R6 Ballot (2nd Draft)

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9.2 Resource Condition - Content

Patient Care icon Work GroupMaturity Level: 5 Trial UseSecurity Category: Patient 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

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. Oftentimes, 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:

  • 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

These examples may also be represented using other resources, such as FamilyMemberHistory, Observation, RiskAssessment, or Procedure.

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. In an inpatient scenario, a nursing problem list may document symptoms (such as respiratory alteration) as conditions if they are the focus of care provision. It became a problem because the nurse (clinician) wants to manage it. By contrast, headache may be captured as an Observation when it contributes to the establishment of a meningitis Condition.

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.

Note that a Condition represents an instance of a condition, not the categorical patient state. This can be a subtle distinction for systemic conditions, but it is easier to see with conditions that can happen more than once, e.g. refuting one record of a wound does not mean that the patient does not have any other wounds, and resolving one case of otitis media does not rule out recurrence. An observation that the patient doesn't have any wounds means the patient doesn't have any wounds at that point in time.

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.

9.2.3 References to this Resource

9.2.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition TU DomainResource Detailed information about conditions, problems or diagnoses
+ Warning: If category is problems list item, the clinicalStatus should not be unknown
+ Rule: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission.
+ Rule: bodyStructure SHALL only be present if Condition.bodySite is not present

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 0..* Identifier External Ids for this condition

... clinicalStatus ?!ΣC 1..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved | unknown
Binding: Condition Clinical Status Codes (Required)
... verificationStatus ?!Σ 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: Condition Verification Status (Required)
... severity 0..1 CodeableConcept Subjective severity of condition
Binding: Condition/Diagnosis Severity (Preferred)
... code Σ 0..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: Condition/Problem/Diagnosis Codes (Example)
... bodySite ΣC 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMED CT Body Structures (Example)

... bodyStructure C 0..1 Reference(BodyStructure) Anatomical body structure
... subject Σ 1..1 Reference(Patient | Group) Who has the condition?
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this Condition was created
... 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] C 0..1 When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate Σ 0..1 dateTime Date condition was first recorded
... recorder Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device) Person or device that asserts this condition
... stage CTU 0..* BackboneElement Stage/grade, usually assessed formally
+ Rule: Stage SHALL have summary or assessment

.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Binding: Condition Stage (Example)
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment

.... type 0..1 CodeableConcept Kind of staging
Binding: Condition Stage Type (Example)
... evidence ΣTU 0..* CodeableReference(Any) Supporting evidence for the condition
Binding: SNOMED CT Clinical Findings (Example)

