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. an encounter
2. date record was first recorded

Additional USCDI Requirements:

These Additional USCDI Requirements elements are not Mandatory or Must Support but are required for ASTP Health IT certification testing and are included in the formal definition of the profile and the Condition examples.

1. a recorder*

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. When using ICD codes, only non-header ICD-10-CM codes 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.

• *The profile elements Condition.asserter and Condition.recorder communicate the individual level provenance author data corresponding to the U.S. Core Data for Interoperability (USCDI) Provenance Author Data Elements.

Changes since version 7.0.0:

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
clinicalStatus	?!ΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!ΣC	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by value:$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
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 Bindings Purpose Documentation US Core Condition Codes Current Current Required for new records
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
recordedDate	SΣ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 From the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 From the FHIR Standard
Condition.category	extensible	ConditionCategoryCodes http://hl7.org/fhir/ValueSet/condition-category From the FHIR Standard
Condition.category:us-core	extensible	Pattern Value: encounter-diagnosis http://hl7.org/fhir/ValueSet/condition-category From the FHIR Standard
Condition.code	preferred	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code From this IG

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()

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by value:$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 Bindings Purpose Documentation US Core Condition Codes Current Current Required for new records
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
recordedDate	S	0..1	dateTime	Date record was first recorded
recorder		0..1	Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Condition.code	preferred	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code From this IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
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 condition
clinicalStatus	?!ΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!ΣC	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by value:$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 Bindings Purpose Documentation US Core Condition Codes Current Current Required for new records
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]	Σ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	C	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	SΣ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: 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 Constraints: con-1
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 Constraints: con-2
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	URI
Condition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 From the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 From the FHIR Standard
Condition.category	extensible	ConditionCategoryCodes http://hl7.org/fhir/ValueSet/condition-category From the FHIR Standard
Condition.category:us-core	extensible	Pattern Value: encounter-diagnosis http://hl7.org/fhir/ValueSet/condition-category From the FHIR Standard
Condition.severity	preferred	Condition/DiagnosisSeverity http://hl7.org/fhir/ValueSet/condition-severity From the FHIR Standard
Condition.code	preferred	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code From this IG
Condition.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site From the FHIR Standard
Condition.stage.summary	example	ConditionStage http://hl7.org/fhir/ValueSet/condition-stage From the FHIR Standard
Condition.stage.type	example	ConditionStageType http://hl7.org/fhir/ValueSet/condition-stage-type From the FHIR Standard
Condition.evidence.code	example	ManifestationAndSymptomCodes http://hl7.org/fhir/ValueSet/manifestation-or-symptom From the FHIR Standard

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()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
clinicalStatus	?!ΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!ΣC	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by value:$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
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 Bindings Purpose Documentation US Core Condition Codes Current Current Required for new records
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
recordedDate	SΣ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 From the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 From the FHIR Standard
Condition.category	extensible	ConditionCategoryCodes http://hl7.org/fhir/ValueSet/condition-category From the FHIR Standard
Condition.category:us-core	extensible	Pattern Value: encounter-diagnosis http://hl7.org/fhir/ValueSet/condition-category From the FHIR Standard
Condition.code	preferred	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code From this IG

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()

Differential View

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by value:$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 Bindings Purpose Documentation US Core Condition Codes Current Current Required for new records
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
recordedDate	S	0..1	dateTime	Date record was first recorded
recorder		0..1	Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Who recorded the condition
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Condition.code	preferred	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code From this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses Constraints: con-3, con-4, con-5
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 condition
clinicalStatus	?!ΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!ΣC	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
Slices for category	S	1..*	CodeableConcept	category codes Slice: Unordered, Open by value:$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 Bindings Purpose Documentation US Core Condition Codes Current Current Required for new records
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]	Σ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	C	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	SΣ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(US Core Practitioner Profile | US Core Patient Profile | PractitionerRole | US Core RelatedPerson Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: 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 Constraints: con-1
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 Constraints: con-2
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	URI
Condition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 From the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 From the FHIR Standard
Condition.category	extensible	ConditionCategoryCodes http://hl7.org/fhir/ValueSet/condition-category From the FHIR Standard
Condition.category:us-core	extensible	Pattern Value: encounter-diagnosis http://hl7.org/fhir/ValueSet/condition-category From the FHIR Standard
Condition.severity	preferred	Condition/DiagnosisSeverity http://hl7.org/fhir/ValueSet/condition-severity From the FHIR Standard
Condition.code	preferred	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code From this IG
Condition.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site From the FHIR Standard
Condition.stage.summary	example	ConditionStage http://hl7.org/fhir/ValueSet/condition-stage From the FHIR Standard
Condition.stage.type	example	ConditionStageType http://hl7.org/fhir/ValueSet/condition-stage-type From the FHIR Standard
Condition.evidence.code	example	ManifestationAndSymptomCodes http://hl7.org/fhir/ValueSet/manifestation-or-symptom From the FHIR Standard

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: 6 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)
• US Core Practitioner Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner)
• US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson)

Slices

This structure defines the following Slices:

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

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.

• 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=encounter-diagnosis

   Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category = "encounter-diagnosis". (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 Conditions with no 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=encounter-diagnosis&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 = "encounter-diagnosis" for all "active" statuses (active,relapse,remission). This will exclude Conditions with no 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=encounter-diagnosis&encounter=Encounter/1036

   Implementation Notes: Fetches a bundle of all Condition resources for the specified patient, encounter, and category = "encounter-diagnosis". 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|39065001

   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,le
   • 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 date)