Example Usage Scenarios:

The following are example usage scenarios for this profile:

• Query for a Patient’s current or historical encounter diagnosis
• Record or update a Patient’s encounter diagnosis

Mandatory and Must Support Data Elements

The following data-elements must always be present (Mandatory definition) 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 Views below provides the formal summary, definitions, and terminology requirements.

Each Condition Must Have:

1. a category code of ‘encounter-diagnosis’
2. a code that identifies the condition
3. a patient

Each Condition Must Support:

1. a clinical status of the condition (e.g., active or resolved)
2. a verification status
3. an encounter
4. a date of diagnosis*
5. abatement date (in other words, date of resolution or remission)
6. a date when recorded*

*see guidance below

Profile Specific Implementation Guidance:

• For Problems and Health Concerns use the US Core Condition Problems and Health Concerns Profile.
• For USCDI v2+ the applicable vocabulary standards for Encounter Diagnosis are SNOMED CT and ICD-10-CM. For general guidance on extensible binding to coded data, review this section in the General Requirements page.
  • The US Core Condition Codes supports ICD-9-CM for historical purposes only. ICD-10-CM is available and SHOULD be used as the primary code for current encounter diagnoses.
• The encounter SHOULD always be referenced in Condition.encounter.
• 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.
• *There is no single element in Condition that represents the date of diagnosis. It may be the assertedDate Extension, Condition.onsetDateTime, or Condition.recordedDate.
  • Although all three are marked as Must Support, the server is not required to support all.
  • A server SHALL support Condition.recordedDate.
  • A server SHALL support at least one of assertedDate Extension and Condition.onsetDateTime. A server may support both, which means they support all 3 dates.
  • The client application SHALL support all three elements.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
assertedDate	S	0..1	dateTime	Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
clinicalStatus	S	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus	S	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by pattern:$this
category:us-core	S	1..1	CodeableConcept	encounter-diagnosis Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
code	S	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
subject	S	1..1	Reference(US Core Patient Profile S | Group)	Who has the condition?
encounter	S	0..1	Reference(US Core Encounter Profile)	Encounter created as part of
onset[x]	S	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime S
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	S	0..1		When in resolution/remission
abatementDateTime			dateTime S
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	S	0..1	dateTime	Date record was first recorded
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.code	extensible	USCoreConditionCodes

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
assertedDate	S	0..1	dateTime	Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
clinicalStatus	?!SΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core	S	1..1	CodeableConcept	encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
code	SΣ	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	Encounter created as part of
onset[x]	SΣ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime
abatement[x]	SC	0..1		When in resolution/remission
abatementDateTime			dateTime
recordedDate	SΣ	0..1	dateTime	Date record was first recorded
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.category	extensible	ConditionCategoryCodes
Condition.category:us-core	extensible	Pattern: encounter-diagnosis
Condition.code	extensible	USCoreConditionCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
con-3	best practice	Condition	Condition.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-4	error	Condition	If 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-5	error	Condition	Condition.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-2	error	Condition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Condition	If 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-4	error	Condition	If 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-5	error	Condition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Condition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
assertedDate	S	0..1	dateTime	Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!SΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core	S	1..1	CodeableConcept	encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
severity		0..1	CodeableConcept	Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
code	SΣ	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	SΣ	1..1	Reference(US Core Patient Profile S | Group)	Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	Encounter created as part of
onset[x]	SΣ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime S
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	SC	0..1		When in resolution/remission
abatementDateTime			dateTime S
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	SΣ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Who recorded the condition
asserter	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Person who asserts this condition
stage	C	0..*	BackboneElement	Stage/grade, usually assessed formally
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
summary	C	0..1	CodeableConcept	Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment	C	0..*	Reference(ClinicalImpression | DiagnosticReport | Observation)	Formal record of assessment
type		0..1	CodeableConcept	Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
evidence	C	0..*	BackboneElement	Supporting evidence
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	ΣC	0..*	CodeableConcept	Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail	ΣC	0..*	Reference(Resource)	Supporting information found elsewhere
note		0..*	Annotation	Additional information about the Condition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Condition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.category	extensible	ConditionCategoryCodes
Condition.category:us-core	extensible	Pattern: encounter-diagnosis
Condition.severity	preferred	Condition/DiagnosisSeverity
Condition.code	extensible	USCoreConditionCodes
Condition.bodySite	example	SNOMEDCTBodyStructures
Condition.stage.summary	example	ConditionStage
Condition.stage.type	example	ConditionStageType
Condition.evidence.code	example	ManifestationAndSymptomCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
con-1	error	Condition.stage	Stage SHALL have summary or assessment : summary.exists() or assessment.exists()
con-2	error	Condition.evidence	evidence SHALL have code or details : code.exists() or detail.exists()
con-3	best practice	Condition	Condition.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-4	error	Condition	If 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-5	error	Condition	Condition.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-2	error	Condition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Condition	If 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-4	error	Condition	If 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-5	error	Condition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Condition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
assertedDate	S	0..1	dateTime	Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
clinicalStatus	S	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus	S	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by pattern:$this
category:us-core	S	1..1	CodeableConcept	encounter-diagnosis Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
code	S	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
subject	S	1..1	Reference(US Core Patient Profile S | Group)	Who has the condition?
encounter	S	0..1	Reference(US Core Encounter Profile)	Encounter created as part of
onset[x]	S	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime S
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	S	0..1		When in resolution/remission
abatementDateTime			dateTime S
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	S	0..1	dateTime	Date record was first recorded
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.code	extensible	USCoreConditionCodes

