BSeR: Bidirectional Services_eReferral

This page is part of the Bidirectional Services eReferrals (BSeR) (v1.0.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

StructureDefinition: BSeR_Diagnosis

A health condition of the referral patient.

The official URL for this profile is:

http://hl7.org/fhir/us/bser/StructureDefinition/BSeR-Diagnosis

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USCoreCondition

Summary

Mandatory: 4 elements
Fixed Value: 1 element

This structure is derived from USCoreCondition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*USCoreCondition
... category 1..1CodeableConceptFixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: problem-list-item
..... display1..1stringRepresentation defined by the system
Fixed Value: Problem List Item
... code 1..1CodeableConceptBinding: US Core Condition Code (extensible)
.... coding 1..1Coding
..... code 1..1code
..... display 0..1string
... onset[x] 0..1
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetStringstring

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*USCoreConditionDetailed information about conditions, problems or diagnoses
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣI0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... category SI1..1CodeableConceptproblem-list-item | encounter-diagnosis | health-concern
Binding: US Core Condition Category Codes (extensible)

Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: problem-list-item
..... display1..1stringRepresentation defined by the system
Fixed Value: Problem List Item
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... severity I0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred)
... code SΣI1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: US Core Condition Code (extensible)
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding ΣI1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system ΣI0..1uriIdentity of the terminology system
..... version ΣI0..1stringVersion of the system - if relevant
..... code ΣI1..1codeSymbol in syntax defined by the system
..... display ΣI0..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text ΣI0..1stringPlain text representation of the concept
... bodySite ΣI0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example)
... subject SΣI1..1Reference(US Core Patient Profile)Who has the condition?
... encounter ΣI0..1Reference(Encounter)Encounter created as part of
... onset[x] ΣI0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetStringstring
... abatement[x] I0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate ΣI0..1dateTimeDate record was first recorded
... recorder ΣI0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
... asserter ΣI0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Person who asserts this condition
... stage I0..*BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example)
.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type I0..1CodeableConceptKind of staging
Binding: ConditionStageType (example)
... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example)
.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note I0..*AnnotationAdditional information about the Condition

doco Documentation for this format

This structure is derived from USCoreCondition

Summary

Mandatory: 4 elements
Fixed Value: 1 element

Differential View

This structure is derived from USCoreCondition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*USCoreCondition
... category 1..1CodeableConceptFixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: problem-list-item
..... display1..1stringRepresentation defined by the system
Fixed Value: Problem List Item
... code 1..1CodeableConceptBinding: US Core Condition Code (extensible)
.... coding 1..1Coding
..... code 1..1code
..... display 0..1string
... onset[x] 0..1
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetStringstring

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*USCoreConditionDetailed information about conditions, problems or diagnoses
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣI0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... category SI1..1CodeableConceptproblem-list-item | encounter-diagnosis | health-concern
Binding: US Core Condition Category Codes (extensible)

Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: problem-list-item
..... display1..1stringRepresentation defined by the system
Fixed Value: Problem List Item
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... severity I0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred)
... code SΣI1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: US Core Condition Code (extensible)
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding ΣI1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system ΣI0..1uriIdentity of the terminology system
..... version ΣI0..1stringVersion of the system - if relevant
..... code ΣI1..1codeSymbol in syntax defined by the system
..... display ΣI0..1stringRepresentation defined by the system
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text ΣI0..1stringPlain text representation of the concept
... bodySite ΣI0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example)
... subject SΣI1..1Reference(US Core Patient Profile)Who has the condition?
... encounter ΣI0..1Reference(Encounter)Encounter created as part of
... onset[x] ΣI0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetStringstring
... abatement[x] I0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate ΣI0..1dateTimeDate record was first recorded
... recorder ΣI0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
... asserter ΣI0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Person who asserts this condition
... stage I0..*BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example)
.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type I0..1CodeableConceptKind of staging
Binding: ConditionStageType (example)
... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example)
.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note I0..*AnnotationAdditional information about the Condition

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

Terminology Bindings

PathConformanceValueSet / Code
Condition.languagepreferredCommonLanguages
Max Binding: AllLanguages
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleFixed Value: problem-list-item("Problem List Item")
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codeextensibleUSCoreConditionCode
Condition.bodySiteexampleSNOMEDCTBodyStructures
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleManifestationAndSymptomCodes

Constraints

Constraints

IdPathDetailsRequirements
con-3ConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
: clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4ConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5ConditionCondition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2ConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3ConditionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4ConditionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5ConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6ConditionA resource should have narrative for robust management
: text.`div`.exists()
us-core-1ConditionA code in Condition.category SHOULD be from US Core Condition Category Codes value set.
: where(category in 'http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category').exists()
ele-1Condition.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.clinicalStatusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.verificationStatusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.severityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.code.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.code.codingAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.coding.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.code.coding.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.code.coding.systemAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.coding.versionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.coding.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.coding.displayAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.coding.userSelectedAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.code.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.bodySiteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.onset[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.abatement[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.recordedDateAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.recorderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.asserterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
con-1Condition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
ele-1Condition.stageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.stage.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.stage.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.stage.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.stage.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.stage.summaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.stage.assessmentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.stage.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
con-2Condition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
ele-1Condition.evidenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.evidence.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.evidence.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.evidence.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Condition.evidence.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Condition.evidence.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.evidence.detailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Condition.noteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())