... note 0..* Annotation Additional information about the Condition


doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

Condition (DomainResource)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 serveridentifier : Identifier [0..*]The clinical status of the condition (this element modifies the meaning of other elements)clinicalStatus : CodeableConcept [1..1] « null (Strength=Required) ConditionClinicalStatusCodes! » « This element has or is affected by some invariantsC »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 (this element modifies the meaning of other elements)verificationStatus : CodeableConcept [0..1] « null (Strength=Required) ConditionVerificationStatus! »A category assigned to the conditioncategory : CodeableConcept [0..*] « null (Strength=Preferred)ConditionCategoryCodes? » « This element has or is affected by some invariantsC »A subjective assessment of the severity of the condition as evaluated by the clinicianseverity : CodeableConcept [0..1] « null (Strength=Preferred)ConditionDiagnosisSeverity? »Identification of the condition, problem or diagnosiscode : CodeableConcept [0..1] « null (Strength=Example)ConditionProblemDiagnosisCodes?? »The anatomical location where this condition manifests itselfbodySite : CodeableConcept [0..*] « Codes describing anatomical locations. May include laterality. (Strength=Example)SNOMEDCTBodyStructures?? » « This element has or is affected by some invariantsC »Indicates the body structure on the subject's body where this condition manifests itselfbodyStructure : Reference [0..1] « BodyStructure » « This element has or is affected by some invariantsC »Indicates the patient or group who the condition record is associated withsubject : Reference [1..1] « Patient|Group »The Encounter during which this Condition was created or to which the creation of this record is tightly associatedencounter : Reference [0..1] « Encounter »Estimated or actual date or date-time the condition, situation, or concern began, in the opinion of the clinicianonset[x] : DataType [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" - Some conditions, such as chronic conditions, are never really resolved, but they can abateabatement[x] : DataType [0..1] « dateTime|Age|Period|Range|string » « This element has or is affected by some invariantsC »The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated daterecordedDate : dateTime [0..1]Individual who recorded the record and takes responsibility for its contentrecorder : Reference [0..1] « Practitioner|PractitionerRole|Patient| RelatedPerson »Individual or device that is making the condition statementasserter : Reference [0..1] « Practitioner|PractitionerRole|Patient| RelatedPerson|Device »Supporting evidence / manifestations that are the basis for determining the Conditionevidence : CodeableReference [0..*] « Any; null (Strength=Example)SNOMEDCTClinicalFindings?? »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" or "Early Onset". The determination of the stage is disease-specific, such as cancer, retinopathy of prematurity, kidney diseases, Alzheimer's, or Parkinson diseasesummary : CodeableConcept [0..1] « null (Strength=Example)ConditionStage?? » « This element has or is affected by some invariantsC »Reference to a formal record of the evidence on which the staging assessment is basedassessment : Reference [0..*] « ClinicalImpression|DiagnosticReport| Observation » « This element has or is affected by some invariantsC »The kind of staging, such as pathological or clinical stagingtype : CodeableConcept [0..1] « null (Strength=Example)ConditionStageType?? »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 diseasestage[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><!-- I 1..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved | unknown --></clinicalStatus>
 <verificationStatus><!-- 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error --></verificationStatus>
 <category><!-- I 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><!-- I 0..* CodeableConcept Anatomical location, if relevant --></bodySite>
 <bodyStructure><!-- I 0..1 Reference(BodyStructure) Anatomical body structure --></bodyStructure>
 <subject><!-- 1..1 Reference(Group|Patient) Who has the condition? --></subject>
 <encounter><!-- 0..1 Reference(Encounter) The Encounter during which this Condition was created --></encounter>
 <onset[x]><!-- 0..1 dateTime|Age|Period|Range|string Estimated or actual date,  date-time, or age --></onset[x]>
 <abatement[x]><!-- I 0..1 dateTime|Age|Period|Range|string When in resolution/remission --></abatement[x]>
 <recordedDate value="[dateTime]"/><!-- 0..1 Date condition was first recorded -->
 <recorder><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|
   RelatedPerson) Who recorded the condition --></recorder>
 <asserter><!-- 0..1 Reference(Device|Patient|Practitioner|PractitionerRole|
   RelatedPerson) Person or device that asserts this condition --></asserter>
 <stage>  <!-- 0..* Stage/grade, usually assessed formally -->
  <summary><!-- I 0..1 CodeableConcept Simple summary (disease specific) --></summary>
  <assessment><!-- I 0..* Reference(ClinicalImpression|DiagnosticReport|Observation) Formal record of assessment --></assessment>
  <type><!-- 0..1 CodeableConcept Kind of staging --></type>
 </stage>
 <evidence><!-- 0..* CodeableReference(Any) Supporting evidence for the condition --></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" : { CodeableConcept }, // I R!  active | recurrence | relapse | inactive | remission | resolved | unknown
  "verificationStatus" : { CodeableConcept }, // unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
  "category" : [{ CodeableConcept }], // I problem-list-item | encounter-diagnosis
  "severity" : { CodeableConcept }, // Subjective severity of condition
  "code" : { CodeableConcept }, // Identification of the condition, problem or diagnosis
  "bodySite" : [{ CodeableConcept }], // I Anatomical location, if relevant
  "bodyStructure" : { Reference(BodyStructure) }, // I Anatomical body structure
  "subject" : { Reference(Group|Patient) }, // R!  Who has the condition?
  "encounter" : { Reference(Encounter) }, // The Encounter during which this Condition was created
  // 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>",
  "recordedDate" : "<dateTime>", // Date condition was first recorded
  "recorder" : { Reference(Patient|Practitioner|PractitionerRole|
   RelatedPerson) }, // Who recorded the condition
  "asserter" : { Reference(Device|Patient|Practitioner|PractitionerRole|
   RelatedPerson) }, // Person or device that asserts this condition
  "stage" : [{ // Stage/grade, usually assessed formally
    "summary" : { CodeableConcept }, // I Simple summary (disease specific)
    "assessment" : [{ Reference(ClinicalImpression|DiagnosticReport|Observation) }], // I Formal record of assessment
    "type" : { CodeableConcept } // Kind of staging
  }],
  "evidence" : [{ CodeableReference(Any) }], // Supporting evidence for the condition
  "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:identifier  ( [ Identifier ] ... ) ; # 0..* External Ids for this condition
  fhir:clinicalStatus [ CodeableConcept ] ; # 1..1 I active | recurrence | relapse | inactive | remission | resolved | unknown
  fhir:verificationStatus [ CodeableConcept ] ; # 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
  fhir:category  ( [ CodeableConcept ] ... ) ; # 0..* I problem-list-item | encounter-diagnosis
  fhir:severity [ CodeableConcept ] ; # 0..1 Subjective severity of condition
  fhir:code [ CodeableConcept ] ; # 0..1 Identification of the condition, problem or diagnosis
  fhir:bodySite  ( [ CodeableConcept ] ... ) ; # 0..* I Anatomical location, if relevant
  fhir:bodyStructure [ Reference(BodyStructure) ] ; # 0..1 I Anatomical body structure
  fhir:subject [ Reference(Group|Patient) ] ; # 1..1 Who has the condition?
  fhir:encounter [ Reference(Encounter) ] ; # 0..1 The Encounter during which this Condition was created
  # onset[x] : 0..1 Estimated or actual date,  date-time, or age. One of these 5
    fhir:onset [  a fhir:dateTime ; dateTime ]
    fhir:onset [  a fhir:Age ; Age ]
    fhir:onset [  a fhir:Period ; Period ]
    fhir:onset [  a fhir:Range ; Range ]
    fhir:onset [  a fhir:string ; string ]
  # abatement[x] : 0..1 I When in resolution/remission. One of these 5
    fhir:abatement [  a fhir:dateTime ; dateTime ]
    fhir:abatement [  a fhir:Age ; Age ]
    fhir:abatement [  a fhir:Period ; Period ]
    fhir:abatement [  a fhir:Range ; Range ]
    fhir:abatement [  a fhir:string ; string ]
  fhir:recordedDate [ dateTime ] ; # 0..1 Date condition was first recorded
  fhir:recorder [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Who recorded the condition
  fhir:asserter [ Reference(Device|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Person or device that asserts this condition
  fhir:stage ( [ # 0..* Stage/grade, usually assessed formally
    fhir:summary [ CodeableConcept ] ; # 0..1 I Simple summary (disease specific)
    fhir:assessment  ( [ Reference(ClinicalImpression|DiagnosticReport|Observation) ] ... ) ; # 0..* I Formal record of assessment
    fhir:type [ CodeableConcept ] ; # 0..1 Kind of staging
  ] ... ) ;
  fhir:evidence  ( [ CodeableReference(Any) ] ... ) ; # 0..* Supporting evidence for the condition
  fhir:note  ( [ Annotation ] ... ) ; # 0..* Additional information about the Condition
]

