Example Usage Scenarios:

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

• Query for Allergies belonging to a Patient
• Record or update a Patient Allergy

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 AllergyIntolerance Must Have:

1. a clinical status of the allergy (e.g., active or resolved)*
2. a code which tells you what the patient is allergic to
3. a patient

*This 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 AllergyIntolerance Must Support:

1. a verification status
2. a reaction manifestation

Profile Specific Implementation Guidance:

• No Known Allergies may be represented using the US Core-AllergyIntolerance profile with appropriate negation code in AllergyIntolerence.code and the appropriate verification status in AllergyIntolerance.verificationStatus.

  If a patient has not been asked about their allergies, this would be represented as:

  • AllergyIntolerance.code = “1631000175102” (Patient not asked (contextual qualifier) (qualifier value))

  • AllergyIntolerance.verificationStatus = “unconfirmed” or empty (in other words, then element omitted)

  If a patient has been asked, but has indicated they have no known allergies, this would be represented as:

  • AllergyIntolerance.code = “716186003” (No known allergy (situation))

  • AllergyIntolerance.verificationStatus = “confirmed”

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

This structure is derived from AllergyIntolerance

Name	Flags	Card.	Type	Description & Constraints
AllergyIntolerance		0..*	AllergyIntolerance	Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
clinicalStatus	S	0..1	CodeableConcept	(USCDI) active | inactive | resolved Binding: AllergyIntoleranceClinicalStatusCodes (required)
verificationStatus	S	0..1	CodeableConcept	(USCDI) unconfirmed | confirmed | refuted | entered-in-error Binding: AllergyIntoleranceVerificationStatusCodes (required)
code	S	1..1	CodeableConcept	(USCDI) Code that identifies the allergy or intolerance Binding: Common substances for allergy and intolerance documentation including refutations (extensible)
patient	S	1..1	Reference(US Core Patient Profile)	(USCDI) Who the sensitivity is for
reaction	S	0..*	BackboneElement	(USCDI) Adverse Reaction Events linked to exposure to substance
manifestation	S	1..*	CodeableConcept	(USCDI) Clinical symptoms/signs associated with the Event Binding: SNOMEDCTClinicalFindings (extensible)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
AllergyIntolerance.clinicalStatus	required	AllergyIntoleranceClinicalStatusCodes
AllergyIntolerance.verificationStatus	required	AllergyIntoleranceVerificationStatusCodes
AllergyIntolerance.code	extensible	Common substances for allergy and intolerance documentation including refutations
AllergyIntolerance.reaction.manifestation	extensible	SNOMEDCTClinicalFindings

Name	Flags	Card.	Type	Description & Constraints
AllergyIntolerance	C	0..*	AllergyIntolerance	Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
clinicalStatus	?!SΣC	0..1	CodeableConcept	(USCDI) active | inactive | resolved Binding: AllergyIntoleranceClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	(USCDI) unconfirmed | confirmed | refuted | entered-in-error Binding: AllergyIntoleranceVerificationStatusCodes (required)
code	SΣ	1..1	CodeableConcept	(USCDI) Code that identifies the allergy or intolerance Binding: Common substances for allergy and intolerance documentation including refutations (extensible)
patient	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the sensitivity is for
reaction	S	0..*	BackboneElement	(USCDI) Adverse Reaction Events linked to exposure to substance
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
manifestation	S	1..*	CodeableConcept	(USCDI) Clinical symptoms/signs associated with the Event Binding: SNOMEDCTClinicalFindings (extensible)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
AllergyIntolerance.clinicalStatus	required	AllergyIntoleranceClinicalStatusCodes
AllergyIntolerance.verificationStatus	required	AllergyIntoleranceVerificationStatusCodes
AllergyIntolerance.code	extensible	Common substances for allergy and intolerance documentation including refutations
AllergyIntolerance.reaction.manifestation	extensible	SNOMEDCTClinicalFindings

