DSTU2

This page is part of the FHIR Specification (v1.0.2: DSTU 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

4.3.6 Resource Condition - Detailed Descriptions

Detailed Descriptions 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.

Control1..1
Summarytrue
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 processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Need to allow connection to a wider workflow.

Summarytrue
Condition.patient
Definition

Indicates the patient who the condition record is associated with.

Control1..1
TypeReference(Patient)
Summarytrue
Condition.encounter
Definition

Encounter during which the condition was first asserted.

Control0..1
TypeReference(Encounter)
Summarytrue
Comments

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.asserter
Definition

Individual who is making the condition statement.

Control0..1
TypeReference(Practitioner | Patient)
Summarytrue
Condition.dateRecorded
Definition

A date, when the Condition statement was documented.

Control0..1
Typedate
Summarytrue
Comments

The Date Recorded represents the date when this particular Condition record was created in the EHR, not the date of the most recent update in terms of when severity, abatement, etc. were specified.  The date of the last record modification can be retrieved from the resource metadata.

Condition.code
Definition

Identification of the condition, problem or diagnosis.

Control1..1
BindingCondition/Problem/Diagnosis Codes: Identification of the condition or diagnosis. (Example)
TypeCodeableConcept
Summarytrue
Condition.category
Definition

A category assigned to the condition.

Control0..1
BindingCondition Category Codes: A category assigned to the condition. (Preferred)
TypeCodeableConcept
Summarytrue
Comments

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

Condition.clinicalStatus
Definition

The clinical status of the condition.

Control0..1
BindingCondition Clinical Status Codes: The clinical status of the condition or diagnosis. (Preferred)
Typecode
Is Modifiertrue
Summarytrue
Condition.verificationStatus
Definition

The verification status to support the clinical status of the condition.

Control1..1
BindingConditionVerificationStatus: The verification status to support or decline the clinical status of the condition or diagnosis. (Required)
Typecode
Is Modifiertrue
Summarytrue
Condition.severity
Definition

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

Control0..1
BindingCondition/Diagnosis Severity: A subjective assessment of the severity of the condition as evaluated by the clinician. (Preferred)
TypeCodeableConcept
Summarytrue
Comments

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

Condition.onset[x]
Definition

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

Control0..1
TypedateTime|Age|Period|Range|string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
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.

Control0..1
TypedateTime|Age|boolean|Period|Range|string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
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.

Control0..1
Summarytrue
InvariantsDefined on this element
con-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.

Control0..1
BindingCondition Stage: Codes describing condition stages (e.g. Cancer stages). (Example)
TypeCodeableConcept
Summarytrue
InvariantsAffect this element
con-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.

Control0..*
TypeReference(ClinicalImpression | DiagnosticReport | Observation)
Summarytrue
InvariantsAffect this element
con-1: Stage SHALL have summary or assessment (xpath: exists(f:summary) or exists(f:assessment))
To DoWhen 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.

Control0..*
Summarytrue
Comments

The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.

InvariantsDefined on this element
con-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.

Control0..1
BindingManifestation and Symptom Codes: Codes that describe the manifestation or symptoms of a condition. (Example)
TypeCodeableConcept
Summarytrue
InvariantsAffect this element
con-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.

Control0..*
TypeReference(Any)
Summarytrue
InvariantsAffect this element
con-2: evidence SHALL have code or details (xpath: exists(f:code) or exists(f:detail))
Condition.bodySite
Definition

The anatomical location where this condition manifests itself.

Control0..*
BindingSNOMED CT Body Structures: Codes describing anatomical locations. May include laterality. (Example)
TypeCodeableConcept
Summarytrue
Comments

May be a summary code, or a reference to a very precise definition of the location, or both.

Condition.notes
Definition

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

Control0..1
Typestring
Summarytrue