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
Definitions for the qicore-condition Profile.
Condition(QICore-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 | 0..* |
Type | Condition |
Condition.id | |
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. |
Control | 0..1 |
Type | id |
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID. |
Condition.meta | |
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource. |
Control | 0..1 |
Type | Meta |
Condition.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. |
Control | 0..1 |
Type | uri |
Is Modifier | true |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible. |
Condition.language | |
Definition | The base language in which the resource is written. |
Control | 0..1 |
Binding | A human language. The codes SHALL be taken from http://tools.ietf.org/html/bcp47 |
Type | code |
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). |
Condition.text | |
Definition | A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. |
Control | 0..1 This element is affected by the following invariants: dom-1 |
Type | Narrative |
Alternate Names | narrative, html, xhtml, display |
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. |
Condition.contained | |
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. |
Control | 0..* |
Type | Resource |
Alternate Names | inline resources, anonymous resources, contained resources |
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. |
Condition.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Slicing | This element introduces a set of slices. The slicing rules are:
|
Condition.extension (http://hl7.org/fhir/StructureDefinition/condition-criticality) | |
Definition | Characterizes potential impact of the condition on life, durable physiological function, or quality of life. May include concepts such as self-resolving, life-threatening, requires hospitalization, or potential loss of function or capacity. Different from severity in that a moderate subarachnoid hemorrhage is likely to be highly critical, whereas a moderate headache is not as important. |
Control | 0..1 |
Type | Extension (Extension Type: CodeableConcept) |
Comments | What is the value set for this? |
Condition.extension(bodySiteInstance) | |
Definition | An Extension |
Control | 0..* |
Type | Reference(QICore-BodySite) |
Must Support | true |
Condition.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
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). |
Control | 0..* |
Type | Identifier |
Requirements | Need to allow connection to a wider workflow. |
Condition.patient | |
Definition | Indicates the patient who the condition record is associated with. |
Control | 1..1 |
Type | Reference(QICore-Patient) |
Must Support | true |
Condition.encounter | |
Definition | Encounter during which the condition was first asserted. |
Control | 0..1 |
Type | Reference(QICore-Encounter) |
Must Support | true |
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. |
Control | 0..1 |
Type | Choice of: Reference(QICore-Patient), Reference(QICore-Practitioner) |
Condition.dateRecorded | |
Definition | A date, when the Condition statement was documented. |
Control | 0..1 |
Type | date |
Must Support | true |
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. |
Control | 1..1 |
Binding | The code for the condition The codes SHOULD be taken from Problem Value Set |
Type | CodeableConcept |
Must Support | true |
Condition.category | |
Definition | A category assigned to the condition. |
Control | 0..1 |
Binding | A category assigned to the condition. The codes SHOULD be taken from Condition Category Codes |
Type | CodeableConcept |
Must Support | true |
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. |
Control | 0..1 |
Binding | The clinical status of the condition or diagnosis. The codes SHOULD be taken from Condition Clinical Status Codes |
Type | code |
Is Modifier | true |
Must Support | true |
Condition.verificationStatus | |
Definition | The verification status to support the clinical status of the condition. |
Control | 1..1 |
Binding | The verification status to support or decline the clinical status of the condition or diagnosis. The codes SHALL be taken from ConditionVerificationStatus |
Type | code |
Is Modifier | true |
Condition.severity | |
Definition | A subjective assessment of the severity of the condition as evaluated by the clinician. |
Control | 0..1 |
Binding | A subjective assessment of the severity of the condition as evaluated by the clinician. The codes SHOULD be taken from Condition/Diagnosis Severity |
Type | CodeableConcept |
Must Support | true |
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. |
Control | 0..1 |
Type | Choice of: dateTime, Quantity(Age), Period, Range, string |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Must Support | true |
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 | Choice of: dateTime, Quantity(Age), boolean, Period, Range, string |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Must Support | true |
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 |
Type | BackboneElement |
Must Support | true |
Invariants | Defined on this element con-1: Stage SHALL have summary or assessment (xpath: exists(f:summary) or exists(f:assessment)) |
Condition.stage.id | |
Definition | unique id for the element within a resource (for internal references). |
Control | 0..1 |
Type | id |
Condition.stage.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Condition.stage.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
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 This element is affected by the following invariants: con-1 |
Binding | Codes describing condition stages (e.g. Cancer stages). For example codes, see Condition Stage |
Type | CodeableConcept |
Must Support | true |
Condition.stage.assessment | |
Definition | Reference to a formal record of the evidence on which the staging assessment is based. |
Control | 0..* This element is affected by the following invariants: con-1 |
Type | Choice of: Reference(ClinicalImpression), Reference(DiagnosticReport), Reference(Observation) |
Condition.evidence | |
Definition | Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed. |
Control | 0..* |
Type | BackboneElement |
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 con-2: evidence SHALL have code or details (xpath: exists(f:code) or exists(f:detail)) |
Condition.evidence.id | |
Definition | unique id for the element within a resource (for internal references). |
Control | 0..1 |
Type | id |
Condition.evidence.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Condition.evidence.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Condition.evidence.code | |
Definition | A manifestation or symptom that led to the recording of this condition. |
Control | 0..1 This element is affected by the following invariants: con-2 |
Binding | Codes that describe the manifestation or symptoms of a condition. For example codes, see Manifestation and Symptom Codes |
Type | CodeableConcept |
Condition.evidence.detail | |
Definition | Links to other relevant information, including pathology reports. |
Control | 0..* This element is affected by the following invariants: con-2 |
Type | Reference(Resource) |
Condition.bodySite | |
Definition | The anatomical location where this condition manifests itself. |
Control | 0..* |
Binding | Codes describing anatomical locations. May include laterality. For example codes, see SNOMED CT Body Structures |
Type | CodeableConcept |
Must Support | true |
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. |
Control | 0..1 |
Type | string |