R6 Ballot (2nd Draft)

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Patient Care icon Work GroupMaturity Level: 5 Trial UseSecurity Category: Patient Compartments: Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the Condition resource.

Condition
Element Id Condition
Definition

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

Short Display Detailed information about conditions, problems or diagnoses
Cardinality 0..*
Type DomainResource
Summary false
Invariants
Defined on this element
con-2Warning If category is problems list item, the clinicalStatus should not be unknowncategory.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-category' and code='problem-list-item').exists() implies clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and code='unknown').exists().not()
con-3Rule If condition is abated, then clinicalStatus must be either inactive, resolved, or remission.abatement.exists() implies (clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='inactive' or code='resolved' or code='remission')).exists())
con-4Rule bodyStructure SHALL only be present if Condition.bodySite is not presentbodySite.exists() implies bodyStructure.empty()
Condition.identifier
Element Id Condition.identifier
Definition

Business identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

Short Display External Ids for this condition
Note This is a business identifier, not a resource identifier (see discussion)
Cardinality 0..*
Type Identifier
Requirements

Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers.

Summary true
Comments

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

Condition.clinicalStatus
Element Id Condition.clinicalStatus
Definition

The clinical status of the condition.

Short Display active | recurrence | relapse | inactive | remission | resolved | unknown
Cardinality 1..1
Terminology Binding Condition Clinical Status Codes (Required)
Type CodeableConcept
Is Modifier true (Reason: This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.)
Summary true
Comments

The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. clinicalStatus is required since it is a modifier element. For conditions that are problems list items, the clinicalStatus should not be unknown. For conditions that are not problem list items, the clinicalStatus may be unknown. For example, conditions derived from a claim are point in time, so those conditions may have a clinicalStatus of unknown

Invariants
Affect this element
con-3Rule If condition is abated, then clinicalStatus must be either inactive, resolved, or remission.abatement.exists() implies (clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='inactive' or code='resolved' or code='remission')).exists())
con-2Warning If category is problems list item, the clinicalStatus should not be unknowncategory.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-category' and code='problem-list-item').exists() implies clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and code='unknown').exists().not()
Condition.verificationStatus
Element Id Condition.verificationStatus
Definition

The verification status to support the clinical status of the condition. The verification status pertains to the condition, itself, not to any specific condition attribute.

Short Display unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Cardinality 0..1
Terminology Binding Condition Verification Status (Required)
Type CodeableConcept
Is Modifier true (Reason: This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.)
Summary true
Comments

verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

Condition.category
Element Id Condition.category
Definition

A category assigned to the condition.

Short Display problem-list-item | encounter-diagnosis
Cardinality 0..*
Terminology Binding Condition Category Codes (Preferred)
Type CodeableConcept
Summary false
Comments

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

Invariants
Affect this element
con-2Warning If category is problems list item, the clinicalStatus should not be unknowncategory.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-category' and code='problem-list-item').exists() implies clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and code='unknown').exists().not()
Condition.severity
Element Id Condition.severity
Definition

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

Short Display Subjective severity of condition
Cardinality 0..1
Terminology Binding Condition/Diagnosis Severity (Preferred)
Type CodeableConcept
Summary false
Comments

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

Condition.code
Element Id Condition.code
Definition

Identification of the condition, problem or diagnosis.

Short Display Identification of the condition, problem or diagnosis
Cardinality 0..1
Terminology Binding Condition/Problem/Diagnosis Codes (Example)
Type CodeableConcept
Requirements

0..1 to account for primarily narrative only resources.

Alternate Names type
Summary true
Condition.bodySite
Element Id Condition.bodySite
Definition

The anatomical location where this condition manifests itself.

Short Display Anatomical location, if relevant
Cardinality 0..*
Terminology Binding SNOMED CT Body Structures (Example)
Type CodeableConcept
Summary true
Comments

Only used if not implicit in code found in Condition.code.

Invariants
Affect this element
con-4Rule bodyStructure SHALL only be present if Condition.bodySite is not presentbodySite.exists() implies bodyStructure.empty()
Condition.bodyStructure
Element Id Condition.bodyStructure
Definition

Indicates the body structure on the subject's body where this condition manifests itself.

Short Display Anatomical body structure
Cardinality 0..1
Type Reference(BodyStructure)
Summary false
Comments

Should be consistent with Condition.code. Cannot be used if Condition.bodySite is used.

Invariants
Affect this element
con-4Rule bodyStructure SHALL only be present if Condition.bodySite is not presentbodySite.exists() implies bodyStructure.empty()
Condition.subject
Element Id Condition.subject
Definition

Indicates the patient or group who the condition record is associated with.

Short Display Who has the condition?
Cardinality 1..1
Type Reference(Patient | Group)
Requirements

Group is typically used for veterinary or public health use cases.

Alternate Names patient
Summary true
Condition.encounter
Element Id Condition.encounter
Definition

The Encounter during which this Condition was created or to which the creation of this record is tightly associated.

Short Display The Encounter during which this Condition was created
Cardinality 0..1
Type Reference(Encounter)
Summary true
Comments

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".

