QI-Core Implementation Guide
5.0.0 - STU5
QI-Core Implementation Guide
5.0.0 - STU5
This page is part of the Quality Improvement Core Framework (v5.0.0: STU5 (v5.0.0)) based on FHIR R4. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis | Version: 5.0.0 | |||
| Active as of 2022-04-20 | Computable Name: QICoreConditionEncounterDiagnosis | |||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
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The QI Core Condition Encounter Diagnosis Profile is based upon the US Core Condition Encounter Diagnosis Profile. In version 5.0.0, The QI Core Condition Profile has been split into the QI Core Condition Encounter Diagnosis Profile and QI Core Condition Problems and Health Concerns Profile. To promote interoperability and adoption through common implementation, this profile defines constraints and extensions on the Condition resource for the minimal set of data to record, search, and fetch information about an encounter diagnosis. It Defines the core set of elements and extensions for quality rule and measure authors.
[ConditionEncounterDiagnosis: Diabetes] Condition
where Condition.getEncounter().status = 'finished'
| Severe Burn Example |
| Appendicitis Example |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreConditionEncounterDiagnosisProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Condition | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses | |
  severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): Codes describing anatomical locations. May include laterality. |
| bodySite | S | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (preferred): Codes describing anatomical locations. May include laterality. |
 subject | S | 1..1 | Reference(QICore Patient) | Who has the condition? |
| encounter | S | 0..1 | Reference(QICore Encounter) | Encounter created as part of |
  onset[x] | S | 0..1 | Estimated or actual date, date-time, or age | |
  onsetDateTime | dateTime S | |||
 onsetAge | Age S | |||
| onsetPeriod | Period S | |||
 onsetRange | Range S | |||
| abatement[x] | S | 0..1 | When in resolution/remission | |
| abatementDateTime | dateTime S | |||
| abatementAge | Age S | |||
| abatementPeriod | Period S | |||
| abatementRange | Range S | |||
| asserter | 0..1 | Reference(QICore Patient | QICore Practitioner | QICore RelatedPerson) | Person who asserts this condition | |
 stage | S | 0..* | BackboneElement | Stage/grade, usually assessed formally |
 summary | S | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (preferred): Codes describing condition stages (e.g. Cancer stages). |
| assessment | 0..* | Reference(ClinicalImpression | QICore DiagnosticReport Profile for Laboratory Results Reporting | QICore Observation) | Formal record of assessment | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Condition.severity | preferred | Condition/DiagnosisSeverity |
| Condition.bodySite | preferred | SNOMEDCTBodyStructures |
| Condition.stage.summary | preferred | ConditionStage |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required) |
| verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required) |
 Slices for category | S | 1..* | CodeableConcept | category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. |
 category:us-core | S | 1..1 | CodeableConcept | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following |
  coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis | |
| severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): Codes describing anatomical locations. May include laterality. |
| code | SΣ | 1..1 | CodeableConcept | 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 (preferred): Codes describing anatomical locations. May include laterality. |
| subject | SΣ | 1..1 | Reference(QICore Patient) | Who has the condition? |
| encounter | SΣ | 0..1 | Reference(QICore Encounter) | Encounter created as part of |
| onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |
| onsetDateTime | dateTime | |||
| onsetAge | Age | |||
| onsetPeriod | Period | |||
| onsetRange | Range | |||
| abatement[x] | SC | 0..1 | When in resolution/remission | |
| abatementDateTime | dateTime | |||
| abatementAge | Age | |||
| abatementPeriod | Period | |||
| abatementRange | Range | |||
| recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded |
| asserter | Σ | 0..1 | Reference(QICore Patient | QICore Practitioner | QICore RelatedPerson) | Person who asserts this condition |
| stage | SC | 0..* | BackboneElement | Stage/grade, usually assessed formally |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| summary | SC | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (preferred): Codes describing condition stages (e.g. Cancer stages). |
| assessment | C | 0..* | Reference(ClinicalImpression | QICore DiagnosticReport Profile for Laboratory Results Reporting | QICore Observation) | Formal record of assessment |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Condition.clinicalStatus | required | ConditionClinicalStatusCodes |
| Condition.verificationStatus | required | ConditionVerificationStatus |
| Condition.category | extensible | ConditionCategoryCodes |
| Condition.category:us-core | extensible | Pattern: encounter-diagnosis |
| Condition.severity | preferred | Condition/DiagnosisSeverity |
| Condition.code | extensible | USCoreConditionCodes |
| Condition.bodySite | preferred | SNOMEDCTBodyStructures |
| Condition.stage.summary | preferred | ConditionStage |
| Id | Grade | Path(s) | Details | Requirements |
| con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.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() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses | ||||
