US Core Implementation Guide
7.0.0 - STU7 United States of America flag

This page is part of the US Core (v7.0.0: STU7) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: US Core Condition Encounter Diagnosis Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis Version: 7.0.0
Standards status: Trial-use Maturity Level: 3 Computable Name: USCoreConditionEncounterDiagnosisProfile
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.14

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The US Core Condition Encounter Diagnosis Profile inherits from the FHIR Condition resource; refer to it for scope and usage definitions. US Core version 5.0.0 split the US Core Condition Profile into this profile and the US Core Condition Problems and Health Concerns Profile. This profile meets the requirements of the U.S. Core Data for Interoperability (USCDI) Encounter Diagnosis Data Element. It sets minimum expectations for the Condition resource to record, search, and fetch information about an encounter diagnosis. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

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.
  • *The Condition.code has an additional binding of “current” and a base “preferred” binding.
    • For the conformance rules on the current binding for coded data, review this section in the General Requirements page.
    • USCDI’s applicable vocabulary standards for Encounter Diagnosis are SNOMED CT and ICD-10-CM.
      • The US Core Condition Codes only supports ICD-9-CM for historical purposes. 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 three dates.
    • The client application SHALL support all three elements.

Usage:

Formal Views of Profile Content

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

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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 (preferred): Valueset to describe the actual problem experienced by the patient

Additional BindingsPurpose
US Core Condition Codes Current
... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.codepreferredUSCoreConditionCodes
Additional Bindings Purpose Documentation
US Core Condition Codes Current

US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data.
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... 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 (preferred): Valueset to describe the actual problem experienced by the patient

Additional BindingsPurpose
US Core Condition Codes Current
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.codepreferredUSCoreConditionCodes
Additional Bindings Purpose Documentation
US Core Condition Codes Current

US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data.
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... 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 BindingsPurpose
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 (preferred): Valueset to describe the actual problem experienced by the patient

Additional BindingsPurpose
US Core Condition Codes Current
... 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
con-1: Stage SHALL have summary or assessment
.... 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
con-2: evidence SHALL have code or details
.... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severitypreferredCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codepreferredUSCoreConditionCodes
Additional Bindings Purpose Documentation
US Core Condition Codes Current

US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data.
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
from this IG
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryexampleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

This structure is derived from Condition

Summary

Mandatory: 3 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Condition.category

Maturity: 3

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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 (preferred): Valueset to describe the actual problem experienced by the patient

Additional BindingsPurpose
US Core Condition Codes Current
... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.codepreferredUSCoreConditionCodes
Additional Bindings Purpose Documentation
US Core Condition Codes Current

US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data.
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... 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 (preferred): Valueset to describe the actual problem experienced by the patient

Additional BindingsPurpose
US Core Condition Codes Current
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.codepreferredUSCoreConditionCodes
Additional Bindings Purpose Documentation
US Core Condition Codes Current

US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data.
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
... 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 BindingsPurpose
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 (preferred): Valueset to describe the actual problem experienced by the patient

Additional BindingsPurpose
US Core Condition Codes Current
... 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
con-1: Stage SHALL have summary or assessment
.... 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
con-2: evidence SHALL have code or details
.... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severitypreferredCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codepreferredUSCoreConditionCodes
Additional Bindings Purpose Documentation
US Core Condition Codes Current

US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data.
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
from this IG
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.stage.summaryexampleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

This structure is derived from Condition

Summary

Mandatory: 3 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Condition.category

Maturity: 3

 

Other representations of profile: CSV, Excel, Schematron

Notes:

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.

  • See the Scopes Format section for a description of the SMART scopes syntax.
  • See the Search Syntax section for a description of the US Core search syntax.
  • 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.

US Core Scopes

Servers providing access to encounter diagnosis data SHALL support these US Core SMART Scopes:

  • resource level scopes: <patient|user|system>/Condition.rs

  • granular scopes: <patient|user|system>.Condition.rs?category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis

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)

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

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

    Example:

    1. GET [base]/Condition?patient=1032702&_lastUpdated=ge2024-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and _lastUpdated. See the US Core General Guidance page for Searching Using lastUpdated. (how to search by reference and how to search by token and how to search by date)