Constraints

Id	Grade	Path(s)	Details	Requirements
ait-1	error	AllergyIntolerance	AllergyIntolerance.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. : verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').exists() or clinicalStatus.exists()
ait-2	error	AllergyIntolerance	AllergyIntolerance.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').empty() or clinicalStatus.empty()
dom-2	error	AllergyIntolerance	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	AllergyIntolerance	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	AllergyIntolerance	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	AllergyIntolerance	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	AllergyIntolerance	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
AllergyIntolerance	C	0..*	AllergyIntolerance	Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
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
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External ids for this item
clinicalStatus	?!SΣC	0..1	CodeableConcept	(USCDI) active | inactive | resolved Binding: AllergyIntoleranceClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	(USCDI) unconfirmed | confirmed | refuted | entered-in-error Binding: AllergyIntoleranceVerificationStatusCodes (required)
type	Σ	0..1	code	allergy | intolerance - Underlying mechanism (if known) Binding: AllergyIntoleranceType (required): Identification of the underlying physiological mechanism for a Reaction Risk.
category	Σ	0..*	code	food | medication | environment | biologic Binding: AllergyIntoleranceCategory (required): Category of an identified substance associated with allergies or intolerances.
criticality	Σ	0..1	code	low | high | unable-to-assess Binding: AllergyIntoleranceCriticality (required): Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance.
code	SΣ	1..1	CodeableConcept	(USCDI) Code that identifies the allergy or intolerance Binding: Common substances for allergy and intolerance documentation including refutations (extensible)
patient	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the sensitivity is for
encounter		0..1	Reference(Encounter)	Encounter when the allergy or intolerance was asserted
onset[x]		0..1		When allergy or intolerance was identified
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
recordedDate		0..1	dateTime	Date first version of the resource instance was recorded
recorder		0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Who recorded the sensitivity
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Source of the information about the allergy
lastOccurrence		0..1	dateTime	Date(/time) of last known occurrence of a reaction
note		0..*	Annotation	Additional text not captured in other fields
reaction	S	0..*	BackboneElement	(USCDI) Adverse Reaction Events linked to exposure to substance
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
substance		0..1	CodeableConcept	Specific substance or pharmaceutical product considered to be responsible for event Binding: SubstanceCode (example): Codes defining the type of the substance (including pharmaceutical products).
manifestation	S	1..*	CodeableConcept	(USCDI) Clinical symptoms/signs associated with the Event Binding: SNOMEDCTClinicalFindings (extensible)
description		0..1	string	Description of the event as a whole
onset		0..1	dateTime	Date(/time) when manifestations showed
severity		0..1	code	mild | moderate | severe (of event as a whole) Binding: AllergyIntoleranceSeverity (required): Clinical assessment of the severity of a reaction event as a whole, potentially considering multiple different manifestations.
exposureRoute		0..1	CodeableConcept	How the subject was exposed to the substance Binding: SNOMEDCTRouteCodes (example): A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject.
note		0..*	Annotation	Text about event not captured in other fields
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
AllergyIntolerance.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
AllergyIntolerance.clinicalStatus	required	AllergyIntoleranceClinicalStatusCodes
AllergyIntolerance.verificationStatus	required	AllergyIntoleranceVerificationStatusCodes
AllergyIntolerance.type	required	AllergyIntoleranceType
AllergyIntolerance.category	required	AllergyIntoleranceCategory
AllergyIntolerance.criticality	required	AllergyIntoleranceCriticality
AllergyIntolerance.code	extensible	Common substances for allergy and intolerance documentation including refutations
AllergyIntolerance.reaction.substance	example	SubstanceCode
AllergyIntolerance.reaction.manifestation	extensible	SNOMEDCTClinicalFindings
AllergyIntolerance.reaction.severity	required	AllergyIntoleranceSeverity
AllergyIntolerance.reaction.exposureRoute	example	SNOMEDCTRouteCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
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 AllergyIntolerance

Name	Flags	Card.	Type	Description & Constraints
AllergyIntolerance		0..*	AllergyIntolerance	Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
clinicalStatus	S	0..1	CodeableConcept	(USCDI) active | inactive | resolved Binding: AllergyIntoleranceClinicalStatusCodes (required)
verificationStatus	S	0..1	CodeableConcept	(USCDI) unconfirmed | confirmed | refuted | entered-in-error Binding: AllergyIntoleranceVerificationStatusCodes (required)
code	S	1..1	CodeableConcept	(USCDI) Code that identifies the allergy or intolerance Binding: Common substances for allergy and intolerance documentation including refutations (extensible)
patient	S	1..1	Reference(US Core Patient Profile)	(USCDI) Who the sensitivity is for
reaction	S	0..*	BackboneElement	(USCDI) Adverse Reaction Events linked to exposure to substance
manifestation	S	1..*	CodeableConcept	(USCDI) Clinical symptoms/signs associated with the Event Binding: SNOMEDCTClinicalFindings (extensible)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
AllergyIntolerance.clinicalStatus	required	AllergyIntoleranceClinicalStatusCodes
AllergyIntolerance.verificationStatus	required	AllergyIntoleranceVerificationStatusCodes
AllergyIntolerance.code	extensible	Common substances for allergy and intolerance documentation including refutations
AllergyIntolerance.reaction.manifestation	extensible	SNOMEDCTClinicalFindings

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
AllergyIntolerance	C	0..*	AllergyIntolerance	Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
clinicalStatus	?!SΣC	0..1	CodeableConcept	(USCDI) active | inactive | resolved Binding: AllergyIntoleranceClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	(USCDI) unconfirmed | confirmed | refuted | entered-in-error Binding: AllergyIntoleranceVerificationStatusCodes (required)
code	SΣ	1..1	CodeableConcept	(USCDI) Code that identifies the allergy or intolerance Binding: Common substances for allergy and intolerance documentation including refutations (extensible)
patient	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the sensitivity is for
reaction	S	0..*	BackboneElement	(USCDI) Adverse Reaction Events linked to exposure to substance
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
manifestation	S	1..*	CodeableConcept	(USCDI) Clinical symptoms/signs associated with the Event Binding: SNOMEDCTClinicalFindings (extensible)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
AllergyIntolerance.clinicalStatus	required	AllergyIntoleranceClinicalStatusCodes
AllergyIntolerance.verificationStatus	required	AllergyIntoleranceVerificationStatusCodes
AllergyIntolerance.code	extensible	Common substances for allergy and intolerance documentation including refutations
AllergyIntolerance.reaction.manifestation	extensible	SNOMEDCTClinicalFindings

