardinality changed from 1 to *

Condition.stage.type

Added Element

See the Full Difference for further information

This analysis is available as XML or JSON.

See R2 <--> R3 Conversion Maps (status = 14 tests that all execute ok. 11 fail round-trip testing and 14 r3 resources are invalid (14 errors).). Note: these have note yet been updated to be R3 to R4

Structure

Name	Flags	Card.	Type	Description & Constraints
Condition	I TU		DomainResource	Detailed information about conditions, problems or diagnoses + Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error + 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 Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!Σ I	0..1	code	active \| recurrence \| relapse \| well-controlled \| poorly-controlled \| inactive \| remission \| resolved Condition Clinical Status Codes (Required)
verificationStatus	?!Σ I	0..1	code	unconfirmed \| provisional \| differential \| confirmed \| refuted \| entered-in-error ConditionVerificationStatus (Required)
category		0..*	CodeableConcept	problem-list-item \| encounter-diagnosis Condition Category Codes (Example)
severity		0..1	CodeableConcept	Subjective severity of condition Condition/Diagnosis Severity (Preferred)
code	Σ	0..1	CodeableConcept	Identification of the condition, problem or diagnosis Condition/Problem/Diagnosis Codes (Example)
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant SNOMED CT Body Structures (Example)
subject	Σ	1..1	Reference(Patient \| Group)	Who has the condition?
context	Σ	0..1	Reference(Encounter \| EpisodeOfCare)	Encounter or episode when condition first asserted
onset[x]	Σ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	I	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
assertedDate	Σ	0..1	dateTime	Date record was believed accurate
recorder	Σ	0..1	Reference(Practitioner \| Patient \| RelatedPerson)	Who recorded the condition
asserter	Σ	0..1	Reference(Practitioner \| PractitionerRole \| Patient \| RelatedPerson)	Person who asserts this condition
stage	I	0..*	BackboneElement	Stage/grade, usually assessed formally + Stage SHALL have summary or assessment
summary	I	0..1	CodeableConcept	Simple summary (disease specific) Condition Stage (Example)
assessment	I	0..*	Reference(ClinicalImpression \| DiagnosticReport \| Observation)	Formal record of assessment
type		0..1	CodeableConcept	Kind of staging Condition Stage Type (Example)
evidence	I	0..*	BackboneElement	Supporting evidence + evidence SHALL have code or details
code	Σ I	0..*	CodeableConcept	Manifestation/symptom Manifestation and Symptom Codes (Example)
detail	Σ I	0..*	Reference(Any)	Supporting information found elsewhere
note		0..*	Annotation	Additional information about the Condition
Documentation for this format

UML Diagram (Legend)

XML Template

<Condition xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <clinicalStatus value="[code]"/><!--  0..1 active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved -->
 <verificationStatus value="[code]"/><!--  0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error -->
 <category><!-- 0..* CodeableConcept problem-list-item | encounter-diagnosis --></category>
 <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity>
 <code><!-- 0..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 or episode 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|Period|Range|string When in resolution/remission --></abatement[x]>
 <assertedDate value="[dateTime]"/><!-- 0..1 Date record was believed accurate -->
 <recorder><!-- 0..1 Reference(Practitioner|Patient|RelatedPerson) Who recorded the condition --></recorder>
 <asserter><!-- 0..1 Reference(Practitioner|PractitionerRole|Patient|
   RelatedPerson) Person who asserts this condition --></asserter>
 <stage>  <!-- 0..* 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>
  <type><!-- 0..1 CodeableConcept Kind of staging --></type>
 </stage>
 <evidence>  <!-- 0..* Supporting evidence -->
  <code><!--  0..* 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

{
  "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>", // C? active | recurrence | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  "verificationStatus" : "<code>", // C? unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
  "category" : [{ CodeableConcept }], // problem-list-item | encounter-diagnosis
  "severity" : { CodeableConcept }, // Subjective severity of condition
  "code" : { CodeableConcept }, // 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 or episode 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]: When in resolution/remission. One of these 5:
  "abatementDateTime" : "<dateTime>",
  "abatementAge" : { Age },
  "abatementPeriod" : { Period },
  "abatementRange" : { Range },
  "abatementString" : "<string>",
  "assertedDate" : "<dateTime>", // Date record was believed accurate
  "recorder" : { Reference(Practitioner|Patient|RelatedPerson) }, // Who recorded the condition
  "asserter" : { Reference(Practitioner|PractitionerRole|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
    "type" : { CodeableConcept } // Kind of staging
  }],
  "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/> .


[ 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 | relapse | well-controlled | poorly-controlled | inactive | remission | resolved
  fhir:Condition.verificationStatus [ code ]; # 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
  fhir:Condition.category [ CodeableConcept ], ... ; # 0..* problem-list-item | encounter-diagnosis
  fhir:Condition.severity [ CodeableConcept ]; # 0..1 Subjective severity of condition
  fhir:Condition.code [ CodeableConcept ]; # 0..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 or episode 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 When in resolution/remission. One of these 5
    fhir:Condition.abatementDateTime [ dateTime ]
    fhir:Condition.abatementAge [ Age ]
    fhir:Condition.abatementPeriod [ Period ]
    fhir:Condition.abatementRange [ Range ]
    fhir:Condition.abatementString [ string ]
  fhir:Condition.assertedDate [ dateTime ]; # 0..1 Date record was believed accurate
  fhir:Condition.recorder [ Reference(Practitioner|Patient|RelatedPerson) ]; # 0..1 Who recorded the condition
  fhir:Condition.asserter [ Reference(Practitioner|PractitionerRole|Patient|RelatedPerson) ]; # 0..1 Person who asserts this condition
  fhir:Condition.stage [ # 0..* 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.stage.type [ CodeableConcept ]; # 0..1 Kind of staging
  ], ...;
  fhir:Condition.evidence [ # 0..* Supporting evidence
    fhir:Condition.evidence.code [ CodeableConcept ], ... ; # 0..* 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.verificationStatus

Default Value "unknown" removed

Condition.abatement[x]

Remove boolean

Condition.recorder

Added Element

Condition.asserter

Type changed from Reference(Practitioner|Patient|RelatedPerson) to Reference(Practitioner|PractitionerRole|Patient|RelatedPerson)

Condition.stage

Max Cardinality changed from 1 to *

Condition.stage.type

Added Element

See the Full Difference for further information

This analysis is available as XML or JSON.

