This profile describes how applications fetch Condition resources that provide information about a patient’s problems.

Example Usage Scenarios:

The most important and obvious use of the condition to resource is to get a list of the patient’s current problem list. However there are many other uses for the condition resource, such as recording primary and secondary diagnoses for encounters, or justification for past medications etc.

All servers SHALL provide an API to access Condition Resources as described here.

Clients access Condition resources using one of these two calls:

GET [url]/Condition/[id]

where id is found in some other resource that refers to a Condition. The result of this read is a Condition resource, or an error if there is no resource the client can access for that id. Alternatively, the client may search for condition resources.

The current problem list is retrieved by specifying the patient, category and and clinical-status:

GET [url]/Condition?patient=[patient-id]&category=problem-list-item&clinical-status=active

Regardless of which way they are accessed, all Condition resources have to conform to the following rules:

• They SHOULD have a clinicalStatus
• They SHOULD have a verificationStatus
• They SHALL have at least one category
• They SHALL have a code
• They SHALL have a subject

Servers may choose to provide additional information, or may be required to do so by national or other additional profiles on conditions that apply in the servers context.

Condition Codes

All Condition resources are required to have a code, but the coding systems used around the world and even within jurisdictions very wildly. This specification does not fix any kind of value set that controls what kind of codes can be used - other national specifications etc will place their own restrictions on the codes.

Client Applications should be prepared to encounter codes they do not recognise and handle the records accordingly. Servers SHOULD populate Condition.code.coding.display and/or Condition.code.text so that clients can always at least display the condition even if they do not know the codes that are used.

Clients should be careful making use of the code search parameter given that the codes used vary so much.

Safety Issues

• Clients SHALL not treat all conditions as if they are part of the patient’s current problem list
  • Note that some Condition resources may not have these status codes - this is usually due to poor record keeping reflected in legacy data
  • Servers SHOULD avoid leaving these status codes missing
• Clients SHALL pay attention to the clinicalStatus and verificationStatus and display and process them correctly
• Clients SHALL still work safely when the server does not support all the search parameters listed above (see Search advice)

• Text Summary
• Differential Table
• Snapshot Table
• Snapshot Table (Must Support)
• All

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
clinicalStatus	S	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved
verificationStatus	S	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
category	S	1..*	CodeableConcept	problem-list-item | encounter-diagnosis
code	S	1..1	CodeableConcept	Identification of the condition, problem or diagnosis
subject	S	1..1	Reference(IPA-Patient)	Who has the condition?
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Condition	I	0..*	Condition	Detailed information about conditions, problems or diagnoses
id	Σ	0..1	string	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) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!SΣI	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!SΣI	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
category	S	1..*	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
severity		0..1	CodeableConcept	Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
code	SΣ	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	SΣ	1..1	Reference(IPA-Patient)	Who has the condition?
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
onset[x]	Σ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	I	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	Σ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Who recorded the condition
asserter	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Person who asserts this condition
stage	I	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	I	0..1	CodeableConcept	Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment	I	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	I	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	ΣI	0..*	CodeableConcept	Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail	ΣI	0..*	Reference(Resource)	Supporting information found elsewhere
note		0..*	Annotation	Additional information about the Condition
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Condition	I	0..*	Condition	Detailed information about conditions, problems or diagnoses
clinicalStatus	?!ΣI	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!ΣI	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
category		1..*	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
code	Σ	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
subject	Σ	1..1	Reference(IPA-Patient)	Who has the condition?
Documentation for this format

This structure is derived from Condition

Summary

Mandatory: 3 elements
Must-Support: 5 elements

Structures

This structure refers to these other structures:

• IPA-Patient (http://hl7.org/fhir/uv/ipa/StructureDefinition/ipa-patient)

Differential View

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
clinicalStatus	S	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved
verificationStatus	S	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
category	S	1..*	CodeableConcept	problem-list-item | encounter-diagnosis
code	S	1..1	CodeableConcept	Identification of the condition, problem or diagnosis
subject	S	1..1	Reference(IPA-Patient)	Who has the condition?
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Condition	I	0..*	Condition	Detailed information about conditions, problems or diagnoses
id	Σ	0..1	string	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) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!SΣI	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!SΣI	0..1	CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
category	S	1..*	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
severity		0..1	CodeableConcept	Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
code	SΣ	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	SΣ	1..1	Reference(IPA-Patient)	Who has the condition?
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
onset[x]	Σ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	I	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	Σ	0..1	dateTime	Date record was first recorded
recorder	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Who recorded the condition
asserter	Σ	0..1	Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)	Person who asserts this condition
stage	I	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	I	0..1	CodeableConcept	Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
assessment	I	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	I	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	ΣI	0..*	CodeableConcept	Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
detail	ΣI	0..*	Reference(Resource)	Supporting information found elsewhere
note		0..*	Annotation	Additional information about the Condition
Documentation for this format