Constraints

Id	Grade	Path(s)	Details	Requirements
ait-1	error	AllergyIntolerance	AllergyIntolerance.clinicalStatus SHALL be present if verificationStatus is not entered-in-error. : verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').exists() or clinicalStatus.exists()
ait-2	error	AllergyIntolerance	AllergyIntolerance.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system = 'http://terminology.hl7.org/CodeSystem/allergyintolerance-verification' and code = 'entered-in-error').empty() or clinicalStatus.empty()
dom-2	error	AllergyIntolerance	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	AllergyIntolerance	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	AllergyIntolerance	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	AllergyIntolerance	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	AllergyIntolerance	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
AllergyIntolerance	C	0..*	AllergyIntolerance	Allergy or Intolerance (generally: Risk of adverse reaction to a substance)
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
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External ids for this item
clinicalStatus	?!SΣC	0..1	CodeableConcept	(USCDI) active | inactive | resolved Binding: AllergyIntoleranceClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	(USCDI) unconfirmed | confirmed | refuted | entered-in-error Binding: AllergyIntoleranceVerificationStatusCodes (required)
type	Σ	0..1	code	allergy | intolerance - Underlying mechanism (if known) Binding: AllergyIntoleranceType (required): Identification of the underlying physiological mechanism for a Reaction Risk.
category	Σ	0..*	code	food | medication | environment | biologic Binding: AllergyIntoleranceCategory (required): Category of an identified substance associated with allergies or intolerances.
criticality	Σ	0..1	code	low | high | unable-to-assess Binding: AllergyIntoleranceCriticality (required): Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance.
code	SΣ	1..1	CodeableConcept	(USCDI) Code that identifies the allergy or intolerance Binding: Common substances for allergy and intolerance documentation including refutations (extensible)
patient	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the sensitivity is for
encounter		0..1	Reference(Encounter)	Encounter when the allergy or intolerance was asserted
onset[x]		0..1		When allergy or intolerance was identified
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
recordedDate		0..1	dateTime	Date first version of the resource instance was recorded
recorder		0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Who recorded the sensitivity
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Source of the information about the allergy
lastOccurrence		0..1	dateTime	Date(/time) of last known occurrence of a reaction
note		0..*	Annotation	Additional text not captured in other fields
reaction	S	0..*	BackboneElement	(USCDI) Adverse Reaction Events linked to exposure to substance
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
substance		0..1	CodeableConcept	Specific substance or pharmaceutical product considered to be responsible for event Binding: SubstanceCode (example): Codes defining the type of the substance (including pharmaceutical products).
manifestation	S	1..*	CodeableConcept	(USCDI) Clinical symptoms/signs associated with the Event Binding: SNOMEDCTClinicalFindings (extensible)
description		0..1	string	Description of the event as a whole
onset		0..1	dateTime	Date(/time) when manifestations showed
severity		0..1	code	mild | moderate | severe (of event as a whole) Binding: AllergyIntoleranceSeverity (required): Clinical assessment of the severity of a reaction event as a whole, potentially considering multiple different manifestations.
exposureRoute		0..1	CodeableConcept	How the subject was exposed to the substance Binding: SNOMEDCTRouteCodes (example): A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject.
note		0..*	Annotation	Text about event not captured in other fields
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
AllergyIntolerance.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
AllergyIntolerance.clinicalStatus	required	AllergyIntoleranceClinicalStatusCodes
AllergyIntolerance.verificationStatus	required	AllergyIntoleranceVerificationStatusCodes
AllergyIntolerance.type	required	AllergyIntoleranceType
AllergyIntolerance.category	required	AllergyIntoleranceCategory
AllergyIntolerance.criticality	required	AllergyIntoleranceCriticality
AllergyIntolerance.code	extensible	Common substances for allergy and intolerance documentation including refutations
AllergyIntolerance.reaction.substance	example	SubstanceCode
AllergyIntolerance.reaction.manifestation	extensible	SNOMEDCTClinicalFindings
AllergyIntolerance.reaction.severity	required	AllergyIntoleranceSeverity
AllergyIntolerance.reaction.exposureRoute	example	SNOMEDCTRouteCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
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 AllergyIntolerance

Summary

Mandatory: 1 element
Must-Support: 6 elements

Structures

This structure refers to these other structures:

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

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.

• Servers providing access to allergy and intolerance data can use US Core SMART Scopes for:
  • resource level scopes (for example, patient/AllergyIntolerance.rs).
• 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 allergies for a patient using the patient search parameter:

   GET [base]/AllergyIntolerance?patient={Type/}[id]

   Example:

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

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

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]/AllergyIntolerance?patient={Type/}[id]&clinical-status={system|}[code]

   Example:

   1. GET [base]/AllergyIntolerance?patient=[id]&clinical-status=http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical|active

   Implementation Notes: Fetches a bundle of all AllergyIntolerance resources for the specified patient and status code. 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)