HL7 FHIR® US Core Implementation Guide STU 3

This page is part of the US Core (v2.1.0: STU3 Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.1. For a full list of available versions, see the Directory of published versions

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 current or historical problems
  • Record or update a Patient’s problem

Mandatory and Must Support Data Elements

The following data-elements are mandatory (i.e data MUST be present) or must be supported if the data is present in the sending system (Must Support definition). They 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 category
  3. a code that identifies the problem
  4. a patient

*The status element has the following constraints: SHALL be present if verification status is not entered-in-error and SHALL NOT be present if verification Status is entered-in-error.

Each Condition must support:

  1. a verification status

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.
  • To search for an encounter diagnosis, query for Conditions that reference the Encounter of interest and have a category of encounter-diagnosis. An example search is shown in the Quick Start section below.

Examples

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

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition

Published on Tue May 21 00:00:00 EDT 2019 as active by the Health Level Seven International (Infrastructure and Messaging - Data Access Framework).

This profile builds on Condition

Condition

Summary of the Mandatory Requirements

  1. One or more CodeableConcepts in Condition.category with an extensible binding to US Core Condition Category Codes
  2. A CodeableConcept in Condition.code with an extensible binding to US Core Problem
  3. A Patient Reference in Condition.subject

Summary of the Must Support Requirements

  1. A CodeableConcept in Condition.clinicalStatus with a required binding to Condition Clinical Status Codes
  2. A CodeableConcept in Condition.verificationStatus with a required binding to ConditionVerificationStatus

Summary of Constraints

  1. Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
  2. If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
  3. Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
  4. A code in Condition.category SHOULD be from US Core Condition Category Codes value set.
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*Detailed information about conditions, problems or diagnoses
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: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..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..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣI0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: US Core Condition Category Codes (extensible)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: US Core Problem (extensible)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example)
... subject SΣ1..1Reference(US Core Patient Profile)Who has the condition?
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... onset[x] Σ0..1dateTime, Age, Period, Range, stringEstimated or actual date, date-time, or age
... abatement[x] I0..1dateTime, Age, Period, Range, stringWhen in resolution/remission
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
... asserter Σ0..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 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*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 0..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 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example)
.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Condition

Summary of the Mandatory Requirements

  1. One or more CodeableConcepts in Condition.category with an extensible binding to US Core Condition Category Codes
  2. A CodeableConcept in Condition.code with an extensible binding to US Core Problem
  3. A Patient Reference in Condition.subject

Summary of the Must Support Requirements

  1. A CodeableConcept in Condition.clinicalStatus with a required binding to Condition Clinical Status Codes
  2. A CodeableConcept in Condition.verificationStatus with a required binding to ConditionVerificationStatus

Summary of Constraints

  1. Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
  2. If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
  3. Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
  4. A code in Condition.category SHOULD be from US Core Condition Category Codes value set.

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*Detailed information about conditions, problems or diagnoses
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: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..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..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣI0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: US Core Condition Category Codes (extensible)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: US Core Problem (extensible)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example)
... subject SΣ1..1Reference(US Core Patient Profile)Who has the condition?
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... onset[x] Σ0..1dateTime, Age, Period, Range, stringEstimated or actual date, date-time, or age
... abatement[x] I0..1dateTime, Age, Period, Range, stringWhen in resolution/remission
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
... asserter Σ0..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 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*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 0..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 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (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), Schema: XML Schematron


Quick Start

Below is an overview of the required set of RESTful FHIR interactions - for example, search and read operations - for this profile. See the Conformance requirements for a complete list of supported RESTful interactions for this IG.

Mandatory Search Parameters:

The following search parameters, search parameter combinations and search parameter modifiers, comparators, chains and composites SHALL be supported. the modifiers, comparators, chains and composites that are listed as optional SHOULD be supported.:

  1. SHALL support searching for all conditions including problems, health concerns, and encounter diagnosis for a patient using the patient search parameter:

    GET [base]/Condition?patient=[reference]

    Example:

    1. GET [base]/Condition?patient=1137192

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient (how to search by reference)

Optional Search Parameters:

The following search parameters, search parameter combinations and search parameter modifiers, comparators, chains and composites SHOULD be supported.

  1. SHOULD support searching using the combination of the patient and clinical-status search parameters:

    GET [base]/Condition?patient=[reference]&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

    Example:

    1. GET [base/Condition?patient=1032702&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

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

  2. SHOULD support searching using the combination of the patient and category search parameters:

    GET [base]/Condition?patient=[reference]&category={[system]}|[code]

    Example:

    1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|problem
    2. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|health-concern
    3. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis

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

  3. SHOULD support searching using the combination of the patient and code search parameters:

    GET [base]/Condition?patient=[reference]&code={[system]}|[code]

    Example:

    1. GET [base]/Condition?patient=1032702&code=[http://snomed.info/sct|442311008]

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

  4. SHOULD support searching using the combination of the patient and onset-date search parameters:

    • including support for these onset-date comparators: gt,lt,ge,le
    • including optional support for composite AND search on onset-date (e.g.onset-date=[date]&onset-date=[date]]&...)

    GET [base]/Condition?patient=[reference]&onset-date={gt|lt|ge|le}[date]{&onset-date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Condition?patient=555580&date=ge2018-01-14

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)