US Core Implementation Guide (Release 1.0.1)

This page is part of the US Core (v1.0.1: STU1) based on FHIR R3. The current version which supercedes this version is 5.0.1. For a full list of available versions, see the Directory of published versions

1.0 - StructureDefinition-us-core-condition

This profile sets minimum expectations for the Condition resource to record, search and fetch a list of problems and health concerns associated with a patient. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile.

Example Usage Scenarios:

The following are example usage scenarios for the US Core-Condition profile:

  • Query for a Patient’s problems
  • Record or update a Patient’s problem
Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Condition must have:

  1. a status of the problem
  2. a verification status
  3. a category
  4. a code that identifies the problem
  5. a patient

Profile specific implementation guidance:

  • The US Core Condition Category Codes support the separate concepts of problems and health concerns so API consumers can separate health concerns and problems. However this is not mandatory for 2015 certification
  • The 2015 Certification rule requires the use of SNOMED CT for problem list entries. Following the rules for extensible binding to coded data types, ICD or other local codes can be used as translations to or in addition to SNOMED CT.

Examples

  • Condition-hc1 is an example of a condition categorized as a “problem”
  • Condition-example is an example of a condition categorized as a “health-concern”

1.2 - Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition

This profile builds on Condition.

This profile was published on Thu Aug 21 00:00:00 AEST 2014 as a draft by Health Level Seven International (Infrastructure and Messaging - Data Access Framework).

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

Complete Summary of the Mandatory Requirements

  1. Conditionally One clinical status in Condition.clinicalStatus
  2. One code in Condition.verificationStatus which is bound to ConditionVerificationStatus value set
  3. At least on code in Condition.category which has an extensible binding to US Core Condition Category Codes value set
  4. One Identification of the problem or health concern in Condition.code which has an extensible binding to Problem Value Set
  5. One patient reference in Condition.patient
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*US Core Condition Profile
us-core-1: A code in Condition.category SHOULD be from US Core Condition Category Codes value set.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI0..1codeactive | recurrence | inactive | remission | resolved
Binding: Condition Clinical Status Codes (required)
... verificationStatus ?!SΣI1..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding: ConditionVerificationStatus (required)
... category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: US Core Condition Category Codes (preferred)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (preferred)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (extensible)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (example)
... subject SΣ1..1Reference(US Core Patient Profile)Who has the condition?
... context Σ0..1Reference(Encounter), Reference(EpisodeOfCare)Encounter or episode when condition first asserted
... onset[x] Σ0..1dateTime, Age, Period, Range, stringEstimated or actual date, date-time, or age
... abatement[x] I0..1dateTime, Age, boolean, Period, Range, stringIf/when in resolution/remission
... assertedDate Σ0..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(Practitioner), Reference(Patient), Reference(RelatedPerson)Person who asserts this condition
... stage I0..1BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment I0..*Reference(ClinicalImpression), Reference(DiagnosticReport), Reference(Observation)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example)
.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Complete Summary of the Mandatory Requirements

  1. Conditionally One clinical status in Condition.clinicalStatus
  2. One code in Condition.verificationStatus which is bound to ConditionVerificationStatus value set
  3. At least on code in Condition.category which has an extensible binding to US Core Condition Category Codes value set
  4. One Identification of the problem or health concern in Condition.code which has an extensible binding to Problem Value Set
  5. One patient reference in Condition.patient

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*US Core Condition Profile
us-core-1: A code in Condition.category SHOULD be from US Core Condition Category Codes value set.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI0..1codeactive | recurrence | inactive | remission | resolved
Binding: Condition Clinical Status Codes (required)
... verificationStatus ?!SΣI1..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding: ConditionVerificationStatus (required)
... category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: US Core Condition Category Codes (preferred)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (preferred)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (extensible)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (example)
... subject SΣ1..1Reference(US Core Patient Profile)Who has the condition?
... context Σ0..1Reference(Encounter), Reference(EpisodeOfCare)Encounter or episode when condition first asserted
... onset[x] Σ0..1dateTime, Age, Period, Range, stringEstimated or actual date, date-time, or age
... abatement[x] I0..1dateTime, Age, boolean, Period, Range, stringIf/when in resolution/remission
... assertedDate Σ0..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(Practitioner), Reference(Patient), Reference(RelatedPerson)Person who asserts this condition
... stage I0..1BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment I0..*Reference(ClinicalImpression), Reference(DiagnosticReport), Reference(Observation)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example)
.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, CSV), Schema: XML Schematron

 

1.3 - Quick Start

Below is an overview of the required search and read operations for this profile. See the Conformance requirements for the US Core Server for a complete list of supported RESTful operations and search parameters for this IG.

GET /Condition?patient=[id]

Example: GET [base]/Condition?patient=1032702

Support: Mandatory to support search by patient.

Implementation Notes: Search for all problems and health concerns for a patient. Fetches a bundle of all Condition resources for the specified patient. (how to search by reference) and (how to search by token).

GET /Condition?patient=[id]&clinicalstatus=active,recurrance,remission

Example: GET [base]/Condition?patient=1032702&clinicalstatus=active,relapse,remission

Support: Optional to support search by status.

Implementation Notes: Search for all active problems and health concerns for a patient. Fetches a bundle of all Condition resources for the specified patient and all “active” statuses (active,relapse,remission) (how to search by reference) and (how to search by token). This will not return any “entered in error” resources because of the conditional presence of the clinicalStatus element.

GET /Condition?patient=[id]&category=problem

Example: GET [base]/Condition?patient=1032702&category=problem

Support: Optional to support search by patient and category.

Implementation Notes: earch for all Problems for a patient. Fetches a bundle of all Condition resources for the specified patient with a category code of “problem” (how to search by reference) and (how to search by token).

GET /Condition?patient=[id]&category=health-concern

Example: GET [base]/Condition?patient=1032702&category=health-concern

Support: Optional to support search by patient and category.

Implementation Notes: Search for all Health Concerns for a patient. Fetches a bundle of all Condition resources for the specified patient with a category code of “health-concern”(how to search by reference) and (how to search by token).