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
assertedDate	S	0..1	dateTime	Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
clinicalStatus	?!SΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core	S	1..1	CodeableConcept	encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
code	SΣ	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	Encounter created as part of
onset[x]	SΣ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime
abatement[x]	SC	0..1		When in resolution/remission
abatementDateTime			dateTime
recordedDate	SΣ	0..1	dateTime	Date record was first recorded
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.category	extensible	ConditionCategoryCodes
Condition.category:us-core	extensible	Pattern: encounter-diagnosis
Condition.code	extensible	USCoreConditionCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
con-3	best practice	Condition	Condition.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-4	error	Condition	If 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-5	error	Condition	Condition.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-2	error	Condition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Condition	If 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-4	error	Condition	If 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-5	error	Condition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Condition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
assertedDate	S	0..1	dateTime	Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!SΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core	S	1..1	CodeableConcept	encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: encounter-diagnosis
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
severity		0..1	CodeableConcept	Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
code	SΣ	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	SΣ	1..1	Reference(US Core Patient Profile S | Group)	Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	Encounter created as part of
onset[x]	SΣ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime S
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	SC	0..1		When in resolution/remission
abatementDateTime			dateTime S
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	SΣ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Who recorded the condition
asserter	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Person who asserts this condition
stage	C	0..*	BackboneElement	Stage/grade, usually assessed formally
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
summary	C	0..1	CodeableConcept	Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment	C	0..*	Reference(ClinicalImpression | DiagnosticReport | Observation)	Formal record of assessment
type		0..1	CodeableConcept	Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
evidence	C	0..*	BackboneElement	Supporting evidence
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	ΣC	0..*	CodeableConcept	Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail	ΣC	0..*	Reference(Resource)	Supporting information found elsewhere
note		0..*	Annotation	Additional information about the Condition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Condition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.category	extensible	ConditionCategoryCodes
Condition.category:us-core	extensible	Pattern: encounter-diagnosis
Condition.severity	preferred	Condition/DiagnosisSeverity
Condition.code	extensible	USCoreConditionCodes
Condition.bodySite	example	SNOMEDCTBodyStructures
Condition.stage.summary	example	ConditionStage
Condition.stage.type	example	ConditionStageType
Condition.evidence.code	example	ManifestationAndSymptomCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
con-1	error	Condition.stage	Stage SHALL have summary or assessment : summary.exists() or assessment.exists()
con-2	error	Condition.evidence	evidence SHALL have code or details : code.exists() or detail.exists()
con-3	best practice	Condition	Condition.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-4	error	Condition	If 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-5	error	Condition	Condition.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-2	error	Condition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Condition	If 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-4	error	Condition	If 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-5	error	Condition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Condition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Condition

Summary

Mandatory: 3 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)
• US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/StructureDefinition/condition-assertedDate

Slices

This structure defines the following Slices:

• The element Condition.category is sliced based on the value of pattern:$this

Maturity: 3

Quick Start

Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

• The syntax used to describe the interactions is described here.
• See the General Requirements section for additional rules and expectations when a server requires status parameters.
• See the General Guidance section for additional guidance on searching for multiple patients.

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL 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={Type/}[id]

   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)

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

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

   Example:

   1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|problem-list-item
   2. GET [base]/Condition?patient=1032702&category=http://hl7.org/fhir/us/core/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)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

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

   GET [base]/Condition?patient={Type/}[id]&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 exclude diagnoses and health concerns without a clinicalStatus specified. (how to search by reference and how to search by token)

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

   GET [base]/Condition?patient={Type/}[id]&category={system|}[code]&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&category=http://terminology.hl7.org/CodeSystem/condition-category|problem-list-item&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 category for all "active" statuses (active,relapse,remission). This will exclude diagnoses and health concerns without a clinicalStatus specified. (how to search by reference and how to search by token)

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

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

   Example:

   1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis&encounter=1036

   Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category and encounter. When category = "encounter-diagnosis" will return the encounter diagnosis for the encounter. (how to search by reference and how to search by token)

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

   GET [base]/Condition?patient={Type/}[id]&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)

5. 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 AND search on onset-date (e.g.onset-date=[date]&onset-date=[date]]&...)

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

   Example:

   1. GET [base]Condition?patient=555580&onset-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)

6. SHOULD support searching using the combination of the patient and asserted-date search parameters:
   • including support for these asserted-date comparators: gt,lt,ge,le
   • including optional support for AND search on asserted-date (e.g.asserted-date=[date]&asserted-date=[date]]&...)

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

   Example:

   1. GET [base]Condition?patient=555580&asserted-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)

7. SHOULD support searching using the combination of the patient and recorded-date search parameters:
   • including support for these recorded-date comparators: gt,lt,ge,le
   • including optional support for AND search on recorded-date (e.g.recorded-date=[date]&recorded-date=[date]]&...)

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

   Example:

   1. GET [base]Condition?patient=555580&recorded-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)

8. SHOULD support searching using the combination of the patient and abatement-date search parameters:
   • including support for these abatement-date comparators: gt,lt,ge,le
   • including optional support for AND search on abatement-date (e.g.abatement-date=[date]&abatement-date=[date]]&...)

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

   Example:

   1. GET [base]Condition?patient=555580&abatement-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)