| 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.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||
| clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required) | ||||
| verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required) | ||||
| Slices for category | S | 1..* | CodeableConcept | category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. | ||||
| category:us-core | S | 1..1 | CodeableConcept | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following | ||||
 id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
 id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
 text | 0..1 | string | Plain text representation of the concept | |||||
| severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): Codes describing anatomical locations. May include laterality. | ||||
| code | SΣ | 1..1 | CodeableConcept | 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 (preferred): Codes describing anatomical locations. May include laterality. | ||||
| subject | SΣ | 1..1 | Reference(QICore Patient) | Who has the condition? | ||||
| encounter | SΣ | 0..1 | Reference(QICore Encounter) | Encounter created as part of | ||||
| onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||
| onsetDateTime | dateTime S | |||||||
| onsetAge | Age S | |||||||
| onsetPeriod | Period S | |||||||
| onsetRange | Range S | |||||||
| abatement[x] | SC | 0..1 | When in resolution/remission | |||||
| abatementDateTime | dateTime S | |||||||
| abatementAge | Age S | |||||||
| abatementPeriod | Period S | |||||||
| abatementRange | Range S | |||||||
| recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | ||||
| recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||
| asserter | Σ | 0..1 | Reference(QICore Patient | QICore Practitioner | QICore RelatedPerson) | Person who asserts this condition | ||||
| stage | SC | 0..* | BackboneElement | Stage/grade, usually assessed formally | ||||
| 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 | SC | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (preferred): Codes describing condition stages (e.g. Cancer stages). | ||||
| assessment | C | 0..* | Reference(ClinicalImpression | QICore DiagnosticReport Profile for Laboratory Results Reporting | QICore 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 | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Condition.language | preferred | CommonLanguages
| ||||
| Condition.clinicalStatus | required | ConditionClinicalStatusCodes | ||||
| Condition.verificationStatus | required | ConditionVerificationStatus | ||||
| Condition.category | extensible | ConditionCategoryCodes | ||||
| Condition.category:us-core | extensible | Pattern: encounter-diagnosis | ||||
| Condition.severity | preferred | Condition/DiagnosisSeverity | ||||
| Condition.code | extensible | USCoreConditionCodes | ||||
| Condition.bodySite | preferred | SNOMEDCTBodyStructures | ||||
| Condition.stage.summary | preferred | ConditionStage | ||||
| Condition.stage.type | example | ConditionStageType | ||||
| Condition.evidence.code | example | ManifestationAndSymptomCodes |
| 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() | |
| 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: 8 elements
Structures
This structure refers to these other structures:
Differential View
This structure is derived from USCoreConditionEncounterDiagnosisProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Condition | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses | |
| severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): Codes describing anatomical locations. May include laterality. |
| bodySite | S | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (preferred): Codes describing anatomical locations. May include laterality. |
| subject | S | 1..1 | Reference(QICore Patient) | Who has the condition? |
| encounter | S | 0..1 | Reference(QICore Encounter) | Encounter created as part of |
| onset[x] | S | 0..1 | Estimated or actual date, date-time, or age | |
| onsetDateTime | dateTime S | |||
| onsetAge | Age S | |||
| onsetPeriod | Period S | |||
| onsetRange | Range S | |||
| abatement[x] | S | 0..1 | When in resolution/remission | |
| abatementDateTime | dateTime S | |||
| abatementAge | Age S | |||
| abatementPeriod | Period S | |||
| abatementRange | Range S | |||
| asserter | 0..1 | Reference(QICore Patient | QICore Practitioner | QICore RelatedPerson) | Person who asserts this condition | |
| stage | S | 0..* | BackboneElement | Stage/grade, usually assessed formally |
| summary | S | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (preferred): Codes describing condition stages (e.g. Cancer stages). |
| assessment | 0..* | Reference(ClinicalImpression | QICore DiagnosticReport Profile for Laboratory Results Reporting | QICore Observation) | Formal record of assessment | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Condition.severity | preferred | Condition/DiagnosisSeverity |
| Condition.bodySite | preferred | SNOMEDCTBodyStructures |
| Condition.stage.summary | preferred | ConditionStage |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required) |
| verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required) |
| Slices for category | S | 1..* | CodeableConcept | category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. |
| category:us-core | S | 1..1 | CodeableConcept | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis | |
| severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): Codes describing anatomical locations. May include laterality. |
