Scope and Usage

Purpose of the resource

The purpose of the Personal Functioning and Engagement Encounter Diagnosis Profile is to facilitate exchange between post-acute care and other health care settings of post-acute care patients’ personal functioning and engagement encounter diagnoses. For this profile, “post-acute care” is defined as “care that is provided to individuals who need additional help recuperating from an acute illness or serious medical procedure” cite. “Encounter diagnosis” is defined as “coded diagnoses associated with an episode of care” cite. Personal Functioning and Engagement relates to a person’s functioning in terms of body functions, activities, and participation cite.

A diagnosis is only enterable by the practitioner who is legally allowed to make the diagnosis. The legal requirements for who is allowed to make a diagnosis vary by state. Attempting to list the legal requirements by state here would be beyond the scope of this FHIR implementation guide.

What is in this resource

The Personal Functioning and Engagement Encounter Diagnosis Profile includes data elements for a patient’s encounter diagnosis. This resource includes the following data elements for the encounter diagnosis:

• Detailed descriptions, date of onset, and date of abatement (if applicable)
• The anatomical location affected (if applicable)
• The clinical status (e.g., active, remission) and verification status (e.g., differential, confirmed),
• A categorization
• A reference to the clinical encounter that it relates to

What is not in this resource

This resource does not encompass a diagnosis related to a disease or pathology that would be found in a radiology or laboratory report; however, it does allow referencing of the Base FHIR DiagnosticReport profile as well as the ClinicalImpression profile, Observation profile, or any other Base resource.

Intended audience and setting for the resource

This resource has been developed for healthcare providers who are involved with and legally allowed to document an encounter diagnosis, as determined by federal and state regulations, as well as EHR implementers. The profile was developed for post-acute care settings, such as skilled nursing facilities and home health, and can also be used in acute care settings.

What the resource can be used for

This resource can be used by post-acute care facilities, as well as acute care hospitals, to document encounter diagnoses related to patients’ personal functioning and engagement.

Example of the Encounter Diagnosis resource supporting documentation of a diagnosis for a patient at a long-term care facility by a nurse practitioner working at the facility – the facility has implemented the Personal Functioning and Engagement Encounter Diagnosis resource into their electronic health record (EHR): When reviewing the EHR record for a patient who has been at the LTC for 2 months, the nurse practitioner on staff observed that the patient started to show symptoms of depression as indicated in the notes documented by the nursing and physical therapy staff. The nurse practitioner visits the patient to do an evaluation, including having them complete a depression screening. The findings of evaluation and screening tool suggest that the patient has moderate depression. Rhe nurse practitioner enters this information in the EHR, which allows for encounter diagnosis information to be documented, and then puts in a referral with a behavioral health specialist, whose EHR also integrates the Encounter Diagnosis data elements and therefore allows the behavioral health specialist to access the patient’s encounter diagnosis information.

How this resource was developed

The Personal Functioning and Engagement Encounter Diagnosis Profile was developed by the Personal Functioning and Engagement subgroup of the Post-Acute Care InterOperability (PACIO) project. The subgroup contained experts in: personal functioning and engagement related diagnoses (e.g., Physical Therapists), EHR implementation and interoperability, HL7 FHIR, and user-centered design. PACIO is sponsored by the US Centers for Medicare and Medicaid Services (CMS) and by the MITRE Corporation.

Boundaries and Relationships

Within boundaries/scope of the resource

The scope of the Personal Functioning and Engagement Encounter Diagnosis Profile encompasses a post-acute care patient’s condition encounter diagnosis that affects their ability to participate in activities and interact with their community and the environment around them.

Other resources that address related content outside the boundaries/scope of this resource

Beginning in U.S. Core version 5.0.0, The US Core Condition Profile has been split into the US Core Condition Encounter Diagnosis profile and US Core Condition Problems and Health Concerns profile. The Personal Functioning and Engagement implementation guide includes PFE-specific profiles of both of these U.S. Core Condition-based profiles.

Relationship to other resources

This profile is derived from the US Core Condition Encounter Diagnosis Profile. Within the Personal Functioning and Engagement Condition Encounter Diagnosis profile, the asserter data element has been elevated to must support. This data element is a reference to an instance of Practitioner, PractitionerRole, Patient, or RelatedPerson. In addition, the US Core Encounter profile may reference a Personal Functioning and Engagement Condition Encounter Diagnosis Profile via its diagnosis data element.

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition	C	0..*	USCoreConditionEncounterDiagnosisProfile	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
Slices for extension				Content/Rules for all slices
extension: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
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	(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(6.1.0))	(USCDI) Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile(6.1.0))	(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
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 Value: 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

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 USCoreConditionEncounterDiagnosisProfile

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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    Filter: Bindings Constraints Obligations
Condition	C	0..*	USCoreConditionEncounterDiagnosisProfile	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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension: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(6.1.0))	(USCDI) Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile(6.1.0))	(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 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 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 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	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

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..*	USCoreConditionEncounterDiagnosisProfile	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
Slices for extension				Content/Rules for all slices
extension: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
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	(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(6.1.0))	(USCDI) Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile(6.1.0))	(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
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 Value: 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

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 USCoreConditionEncounterDiagnosisProfile

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Condition	C	0..*	USCoreConditionEncounterDiagnosisProfile	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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension: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(6.1.0))	(USCDI) Who has the condition?
encounter	SΣ	0..1	Reference(US Core Encounter Profile(6.1.0))	(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 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 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 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	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

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 USCoreConditionEncounterDiagnosisProfile

Summary

Must-Support: 2 elements

Maturity: 3