A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

An Extension

R4: Condition.recorder (new:Reference(Practitioner,PractitionerRole,Patient,RelatedPerson))

Element Condition.recorder has a context of Condition based on following the parent source element upwards and mapping to Condition. Element Condition.recorder has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The clinical status of the condition.

This element is labeled as a modifier because the status contains codes that mark the condition as not currently valid or of concern.

The codes SHALL be taken from Condition Clinical Status Codes http://hl7.org/fhir/ValueSet/condition-clinical|3.0.2
(required to http://hl7.org/fhir/ValueSet/condition-clinical|3.0.2)

The clinical status of the condition or diagnosis.

An Extension

R4: Condition.clinicalStatus additional types (CodeableConcept) additional types from child elements (coding)

Element Condition.clinicalStatus is mapped to FHIR STU3 element Condition.clinicalStatus as SourceIsBroaderThanTarget. The mappings for Condition.clinicalStatus do not cover the following types: CodeableConcept. The mappings for Condition.clinicalStatus do not cover the following types based on type expansion: coding. The target context Condition.clinicalStatus is a modifier element, so this extension does not need to be defined as a modifier. The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

The verification status to support the clinical status of the condition.

verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status.

This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.

The codes SHALL be taken from ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|3.0.2
(required to http://hl7.org/fhir/ValueSet/condition-ver-status|3.0.2)

The verification status to support or decline the clinical status of the condition or diagnosis.

An Extension

R4: Condition.verificationStatus additional types (CodeableConcept) additional types from child elements (coding)

Element Condition.verificationStatus is mapped to FHIR STU3 element Condition.verificationStatus as SourceIsBroaderThanTarget. The mappings for Condition.verificationStatus do not cover the following types: CodeableConcept. The mappings for Condition.verificationStatus do not cover the following types based on type expansion: coding. The target context Condition.verificationStatus is a modifier element, so this extension does not need to be defined as a modifier. verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

Indicates the patient or group who the condition record is associated with.

Group is typically used for veterinary or public health use cases.

R4: Condition.recorder (new:Reference(Practitioner,PractitionerRole,Patient,RelatedPerson))

Element Condition.recorder has a context of Condition based on following the parent source element upwards and mapping to Condition. Element Condition.recorder has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: Condition.clinicalStatus additional types (CodeableConcept) additional types from child elements (coding)

Element Condition.clinicalStatus is mapped to FHIR STU3 element Condition.clinicalStatus as SourceIsBroaderThanTarget. The mappings for Condition.clinicalStatus do not cover the following types: CodeableConcept. The mappings for Condition.clinicalStatus do not cover the following types based on type expansion: coding. The target context Condition.clinicalStatus is a modifier element, so this extension does not need to be defined as a modifier. The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

R4: Condition.verificationStatus additional types (CodeableConcept) additional types from child elements (coding)

Element Condition.verificationStatus is mapped to FHIR STU3 element Condition.verificationStatus as SourceIsBroaderThanTarget. The mappings for Condition.verificationStatus do not cover the following types: CodeableConcept. The mappings for Condition.verificationStatus do not cover the following types based on type expansion: coding. The target context Condition.verificationStatus is a modifier element, so this extension does not need to be defined as a modifier. verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

R4: Condition.asserter

Element Condition.asserter is mapped to FHIR STU3 element Condition.asserter as SourceIsBroaderThanTarget. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element Condition.asserter with unmapped reference targets: PractitionerRole.

R4: Condition.stage.type (new:CodeableConcept)

Element Condition.stage.type has a context of Condition.stage based on following the parent source element upwards and mapping to Condition. Element Condition.stage.type has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

An Extension

R4: Condition.recorder (new:Reference(Practitioner,PractitionerRole,Patient,RelatedPerson))

Element Condition.recorder has a context of Condition based on following the parent source element upwards and mapping to Condition. Element Condition.recorder has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

This records identifiers associated with this condition that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

Need to allow connection to a wider workflow.

The clinical status of the condition.

This element is labeled as a modifier because the status contains codes that mark the condition as not currently valid or of concern.

The codes SHALL be taken from Condition Clinical Status Codes
(required to http://hl7.org/fhir/ValueSet/condition-clinical|3.0.2)

The clinical status of the condition or diagnosis.

unique id for the element within a resource (for internal references)

An Extension

R4: Condition.clinicalStatus additional types (CodeableConcept) additional types from child elements (coding)

Element Condition.clinicalStatus is mapped to FHIR STU3 element Condition.clinicalStatus as SourceIsBroaderThanTarget. The mappings for Condition.clinicalStatus do not cover the following types: CodeableConcept. The mappings for Condition.clinicalStatus do not cover the following types based on type expansion: coding. The target context Condition.clinicalStatus is a modifier element, so this extension does not need to be defined as a modifier. The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

Primitive value for code

The verification status to support the clinical status of the condition.

verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status.

This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.

The codes SHALL be taken from ConditionVerificationStatus
(required to http://hl7.org/fhir/ValueSet/condition-ver-status|3.0.2)

The verification status to support or decline the clinical status of the condition or diagnosis.

unique id for the element within a resource (for internal references)

An Extension

R4: Condition.verificationStatus additional types (CodeableConcept) additional types from child elements (coding)

Element Condition.verificationStatus is mapped to FHIR STU3 element Condition.verificationStatus as SourceIsBroaderThanTarget. The mappings for Condition.verificationStatus do not cover the following types: CodeableConcept. The mappings for Condition.verificationStatus do not cover the following types based on type expansion: coding. The target context Condition.verificationStatus is a modifier element, so this extension does not need to be defined as a modifier. verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.

Primitive value for code

A category assigned to the condition.

The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.

A category assigned to the condition.

A subjective assessment of the severity of the condition as evaluated by the clinician.

Coding of the severity with a terminology is preferred, where possible.

A subjective assessment of the severity of the condition as evaluated by the clinician.

Identification of the condition, problem or diagnosis.

Identification of the condition or diagnosis.

0..1 to account for primarily narrative only resources.

The anatomical location where this condition manifests itself.

Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension body-site-instance. May be a summary code, or a reference to a very precise definition of the location, or both.

Codes describing anatomical locations. May include laterality.

Indicates the patient or group who the condition record is associated with.

Group is typically used for veterinary or public health use cases.

Encounter during which the condition was first asserted.

This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".

Estimated or actual date or date-time the condition began, in the opinion of the clinician.

Age is generally used when the patient reports an age at which the Condition began to occur.

The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate.

There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.

The date on which the existance of the Condition was first asserted or acknowledged.

The assertedDate represents the date when this particular Condition record was created in the EHR, not the date of the most recent update in terms of when severity, abatement, etc. were specified.  The date of the last record modification can be retrieved from the resource metadata.

Individual who is making the condition statement.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

R4: Condition.asserter

Element Condition.asserter is mapped to FHIR STU3 element Condition.asserter as SourceIsBroaderThanTarget. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element Condition.asserter with unmapped reference targets: PractitionerRole.

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Plain text narrative that identifies the resource in addition to the resource reference.

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Clinical stage or grade of a condition. May include formal severity assessments.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

R4: Condition.stage.type (new:CodeableConcept)

Element Condition.stage.type has a context of Condition.stage based on following the parent source element upwards and mapping to Condition. Element Condition.stage.type has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.

Codes describing condition stages (e.g. Cancer stages).

Reference to a formal record of the evidence on which the staging assessment is based.

Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed.

The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A manifestation or symptom that led to the recording of this condition.

Codes that describe the manifestation or symptoms of a condition.

Links to other relevant information, including pathology reports.

Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.