| code | SΣ | 1..1 | CodeableConcept | 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 (preferred): Codes describing anatomical locations. May include laterality. |
| subject | SΣ | 1..1 | Reference(QICore Patient) | Who has the condition? |
| encounter | SΣ | 0..1 | Reference(QICore Encounter) | Encounter created as part of |
| onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |
| onsetDateTime | dateTime | |||
| onsetAge | Age | |||
| onsetPeriod | Period | |||
| onsetRange | Range | |||
| abatement[x] | SC | 0..1 | When in resolution/remission | |
| abatementDateTime | dateTime | |||
| abatementAge | Age | |||
| abatementPeriod | Period | |||
| abatementRange | Range | |||
| recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded |
| asserter | Σ | 0..1 | Reference(QICore Patient | QICore Practitioner | QICore RelatedPerson) | Person who asserts this condition |
| stage | SC | 0..* | BackboneElement | Stage/grade, usually assessed formally |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| summary | SC | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (preferred): Codes describing condition stages (e.g. Cancer stages). |
| assessment | C | 0..* | Reference(ClinicalImpression | QICore DiagnosticReport Profile for Laboratory Results Reporting | QICore Observation) | Formal record of assessment |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Condition.clinicalStatus | required | ConditionClinicalStatusCodes |
| Condition.verificationStatus | required | ConditionVerificationStatus |
| Condition.category | extensible | ConditionCategoryCodes |
| Condition.category:us-core | extensible | Pattern: encounter-diagnosis |
| Condition.severity | preferred | Condition/DiagnosisSeverity |
| Condition.code | extensible | USCoreConditionCodes |
| Condition.bodySite | preferred | SNOMEDCTBodyStructures |
| Condition.stage.summary | preferred | ConditionStage |
| Id | Grade | Path(s) | Details | Requirements |
| con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.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() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Condition | C | 0..* | USCoreConditionEncounterDiagnosisProfile | Detailed information about conditions, problems or diagnoses | ||||
| 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.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||
| clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required) | ||||
| verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required) | ||||
| Slices for category | S | 1..* | CodeableConcept | category codes Slice: Unordered, Open by pattern:$this Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. | ||||
| category:us-core | S | 1..1 | CodeableConcept | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: encounter-diagnosis | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): Codes describing anatomical locations. May include laterality. | ||||
| code | SΣ | 1..1 | CodeableConcept | 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 (preferred): Codes describing anatomical locations. May include laterality. | ||||
| subject | SΣ | 1..1 | Reference(QICore Patient) | Who has the condition? | ||||
| encounter | SΣ | 0..1 | Reference(QICore Encounter) | Encounter created as part of | ||||
| onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||
| onsetDateTime | dateTime S | |||||||
| onsetAge | Age S | |||||||
| onsetPeriod | Period S | |||||||
| onsetRange | Range S | |||||||
| abatement[x] | SC | 0..1 | When in resolution/remission | |||||
| abatementDateTime | dateTime S | |||||||
| abatementAge | Age S | |||||||
| abatementPeriod | Period S | |||||||
| abatementRange | Range S | |||||||
| recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | ||||
| recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||
| asserter | Σ | 0..1 | Reference(QICore Patient | QICore Practitioner | QICore RelatedPerson) | Person who asserts this condition | ||||
| stage | SC | 0..* | BackboneElement | Stage/grade, usually assessed formally | ||||
| 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 | SC | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (preferred): Codes describing condition stages (e.g. Cancer stages). | ||||
| assessment | C | 0..* | Reference(ClinicalImpression | QICore DiagnosticReport Profile for Laboratory Results Reporting | QICore 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 | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Condition.language | preferred | CommonLanguages
| ||||
| Condition.clinicalStatus | required | ConditionClinicalStatusCodes | ||||
| Condition.verificationStatus | required | ConditionVerificationStatus | ||||
| Condition.category | extensible | ConditionCategoryCodes | ||||
| Condition.category:us-core | extensible | Pattern: encounter-diagnosis | ||||
| Condition.severity | preferred | Condition/DiagnosisSeverity | ||||
| Condition.code | extensible | USCoreConditionCodes | ||||
| Condition.bodySite | preferred | SNOMEDCTBodyStructures | ||||
| Condition.stage.summary | preferred | ConditionStage | ||||
| Condition.stage.type | example | ConditionStageType | ||||
| Condition.evidence.code | example | ManifestationAndSymptomCodes |
| 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() | |
| 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: 8 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ http://www.hl7.org/Special/committees/cqi/index.cfm. Package hl7.fhir.us.qicore#5.0.0 based on FHIR 4.0.1. Generated 2023-04-04
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