This page is part of the PACIO Personal Functioning and Engagement Implementation Guide (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

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Resource Profile: Personal Functioning and Engagement Condition Encounter Diagnosis Profile

An exchange of post-acute care condition encounter diagnosis for a patient. This profile is used for exchanging a condition encounter diagnosis.

Usage:

• Examples for this Resource Profile: Condition/PFEIG-Condition-AnemiaDiagnosis, Condition/PFEIG-Condition-DiabetesDiagnosis, Condition/PFEIG-Condition-HemiparesisDiagnosis, Condition/PFEIG-Condition-Hyperlipidemia... Show 2 more, Condition/PFEIG-Condition-KidneyDisease and Condition/PFEIG-Condition-StrokeDiagnosis

Formal Views of Profile Content

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

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

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	USCoreConditionEncounterDiagnosisProfile	Detailed information about conditions, problems or diagnoses
bodySite	S	0..*	CodeableConcept	Anatomical location, if relevant
asserter	S	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Person who asserts this condition
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	USCoreConditionEncounterDiagnosisProfile	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
Slices for extension				Content/Rules for all slices
assertedDate	S	0..1	dateTime	(USCDI) 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	(USCDI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category	S	1..*	CodeableConcept	(USCDI) category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core	S	1..1	CodeableConcept	(USCDI) 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	(USCDI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
bodySite	SΣ	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)	(USCDI) Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	(USCDI) Encounter created as part of
onset[x]	SΣ	0..1		(USCDI) Estimated or actual date, date-time, or age
onsetDateTime			dateTime
abatement[x]	SC	0..1		(USCDI) When in resolution/remission
abatementDateTime			dateTime
recordedDate	SΣ	0..1	dateTime	(USCDI) Date record was first recorded
asserter	SΣ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Person who asserts this condition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status 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: encounter-diagnosis http://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard
Condition.code	extensible	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Condition.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	USCoreConditionEncounterDiagnosisProfile	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 Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
assertedDate	S	0..1	dateTime	(USCDI) 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	(USCDI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category	S	1..*	CodeableConcept	(USCDI) category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core	S	1..1	CodeableConcept	(USCDI) 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	(USCDI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
bodySite	SΣ	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)	(USCDI) Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	(USCDI) Encounter created as part of
onset[x]	SΣ	0..1		(USCDI) Estimated or actual date, date-time, or age
onsetDateTime			dateTime S
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	SC	0..1		(USCDI) When in resolution/remission
abatementDateTime			dateTime S
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	SΣ	0..1	dateTime	(USCDI) Date record was first recorded
recorder	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Who recorded the condition
asserter	SΣ	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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Condition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status 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: 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	extensible	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
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

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Summary

Must-Support: 2 elements

Differential View

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	USCoreConditionEncounterDiagnosisProfile	Detailed information about conditions, problems or diagnoses
bodySite	S	0..*	CodeableConcept	Anatomical location, if relevant
asserter	S	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Person who asserts this condition
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	USCoreConditionEncounterDiagnosisProfile	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
Slices for extension				Content/Rules for all slices
assertedDate	S	0..1	dateTime	(USCDI) 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	(USCDI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category	S	1..*	CodeableConcept	(USCDI) category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core	S	1..1	CodeableConcept	(USCDI) 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	(USCDI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
bodySite	SΣ	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)	(USCDI) Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	(USCDI) Encounter created as part of
onset[x]	SΣ	0..1		(USCDI) Estimated or actual date, date-time, or age
onsetDateTime			dateTime
abatement[x]	SC	0..1		(USCDI) When in resolution/remission
abatementDateTime			dateTime
recordedDate	SΣ	0..1	dateTime	(USCDI) Date record was first recorded
asserter	SΣ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Person who asserts this condition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status 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: encounter-diagnosis http://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard
Condition.code	extensible	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Condition.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	USCoreConditionEncounterDiagnosisProfile	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 Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
assertedDate	S	0..1	dateTime	(USCDI) 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	(USCDI) active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required)
verificationStatus	?!SΣC	0..1	CodeableConcept	(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required)
Slices for category	S	1..*	CodeableConcept	(USCDI) category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
category:us-core	S	1..1	CodeableConcept	(USCDI) 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	(USCDI) Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient
bodySite	SΣ	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)	(USCDI) Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	(USCDI) Encounter created as part of
onset[x]	SΣ	0..1		(USCDI) Estimated or actual date, date-time, or age
onsetDateTime			dateTime S
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	SC	0..1		(USCDI) When in resolution/remission
abatementDateTime			dateTime S
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	SΣ	0..1	dateTime	(USCDI) Date record was first recorded
recorder	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Who recorded the condition
asserter	SΣ	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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Condition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status 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: 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	extensible	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
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

This structure is derived from USCoreConditionEncounterDiagnosisProfile

Summary

Must-Support: 2 elements

Other representations of profile: CSV, Excel, Schematron