This page is part of the FHIR Specification (v4.3.0: R4B - STU). 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
Patient Care Work Group | Maturity Level: 3 | Trial Use | Security 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. | ||||||||||||||||
Cardinality | 0..* | ||||||||||||||||
Type | DomainResource | ||||||||||||||||
Summary | false | ||||||||||||||||
Invariants |
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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. | ||||||||||||||||
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. | ||||||||||||||||
Cardinality | 0..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| true (Reason: This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.)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. | ||||||||||||||||
Invariants |
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Condition.verificationStatus | |||||||||||||||||
Element Id | Condition.verificationStatus | ||||||||||||||||
Definition | The verification status to support the clinical status of the condition. | ||||||||||||||||
Cardinality | 0..1 | ||||||||||||||||
Terminology Binding | ConditionVerificationStatus (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. | ||||||||||||||||
Invariants |
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Condition.category | |||||||||||||||||
Element Id | Condition.category | ||||||||||||||||
Definition | A category assigned to the condition. | ||||||||||||||||
Cardinality | 0..* | ||||||||||||||||
Terminology Binding | Condition Category Codes (Extensible) | ||||||||||||||||
Type | CodeableConcept | ||||||||||||||||
Summary | false | ||||||||||||||||
Comments | The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. | ||||||||||||||||
Condition.severity | |||||||||||||||||
Element Id | Condition.severity | ||||||||||||||||
Definition | A subjective assessment of the severity of the condition as evaluated by the clinician. | ||||||||||||||||
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. | ||||||||||||||||
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. | ||||||||||||||||
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. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension bodySite. May be a summary code, or a reference to a very precise definition of the location, or both. | ||||||||||||||||
Condition.subject | |||||||||||||||||
Element Id | Condition.subject | ||||||||||||||||
Definition | Indicates the patient or group who the condition record is associated with. | ||||||||||||||||
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. | ||||||||||||||||
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 began, in the opinion of the clinician. | ||||||||||||||||
Cardinality | 0..1 | ||||||||||||||||
Type | dateTime|Age|Period|Range|string | ||||||||||||||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||||||||||||||
Summary | true | ||||||||||||||||
Comments | Age is generally used when the patient reports an age at which the Condition began to occur. | ||||||||||||||||
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" - Conditions are never really resolved, but they can abate. | ||||||||||||||||
Cardinality | 0..1 | ||||||||||||||||
Type | dateTime|Age|Period|Range|string | ||||||||||||||||
[x] Note | See Choice of Data Types 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. | ||||||||||||||||
Invariants |
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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. | ||||||||||||||||
Cardinality | 0..1 | ||||||||||||||||
Type | dateTime | ||||||||||||||||
Summary | true | ||||||||||||||||
Condition.recorder | |||||||||||||||||
Element Id | Condition.recorder | ||||||||||||||||
Definition | Individual who recorded the record and takes responsibility for its content. | ||||||||||||||||
Cardinality | 0..1 | ||||||||||||||||
Type | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | ||||||||||||||||
Summary | true | ||||||||||||||||
Condition.asserter | |||||||||||||||||
Element Id | Condition.asserter | ||||||||||||||||
Definition | Individual who is making the condition statement. | ||||||||||||||||
Cardinality | 0..1 | ||||||||||||||||
Type | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | ||||||||||||||||
Summary | true | ||||||||||||||||
Condition.stage | |||||||||||||||||
Element Id | Condition.stage | ||||||||||||||||
Definition | Clinical stage or grade of a condition. May include formal severity assessments. | ||||||||||||||||
Cardinality | 0..* | ||||||||||||||||
Summary | false | ||||||||||||||||
Invariants |
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Condition.stage.summary | |||||||||||||||||
Element Id | Condition.stage.summary | ||||||||||||||||
Definition | A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. | ||||||||||||||||
Cardinality | 0..1 | ||||||||||||||||
Terminology Binding | Condition Stage (Example) | ||||||||||||||||
Type | CodeableConcept | ||||||||||||||||
Summary | false | ||||||||||||||||
Invariants |
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Condition.stage.assessment | |||||||||||||||||
Element Id | Condition.stage.assessment | ||||||||||||||||
Definition | Reference to a formal record of the evidence on which the staging assessment is based. | ||||||||||||||||
Cardinality | 0..* | ||||||||||||||||
Type | Reference(ClinicalImpression | DiagnosticReport | Observation) | ||||||||||||||||
Summary | false | ||||||||||||||||
Invariants |
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Condition.stage.type | |||||||||||||||||
Element Id | Condition.stage.type | ||||||||||||||||
Definition | The kind of staging, such as pathological or clinical 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 of the Condition's verification status, such as evidence that confirmed or refuted the condition. | ||||||||||||||||
Cardinality | 0..* | ||||||||||||||||
Summary | false | ||||||||||||||||
Comments | The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. | ||||||||||||||||
Invariants |
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Condition.evidence.code | |||||||||||||||||
Element Id | Condition.evidence.code | ||||||||||||||||
Definition | A manifestation or symptom that led to the recording of this condition. | ||||||||||||||||
Cardinality | 0..* | ||||||||||||||||
Terminology Binding | Manifestation and Symptom Codes (Example) | ||||||||||||||||
Type | CodeableConcept | ||||||||||||||||
Summary | true | ||||||||||||||||
Invariants |
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Condition.evidence.detail | |||||||||||||||||
Element Id | Condition.evidence.detail | ||||||||||||||||
Definition | Links to other relevant information, including pathology reports. | ||||||||||||||||
Cardinality | 0..* | ||||||||||||||||
Type | Reference(Any) | ||||||||||||||||
Summary | true | ||||||||||||||||
Invariants |
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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. | ||||||||||||||||
Cardinality | 0..* | ||||||||||||||||
Type | Annotation | ||||||||||||||||
Summary | false |