Condition - FHIR v0.0.82

This page is part of the FHIR Specification (v0.0.82: DSTU 1). 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

4.5.5 Resource Condition - Formal Definitions

Formal definitions for the elements in the Condition resource.

Condition
Definition	Use to record detailed information about conditions, problems or diagnoses recognized by a clinician. There are many uses including: recording a Diagnosis during an Encounter; populating a problem List or a Summary Statement, such as a Discharge Summary.
Control	1..1
To Do	* Age is questionable, you might well need a range of Age or even (in practice) a text like "in their teens". => new ballot comment. * Todo: discuss the applicability of assessing stages * Change the description: it is circular.
Condition.identifier
Definition	This records identifiers associated with this condition that are defined by business processed and/ or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).
Control	0..*
Type	Identifier
Requirements	Need to allow connection to a wider workflow.
Condition.subject
Definition	Indicates the patient who the condition record is associated with.
Control	1..1
Type	Resource(Patient)
Condition.encounter
Definition	Encounter during which the condition was first asserted.
Control	0..1
Type	Resource(Encounter)
Condition.asserter
Definition	Person who takes responsibility for asserting the existence of the condition as part of the electronic record.
Control	0..1
Type	Resource(Practitioner \| Patient)
Condition.dateAsserted
Definition	Estimated or actual date the condition/problem/diagnosis was first detected/suspected.
Control	0..1
Type	date
Condition.code
Definition	Identification of the condition, problem or diagnosis.
Control	1..1
Binding	ConditionKind: (See http://hl7.org/fhir/vs/condition-code)
Type	CodeableConcept
Condition.category
Definition	A category assigned to the condition. E.g. complaint \| symptom \| finding \| diagnosis.
Control	0..1
Binding	ConditionCategory: (See http://hl7.org/fhir/vs/condition-category)
Type	CodeableConcept
Comments	The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.
Condition.status
Definition	The clinical status of the condition.
Control	1..1
Binding	ConditionStatus: The clinical status of the Condition or diagnosis (see http://hl7.org/fhir/condition-status for values)
Type	code
Is Modifier	true
Condition.certainty
Definition	The degree of confidence that this condition is correct.
Control	0..1
Binding	ConditionCertainty: (See http://hl7.org/fhir/vs/condition-certainty)
Type	CodeableConcept
Is Modifier	true
Comments	May be a percentage.
Condition.severity
Definition	A subjective assessment of the severity of the condition as evaluated by the clinician.
Control	0..1
Binding	ConditionSeverity: (See http://hl7.org/fhir/vs/condition-severity)
Type	CodeableConcept
Comments	Coding of the severity with a terminology is preferred, where possible.
Condition.onset[x]
Definition	Estimated or actual date the condition began, in the opinion of the clinician.
Control	0..1
Type	date\|Age
Comments	Age is generally used when the patient reports an age at which the Condition began to occur.
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" - Conditions are never really resolved, but they can abate.
Control	0..1
Type	date\|Age\|boolean
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.
Condition.stage
Definition	Clinical stage or grade of a condition. May include formal severity assessments.
Control	0..1
Invariants	Defined on this element Inv-1: Stage SHALL have summary or assessment (xpath: exists(f:summary) or exists(f:assessment))
Condition.stage.summary
Definition	A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.
Control	0..1
Type	CodeableConcept
Invariants	Affect this element Inv-1: Stage SHALL have summary or assessment (xpath: exists(f:summary) or exists(f:assessment))
Condition.stage.assessment
Definition	Reference to a formal record of the evidence on which the staging assessment is based.
Control	0..*
Type	Resource(Any)
Invariants	Affect this element Inv-1: Stage SHALL have summary or assessment (xpath: exists(f:summary) or exists(f:assessment))
To Do	When an assessment resource / framework is developed, this will be changed from Any to something narrower.
Condition.evidence
Definition	Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed.
Control	0..*
Comments	The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
Invariants	Defined on this element Inv-2: evidence SHALL have code or details (xpath: exists(f:code) or exists(f:detail))
Condition.evidence.code
Definition	A manifestation or symptom that led to the recording of this condition.
Control	0..1
Type	CodeableConcept
Invariants	Affect this element Inv-2: evidence SHALL have code or details (xpath: exists(f:code) or exists(f:detail))
Condition.evidence.detail
Definition	Links to other relevant information, including pathology reports.
Control	0..*
Type	Resource(Any)
Invariants	Affect this element Inv-2: evidence SHALL have code or details (xpath: exists(f:code) or exists(f:detail))
Condition.location
Definition	The anatomical location where this condition manifests itself.
Control	0..*
Comments	May be a summary code, or a reference to a very precise definition of the location, or both.
Invariants	Defined on this element Inv-3: location SHALL have code or details (xpath: exists(f:code) or exists(f:detail))
Condition.location.code
Definition	Code that identifies the structural location.
Control	0..1
Type	CodeableConcept
Comments	May include laterality.
Invariants	Affect this element Inv-3: location SHALL have code or details (xpath: exists(f:code) or exists(f:detail))
Condition.location.detail
Definition	Detailed anatomical location information.
Control	0..1
Type	string
Invariants	Affect this element Inv-3: location SHALL have code or details (xpath: exists(f:code) or exists(f:detail))
Condition.relatedItem
Definition	Further conditions, problems, diagnoses, procedures or events that are related in some way to this condition, or the substance that caused/triggered this Condition.
Control	0..*
Comments	Although a condition may be caused by a substance, this is not intended to be used to record allergies/adverse reactions to substances.
Invariants	Defined on this element Inv-4: Relationship SHALL have either a code or a target (xpath: exists(f:code) != exists(f:target))
Condition.relatedItem.type
Definition	The type of relationship that this condition has to the related item.
Control	1..1
Binding	ConditionRelationshipType: The type of relationship between a condition and its related item (see http://hl7.org/fhir/condition-relationship-type for values)
Type	code
Condition.relatedItem.code
Definition	Code that identifies the target of this relationship. The code takes the place of a detailed instance target.
Control	0..1
Binding	ConditionKind: (See http://hl7.org/fhir/vs/condition-code)
Type	CodeableConcept
Invariants	Affect this element Inv-4: Relationship SHALL have either a code or a target (xpath: exists(f:code) != exists(f:target))
Condition.relatedItem.target
Definition	Target of the relationship.
Control	0..1
Type	Resource(Condition \| Procedure \| MedicationAdministration \| Immunization \| MedicationStatement)
Invariants	Affect this element Inv-4: Relationship SHALL have either a code or a target (xpath: exists(f:code) != exists(f:target))
Condition.notes
Definition	Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.
Control	0..1
Type	string