Alternate definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis

9.2.3.1 Terminology Bindings

Path	Definition	Type	Reference
Condition.clinicalStatus	The clinical status of the condition or diagnosis.	Required	Condition Clinical Status Codes
Condition.verificationStatus	The verification status to support or decline the clinical status of the condition or diagnosis.	Required	ConditionVerificationStatus
Condition.category	A category assigned to the condition.	Example	Condition Category Codes
Condition.severity	A subjective assessment of the severity of the condition as evaluated by the clinician.	Preferred	Condition/Diagnosis Severity
Condition.code	Identification of the condition or diagnosis.	Example	Condition/Problem/Diagnosis Codes
Condition.bodySite	Codes describing anatomical locations. May include laterality.	Example	SNOMED CT Body Structures
Condition.stage.summary	Codes describing condition stages (e.g. Cancer stages).	Example	Condition Stage
Condition.stage.type	Codes describing the kind of condition staging (e.g. clinical or pathological).	Example	Condition Stage Type
Condition.evidence.code	Codes that describe the manifestation or symptoms of a condition.	Example	Manifestation and Symptom Codes

Path

Definition

Type

Reference

Condition.clinicalStatus

The clinical status of the condition or diagnosis.

Required

Condition Clinical Status Codes

Condition.verificationStatus

The verification status to support or decline the clinical status of the condition or diagnosis.

Required

ConditionVerificationStatus

Condition.category

A category assigned to the condition.

Example

Condition Category Codes

Condition.severity

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

Preferred

Condition/Diagnosis Severity

Condition.code

Identification of the condition or diagnosis.

Example

Condition/Problem/Diagnosis Codes

Condition.bodySite

Codes describing anatomical locations. May include laterality.

Example

SNOMED CT Body Structures

Condition.stage.summary

Codes describing condition stages (e.g. Cancer stages).

Example

Condition Stage

Condition.stage.type

Codes describing the kind of condition staging (e.g. clinical or pathological).

Example

Condition Stage Type

Condition.evidence.code

Codes that describe the manifestation or symptoms of a condition.

Example

Manifestation 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 clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive')
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error (expression : verificationStatus!='entered-in-error' or clinicalStatus.empty())

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.

Provide feedback here .

Patient Denies Condition

When the patient denies a condition, that can be annotated in the Condition.note element.

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 refutation 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.

9.2.3.10 Diagnosis Role and Rank within an Encounter

To represent the role of the diagnosis within an encounter, such as admission diagnosis or discharge diagnosis, use Encounter.diagnosis.role.

To represent the numeric ranking of the diagnosis within an encounter, such as primary, secondary, or tertiary, use Encounter.diagnosis.rank.

9.2.3.11 Known Issue

A known issue exists with circular references between Condition and ClinicalImpression, which is due to the low maturity level of ClinicalImpression. The Patient Care work group intends to address this issue when ClinicalImpression is considered substantially complete and ready for implementation.

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.

Name	Type	Description	Expression	In Common
abatement-age	quantity	Abatement as age or age range	Condition.abatement.as(Age) \| Condition.abatement.as(Range) \| Condition.abatement.as(Age)
abatement-date	date	Date-related abatements (dateTime and period)	Condition.abatement.as(dateTime) \| Condition.abatement.as(Period)
abatement-string	string	Abatement as a string	Condition.abatement.as(string)
asserted-date	date	Date record was believed accurate	Condition.assertedDate
asserter	reference	Person who asserts this condition	Condition.asserter (Practitioner, Patient, PractitionerRole, RelatedPerson)
body-site	token	Anatomical location, if relevant	Condition.bodySite
category	token	The category of the condition	Condition.category
clinical-status	token	The clinical status of the condition	Condition.clinicalStatus
code	token	Code for the condition	Condition.code	8 Resources
context	reference	Encounter or episode when condition first asserted	Condition.context (EpisodeOfCare, Encounter)
encounter	reference	Encounter when condition first asserted	Condition.context (Encounter)
evidence	token	Manifestation/symptom	Condition.evidence.code
evidence-detail	reference	Supporting information found elsewhere	Condition.evidence.detail (Any)
identifier	token	A unique identifier of the condition record	Condition.identifier	26 Resources
onset-age	quantity	Onsets as age or age range	Condition.onset.as(Age) \| Condition.onset.as(Range)
onset-date	date	Date related onsets (dateTime and Period)	Condition.onset.as(dateTime) \| Condition.onset.as(Period)
onset-info	string	Onsets as a string	Condition.onset.as(string)
patient	reference	Who has the condition?	Condition.subject (Patient)	29 Resources
severity	token	The severity of the condition	Condition.severity
stage	token	Simple summary (disease specific)	Condition.stage.summary
subject	reference	Who has the condition?	Condition.subject (Group, Patient)
verification-status	token	unconfirmed \| provisional \| differential \| confirmed \| refuted \| entered-in-error	Condition.verificationStatus