Condition.onset[x]
Element Id Condition.onset[x]
Definition

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

Short Display Estimated or actual date, date-time, or age
Cardinality 0..1
Type dateTime|Age|Period|Range|string
[x] Note See Choice of Datatypes for further information about how to use [x]
Summary true
Comments

If an event has risen to a level of concern due to its direct or indirect impact on the patient's health, then the date the event occurred is the onset date of the concern. Age is generally used when the patient reports an age at which the Condition began to occur. Period is generally used to convey an imprecise onset that occurred within the time period. For example, Period is not intended to convey the transition period before the chronic bronchitis or COPD condition was diagnosed, but Period can be used to convey an imprecise diagnosis date. Range is generally used to convey an imprecise age range (e.g. 4 to 6 years old). Because a Condition.code can represent multiple levels of granularity and can be modified over time, the onset and abatement dates can have ambiguity whether those dates apply to the current Condition.code or an earlier representation of that Condition.code. For example, if the Condition.code was initially documented as severe asthma, then it is ambiguous whether the onset and abatement dates apply to asthma (overall in that subject's lifetime) or when asthma transitioned to become severe.

Condition.abatement[x]
Element Id Condition.abatement[x]
Definition

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

Short Display When in resolution/remission
Cardinality 0..1
Type dateTime|Age|Period|Range|string
[x] Note See Choice of Datatypes for further information about how to use [x]
Summary false
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. When abatementString exists, it implies the condition is abated. Because a Condition.code can represent multiple levels of granularity and can be modified over time, the onset and abatement dates can have ambiguity whether those dates apply to the current Condition.code or an earlier representation of that Condition.code. For example, if the Condition.code was initially documented as severe asthma, then it is ambiguous whether the onset and abatement dates apply to asthma (overall in that subject's lifetime) or when asthma transitioned to become severe.

Invariants
Affect this element
con-3Rule If condition is abated, then clinicalStatus must be either inactive, resolved, or remission.abatement.exists() implies (clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='inactive' or code='resolved' or code='remission')).exists())
Condition.recordedDate
Element Id Condition.recordedDate
Definition

The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.

Short Display Date condition was first recorded
Cardinality 0..1
Type dateTime
Summary true
Comments

When onset date is unknown, recordedDate can be used to establish if the condition was present on or before a given date. If the recordedDate is known and provided by a sending system, it is preferred that the receiving system preserve that recordedDate value. If the recordedDate is not provided by the sending system, the receipt timestamp is sometimes used as the recordedDate.

Condition.recorder
Element Id Condition.recorder
Definition

Individual who recorded the record and takes responsibility for its content.

Short Display Who recorded the condition
Cardinality 0..1
Type Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
Summary true
Comments

Because the recorder takes responsibility for accurately recording information in the record, the recorder is the most recent author. The recorder might or might not be the asserter. By contrast, the recordedDate is when the condition was first recorded.

Condition.asserter
Element Id Condition.asserter
Definition

Individual or device that is making the condition statement.

Short Display Person or device that asserts this condition
Cardinality 0..1
Type Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device)
Summary true
Condition.stage
Element Id Condition.stage
Definition

A simple summary of the stage such as "Stage 3" or "Early Onset". The determination of the stage is disease-specific, such as cancer, retinopathy of prematurity, kidney diseases, Alzheimer's, or Parkinson disease.

Short Display Stage/grade, usually assessed formally
Cardinality 0..*
Summary false
Invariants
Defined on this element
con-1Rule Stage SHALL have summary or assessmentsummary.exists() or assessment.exists()
Condition.stage.summary
Element Id Condition.stage.summary
Definition

A simple summary of the stage such as "Stage 3" or "Early Onset". The determination of the stage is disease-specific, such as cancer, retinopathy of prematurity, kidney diseases, Alzheimer's, or Parkinson disease.

Short Display Simple summary (disease specific)
Cardinality 0..1
Terminology Binding Condition Stage (Example)
Type CodeableConcept
Summary false
Invariants
Affect this element
con-1Rule Stage SHALL have summary or assessmentsummary.exists() or assessment.exists()
Condition.stage.assessment
Element Id Condition.stage.assessment
Definition

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

Short Display Formal record of assessment
Cardinality 0..*
Type Reference(ClinicalImpression | DiagnosticReport | Observation)
Summary false
Invariants
Affect this element
con-1Rule Stage SHALL have summary or assessmentsummary.exists() or assessment.exists()
Condition.stage.type
Element Id Condition.stage.type
Definition

The kind of staging, such as pathological or clinical staging.

Short Display Kind of staging
Cardinality 0..1
Terminology Binding Condition Stage Type (Example)
Type CodeableConcept
Summary false
Condition.evidence
Element Id Condition.evidence
Definition

Supporting evidence / manifestations that are the basis for determining the Condition.

Short Display Supporting evidence for the condition
Cardinality 0..*
Terminology Binding SNOMED CT Clinical Findings (Example)
Type CodeableReference(Any)
Summary true
Comments

Do not use Condition.evidence for causality. If it is an AdverseEvent, use AdverseEvent.suspectEntity.causality. Causality can also be pre-coordinated into the Condition.code (e.g. SNOMED 90619006 Fall in bathtub, or ICD W16. 2 Fall in (into) filled bathtub or bucket of water). Otherwise, use http://hl7.org/fhir/StructureDefinition/condition-dueTo extension to convey conditions, problems, diagnoses, procedures or events or the substance that caused/triggered this Condition. If the condition was confirmed, but subsequently refuted, then the evidence can be cumulative including all evidence over time. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. For example, if the Condition.code is pneumonia, then there could be an evidence list where Condition.evidence.concept = fever (CodeableConcept), Condition.evidence.concept = cough (CodeableConcept), and Condition.evidence.reference = bronchitis (reference to Condition).

Condition.note
Element Id Condition.note
Definition

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

Short Display Additional information about the Condition
Cardinality 0..*
Type Annotation
Summary false