Changes from both R4 and R4B

Condition
Condition.clinicalStatus
  • Min Cardinality changed from 0 to 1
  • Add code unknown
Condition.category
  • Remove Binding `http://hl7.org/fhir/ValueSet/condition-category` (extensible)
Condition.bodyStructure
  • Added Element
Condition.asserter
  • Type Reference: Added Target Type Device
Condition.evidence
  • Type changed from BackboneElement to CodeableReference
Condition.evidence.code
  • Deleted (-> Condition.evidence)
Condition.evidence.detail
  • Deleted (-> Condition.evidence)

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition TU DomainResource Detailed information about conditions, problems or diagnoses
+ Warning: If category is problems list item, the clinicalStatus should not be unknown
+ Rule: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission.
+ Rule: bodyStructure SHALL only be present if Condition.bodySite is not present

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 0..* Identifier External Ids for this condition

... clinicalStatus ?!ΣC 1..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved | unknown
Binding: Condition Clinical Status Codes (Required)
... verificationStatus ?!Σ 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: Condition Verification Status (Required)
... severity 0..1 CodeableConcept Subjective severity of condition
Binding: Condition/Diagnosis Severity (Preferred)
... code Σ 0..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: Condition/Problem/Diagnosis Codes (Example)
... bodySite ΣC 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMED CT Body Structures (Example)

... bodyStructure C 0..1 Reference(BodyStructure) Anatomical body structure
... subject Σ 1..1 Reference(Patient | Group) Who has the condition?
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this Condition was created
... 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] C 0..1 When in resolution/remission
.... abatementDateTime dateTime
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
... recordedDate Σ 0..1 dateTime Date condition was first recorded
... recorder Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device) Person or device that asserts this condition
... stage CTU 0..* BackboneElement Stage/grade, usually assessed formally
+ Rule: Stage SHALL have summary or assessment

.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Binding: Condition Stage (Example)
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment

.... type 0..1 CodeableConcept Kind of staging
Binding: Condition Stage Type (Example)
... evidence ΣTU 0..* CodeableReference(Any) Supporting evidence for the condition
Binding: SNOMED CT Clinical Findings (Example)

... note 0..* Annotation Additional information about the Condition


doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

Condition (DomainResource)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 serveridentifier : Identifier [0..*]The clinical status of the condition (this element modifies the meaning of other elements)clinicalStatus : CodeableConcept [1..1] « null (Strength=Required) ConditionClinicalStatusCodes! » « This element has or is affected by some invariantsC »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 (this element modifies the meaning of other elements)verificationStatus : CodeableConcept [0..1] « null (Strength=Required) ConditionVerificationStatus! »A category assigned to the conditioncategory : CodeableConcept [0..*] « null (Strength=Preferred)ConditionCategoryCodes? » « This element has or is affected by some invariantsC »A subjective assessment of the severity of the condition as evaluated by the clinicianseverity : CodeableConcept [0..1] « null (Strength=Preferred)ConditionDiagnosisSeverity? »Identification of the condition, problem or diagnosiscode : CodeableConcept [0..1] « null (Strength=Example)ConditionProblemDiagnosisCodes?? »The anatomical location where this condition manifests itselfbodySite : CodeableConcept [0..*] « Codes describing anatomical locations. May include laterality. (Strength=Example)SNOMEDCTBodyStructures?? » « This element has or is affected by some invariantsC »Indicates the body structure on the subject's body where this condition manifests itselfbodyStructure : Reference [0..1] « BodyStructure » « This element has or is affected by some invariantsC »Indicates the patient or group who the condition record is associated withsubject : Reference [1..1] « Patient|Group »The Encounter during which this Condition was created or to which the creation of this record is tightly associatedencounter : Reference [0..1] « Encounter »Estimated or actual date or date-time the condition, situation, or concern began, in the opinion of the clinicianonset[x] : DataType [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" - Some conditions, such as chronic conditions, are never really resolved, but they can abateabatement[x] : DataType [0..1] « dateTime|Age|Period|Range|string » « This element has or is affected by some invariantsC »The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated daterecordedDate : dateTime [0..1]Individual who recorded the record and takes responsibility for its contentrecorder : Reference [0..1] « Practitioner|PractitionerRole|Patient| RelatedPerson »Individual or device that is making the condition statementasserter : Reference [0..1] « Practitioner|PractitionerRole|Patient| RelatedPerson|Device »Supporting evidence / manifestations that are the basis for determining the Conditionevidence : CodeableReference [0..*] « Any; null (Strength=Example)SNOMEDCTClinicalFindings?? »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" or "Early Onset". The determination of the stage is disease-specific, such as cancer, retinopathy of prematurity, kidney diseases, Alzheimer's, or Parkinson diseasesummary : CodeableConcept [0..1] « null (Strength=Example)ConditionStage?? » « This element has or is affected by some invariantsC »Reference to a formal record of the evidence on which the staging assessment is basedassessment : Reference [0..*] « ClinicalImpression|DiagnosticReport| Observation » « This element has or is affected by some invariantsC »The kind of staging, such as pathological or clinical stagingtype : CodeableConcept [0..1] « null (Strength=Example)ConditionStageType?? »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 diseasestage[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><!-- I 1..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved | unknown --></clinicalStatus>
 <verificationStatus><!-- 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error --></verificationStatus>
 <category><!-- I 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><!-- I 0..* CodeableConcept Anatomical location, if relevant --></bodySite>
 <bodyStructure><!-- I 0..1 Reference(BodyStructure) Anatomical body structure --></bodyStructure>
 <subject><!-- 1..1 Reference(Group|Patient) Who has the condition? --></subject>
 <encounter><!-- 0..1 Reference(Encounter) The Encounter during which this Condition was created --></encounter>
 <onset[x]><!-- 0..1 dateTime|Age|Period|Range|string Estimated or actual date,  date-time, or age --></onset[x]>
 <abatement[x]><!-- I 0..1 dateTime|Age|Period|Range|string When in resolution/remission --></abatement[x]>
