Retrieval of Real World Data for Clinical Research
1.0.0-ballot - ballot
Retrieval of Real World Data for Clinical Research
1.0.0-ballot - ballot
This page is part of the Retrieval of Real World Data for Clinical Research (v1.0.0-ballot: STU1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/uv/vulcan-rwd/StructureDefinition/ConditionRwd | Version: 1.0.0-ballot | |||
| Active as of 2022-12-04 | Computable Name: ConditionRwd | |||
A profile on Condition that indicates the minimum set of attributes for use in research studies.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ConditionUvIps
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Condition | 0..* | ConditionUvIps | Documentation of a health problem of the patient | |
  encounter | S | 0..1 | Reference(Encounter) | Encounter created as part of |
 recordedDate | S | 0..1 | dateTime | Date record was first recorded |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Condition | C | 0..* | ConditionUvIps | Documentation of a health problem of the patient | ||||||
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
 clinicalStatus | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||||
| category | S | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problem Type - IPS (preferred)
| ||||||
| severity | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Condition/DiagnosisSeverity (preferred)
| ||||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problems - SNOMED CT + Absent/Unknown - IPS (preferred): Code for a clinical problem that is selected from SNOMED CT or a code for absent/unknown problem
| ||||||
  subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who has the condition? | ||||||
 reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||
| encounter | SΣ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||||
 onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||||
| onsetDateTime | dateTime | |||||||||
| recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | |||||||||
| Condition.clinicalStatus | required | ConditionClinicalStatusCodes | |||||||||
| Condition.category | preferred | ProblemTypeUvIps
| |||||||||
| Condition.severity | preferred | Condition/DiagnosisSeverity
| |||||||||
| Condition.code | preferred | ProblemsSnomedAbsentUnknownUvIps
|
| 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() |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Condition | C | 0..* | ConditionUvIps | Documentation of a health problem of the patient | ||||||
| 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 | |||||||
 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 | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||||
| verificationStatus | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | |||||||
| category | S | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problem Type - IPS (preferred)
| ||||||
| severity | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Condition/DiagnosisSeverity (preferred)
| ||||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problems - SNOMED CT + Absent/Unknown - IPS (preferred): Code for a clinical problem that is selected from SNOMED CT or a code for absent/unknown problem
| ||||||
| bodySite | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example) | |||||||
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who has the condition? | ||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||||
| encounter | SΣ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||||
| onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||||
| onsetDateTime | dateTime S | |||||||||
| onsetAge | Age | |||||||||
| onsetPeriod | Period | |||||||||
| onsetRange | Range | |||||||||
| onsetString | string | |||||||||
| abatement[x] | C | 0..1 | When in resolution/remission | |||||||
| abatementDateTime | dateTime | |||||||||
| abatementAge | Age | |||||||||
| abatementPeriod | Period | |||||||||
| abatementRange | Range | |||||||||
| abatementString | string | |||||||||
| recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | ||||||
| recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||||
| asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | ||||||
| stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally | ||||||
| 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 | ||||||
| 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 | |||||||||
| Condition.language | preferred | CommonLanguages
| |||||||||
| Condition.clinicalStatus | required | ConditionClinicalStatusCodes | |||||||||
| Condition.verificationStatus | required | ConditionVerificationStatus | |||||||||
| Condition.category | preferred | ProblemTypeUvIps
| |||||||||
| Condition.severity | preferred | Condition/DiagnosisSeverity
| |||||||||
| Condition.code | preferred | ProblemsSnomedAbsentUnknownUvIps
| |||||||||
| Condition.bodySite | example | SNOMEDCTBodyStructures | |||||||||
| Condition.subject.type | extensible | ResourceType | |||||||||
| Condition.stage.summary | example | 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 ConditionUvIps
Differential View
This structure is derived from ConditionUvIps
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Condition | 0..* | ConditionUvIps | Documentation of a health problem of the patient | |
| encounter | S | 0..1 | Reference(Encounter) | Encounter created as part of |
| recordedDate | S | 0..1 | dateTime | Date record was first recorded |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Condition | C | 0..* | ConditionUvIps | Documentation of a health problem of the patient | ||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
| clinicalStatus | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||||
| category | S | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problem Type - IPS (preferred)
| ||||||
| severity | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Condition/DiagnosisSeverity (preferred)
| ||||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problems - SNOMED CT + Absent/Unknown - IPS (preferred): Code for a clinical problem that is selected from SNOMED CT or a code for absent/unknown problem
| ||||||
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who has the condition? | ||||||
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||
| encounter | SΣ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||||
| onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||||
| onsetDateTime | dateTime | |||||||||
| recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | |||||||||
| Condition.clinicalStatus | required | ConditionClinicalStatusCodes | |||||||||
| Condition.category | preferred | ProblemTypeUvIps
| |||||||||
| Condition.severity | preferred | Condition/DiagnosisSeverity
| |||||||||
| Condition.code | preferred | ProblemsSnomedAbsentUnknownUvIps
|
| 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() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Condition | C | 0..* | ConditionUvIps | Documentation of a health problem of the patient | ||||||
| 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 | |||||||
| 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 | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||||
| verificationStatus | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | |||||||
| category | S | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problem Type - IPS (preferred)
| ||||||
| severity | S | 0..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Condition/DiagnosisSeverity (preferred)
| ||||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Problems - SNOMED CT + Absent/Unknown - IPS (preferred): Code for a clinical problem that is selected from SNOMED CT or a code for absent/unknown problem
| ||||||
| bodySite | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example) | |||||||
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who has the condition? | ||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||||
| encounter | SΣ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||||
| onset[x] | SΣ | 0..1 | Estimated or actual date, date-time, or age | |||||||
| onsetDateTime | dateTime S | |||||||||
| onsetAge | Age | |||||||||
| onsetPeriod | Period | |||||||||
| onsetRange | Range | |||||||||
| onsetString | string | |||||||||
| abatement[x] | C | 0..1 | When in resolution/remission | |||||||
| abatementDateTime | dateTime | |||||||||
| abatementAge | Age | |||||||||
| abatementPeriod | Period | |||||||||
| abatementRange | Range | |||||||||
| abatementString | string | |||||||||
| recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | ||||||
| recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||||
| asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | ||||||
| stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally | ||||||
| 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 | ||||||
| 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 | |||||||||
| Condition.language | preferred | CommonLanguages
| |||||||||
| Condition.clinicalStatus | required | ConditionClinicalStatusCodes | |||||||||
| Condition.verificationStatus | required | ConditionVerificationStatus | |||||||||
| Condition.category | preferred | ProblemTypeUvIps
| |||||||||
| Condition.severity | preferred | Condition/DiagnosisSeverity
| |||||||||
| Condition.code | preferred | ProblemsSnomedAbsentUnknownUvIps
| |||||||||
| Condition.bodySite | example | SNOMEDCTBodyStructures | |||||||||
| Condition.subject.type | extensible | ResourceType | |||||||||
| Condition.stage.summary | example | 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 ConditionUvIps
Other representations of profile: CSV, Excel, Schematron
IG © 2022+ HL7 International - Biomedical Research & Regulation Work Group. Package hl7.fhir.uv.vulcan-rwd#1.0.0-ballot based on FHIR 4.0.1. Generated 2022-12-04
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