 <recordedDate value="[dateTime]"/><!-- 0..1 Date condition was first recorded -->
 <recorder><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|
   RelatedPerson) Who recorded the condition --></recorder>
 <asserter><!-- 0..1 Reference(Device|Patient|Practitioner|PractitionerRole|
   RelatedPerson) Person or device that asserts this condition --></asserter>
 <stage>  <!-- 0..* Stage/grade, usually assessed formally -->
  <summary><!-- I 0..1 CodeableConcept Simple summary (disease specific) --></summary>
  <assessment><!-- I 0..* Reference(ClinicalImpression|DiagnosticReport|Observation) Formal record of assessment --></assessment>
  <type><!-- 0..1 CodeableConcept Kind of staging --></type>
 </stage>
 <evidence><!-- 0..* CodeableReference(Any) Supporting evidence for the condition --></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" : { CodeableConcept }, // I R!  active | recurrence | relapse | inactive | remission | resolved | unknown
  "verificationStatus" : { CodeableConcept }, // unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
  "category" : [{ CodeableConcept }], // I problem-list-item | encounter-diagnosis
  "severity" : { CodeableConcept }, // Subjective severity of condition
  "code" : { CodeableConcept }, // Identification of the condition, problem or diagnosis
  "bodySite" : [{ CodeableConcept }], // I Anatomical location, if relevant
  "bodyStructure" : { Reference(BodyStructure) }, // I Anatomical body structure
  "subject" : { Reference(Group|Patient) }, // R!  Who has the condition?
  "encounter" : { Reference(Encounter) }, // The Encounter during which this Condition was created
  // 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>",
  "recordedDate" : "<dateTime>", // Date condition was first recorded
  "recorder" : { Reference(Patient|Practitioner|PractitionerRole|
   RelatedPerson) }, // Who recorded the condition
  "asserter" : { Reference(Device|Patient|Practitioner|PractitionerRole|
   RelatedPerson) }, // Person or device that asserts this condition
  "stage" : [{ // Stage/grade, usually assessed formally
    "summary" : { CodeableConcept }, // I Simple summary (disease specific)
    "assessment" : [{ Reference(ClinicalImpression|DiagnosticReport|Observation) }], // I Formal record of assessment
    "type" : { CodeableConcept } // Kind of staging
  }],
  "evidence" : [{ CodeableReference(Any) }], // Supporting evidence for the condition
  "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:identifier  ( [ Identifier ] ... ) ; # 0..* External Ids for this condition
  fhir:clinicalStatus [ CodeableConcept ] ; # 1..1 I active | recurrence | relapse | inactive | remission | resolved | unknown
  fhir:verificationStatus [ CodeableConcept ] ; # 0..1 unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
  fhir:category  ( [ CodeableConcept ] ... ) ; # 0..* I problem-list-item | encounter-diagnosis
  fhir:severity [ CodeableConcept ] ; # 0..1 Subjective severity of condition
  fhir:code [ CodeableConcept ] ; # 0..1 Identification of the condition, problem or diagnosis
  fhir:bodySite  ( [ CodeableConcept ] ... ) ; # 0..* I Anatomical location, if relevant
  fhir:bodyStructure [ Reference(BodyStructure) ] ; # 0..1 I Anatomical body structure
  fhir:subject [ Reference(Group|Patient) ] ; # 1..1 Who has the condition?
  fhir:encounter [ Reference(Encounter) ] ; # 0..1 The Encounter during which this Condition was created
  # onset[x] : 0..1 Estimated or actual date,  date-time, or age. One of these 5
    fhir:onset [  a fhir:dateTime ; dateTime ]
    fhir:onset [  a fhir:Age ; Age ]
    fhir:onset [  a fhir:Period ; Period ]
    fhir:onset [  a fhir:Range ; Range ]
    fhir:onset [  a fhir:string ; string ]
  # abatement[x] : 0..1 I When in resolution/remission. One of these 5
    fhir:abatement [  a fhir:dateTime ; dateTime ]
    fhir:abatement [  a fhir:Age ; Age ]
    fhir:abatement [  a fhir:Period ; Period ]
    fhir:abatement [  a fhir:Range ; Range ]
    fhir:abatement [  a fhir:string ; string ]
  fhir:recordedDate [ dateTime ] ; # 0..1 Date condition was first recorded
  fhir:recorder [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Who recorded the condition
  fhir:asserter [ Reference(Device|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Person or device that asserts this condition
  fhir:stage ( [ # 0..* Stage/grade, usually assessed formally
    fhir:summary [ CodeableConcept ] ; # 0..1 I Simple summary (disease specific)
    fhir:assessment  ( [ Reference(ClinicalImpression|DiagnosticReport|Observation) ] ... ) ; # 0..* I Formal record of assessment
    fhir:type [ CodeableConcept ] ; # 0..1 Kind of staging
  ] ... ) ;
  fhir:evidence  ( [ CodeableReference(Any) ] ... ) ; # 0..* Supporting evidence for the condition
  fhir:note  ( [ Annotation ] ... ) ; # 0..* Additional information about the Condition
]

Changes from both R4 and R4B

Condition
Condition.clinicalStatus
  • Min Cardinality changed from 0 to 1
  • Add code unknown
Condition.category
  • Remove Binding `http://hl7.org/fhir/ValueSet/condition-category` (extensible)
Condition.bodyStructure
  • Added Element
Condition.asserter
  • Type Reference: Added Target Type Device
Condition.evidence
  • Type changed from BackboneElement to CodeableReference
Condition.evidence.code
  • Deleted (-> Condition.evidence)
Condition.evidence.detail
  • Deleted (-> Condition.evidence)

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

 

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

9.2.4.1 Terminology Bindings

Path ValueSet Type Documentation
Condition.clinicalStatus ConditionClinicalStatusCodes Required

Preferred value set for Condition Clinical Status.
Condition.verificationStatus ConditionVerificationStatus Required

The verification status to support or decline the clinical status of the condition or diagnosis.
Condition.category ConditionCategoryCodes Preferred

Preferred value set for Condition Categories.
Condition.severity ConditionDiagnosisSeverity Preferred

Preferred value set for Condition/Diagnosis severity grading.
Condition.code ConditionProblemDiagnosisCodes Example

Example value set for Condition/Problem/Diagnosis codes.
Condition.bodySite SNOMEDCTBodyStructures Example

This value set includes all codes from SNOMED CT icon where concept is-a 442083009 (Anatomical or acquired body site (body structure)).
Condition.stage.summary ConditionStage Example

Value set for stages of cancer and other conditions.
Condition.stage.type ConditionStageType Example

Example value set for the type of stages of cancer and other conditions
Condition.evidence SNOMEDCTClinicalFindings Example

This value set includes all the "Clinical finding" SNOMED CT icon codes - concepts where concept is-a 404684003 (Clinical finding (finding)).

9.2.4.2 Constraints

UniqueKeyLevelLocationDescriptionExpression
img con-1Rule Condition.stageStage SHALL have summary or assessmentsummary.exists() or assessment.exists()
img con-2Warning (base)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()
img con-3Rule (base)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())
img con-4Rule (base)bodyStructure SHALL only be present if Condition.bodySite is not presentbodySite.exists() implies bodyStructure.empty()



9.2.4.3 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.

9.2.4.4 "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.

Note to Implementers: 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 icon is sought regarding the preferred approach.

Provide feedback here icon.

Patient Denies Condition

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

9.2.4.5 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 Condition was considered present and subsequent evidence refuted it. Specifically, Condition.verificationStatus can convey refuted. The corresponding evidence of that refutation can be conveyed in Condition.evidence. When the condition is refuted, other elements may be retained for legal reasons, but those other elements are no longer clinically relevant.
  • 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.

9.2.4.6 Use of Condition.evidence

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

9.2.4.7 Use of Condition.abatementRange

A range is used to communicate an imprecise age of the subject at the time of abatement.

9.2.4.8 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.

9.2.4.9 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.

9.2.4.10 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.

9.2.4.11 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.

9.2.5 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to 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.ofType(Age) | Condition.abatement.ofType(Range)
abatement-date date Date-related abatements (dateTime and period) Condition.abatement.ofType(dateTime) | Condition.abatement.ofType(Period)
abatement-string string Abatement as a string Condition.abatement.ofType(string)
asserter reference Person or device that asserts this condition Condition.asserter
(Practitioner, Device, 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 21 Resources
encounter reference The Encounter during which this Condition was created Condition.encounter
(Encounter)		 29 Resources
evidence token Manifestation/symptom Condition.evidence.concept
evidence-detail reference Supporting information found elsewhere Condition.evidence.reference
identifier token A unique identifier of the condition record Condition.identifier 65 Resources
onset-age quantity Onsets as age or age range Condition.onset.ofType(Age) | Condition.onset.ofType(Range)
onset-date date Date related onsets (dateTime and Period) Condition.onset.ofType(dateTime) | Condition.onset.ofType(Period)
onset-info string Onsets as a string Condition.onset.ofType(string)
patient reference Who has the condition? Condition.subject.where(resolve() is Patient)
(Patient)		 65 Resources
recorded-date date Date record was first recorded Condition.recordedDate
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