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4.5 Resource Condition - Content

Use to record detailed information about conditions, problems or diagnoses recognized by a clinician. There are many uses including: recording a Diagnosis during an Encounter; populating a problem List or a Summary Statement, such as a Discharge Summary.

4.5.1 Scope and Usage

This resource is used to record detailed information about a specific aspect of or issue with the health state of a patient. It is intended for use for issues that have been identified as relevant for tracking and reporting purposes or where there's a need to capture a concrete diagnosis or the gathering of data such as signs and symptoms. There are situations where the same information might appear as both an observation as well as a condition. For example, the appearance of a rash or an instance of a fever are signs and symptoms that would typically be captured using the Observation resource. However, a pattern of ongoing fevers or a persistent or severe rash requiring treatment might be captured as a condition. The Condition resource specifically excludes AdverseReactions and AllergyIntolerances as those are handled with their own resources.

The Condition resource may be used to record positive aspects of the health state of a patient (e.g. pregnancy) as well as the major use, which is for problems/concerns (e.g. hypertension).

Conditions are frequently referenced by other resources as "reasons" for an action (Prescription, Procedure, DiagnosticOrder, etc.)

The conditions represented in this resources are sometimes described as "Problems", and kept as part of a problem list.

4.5.2 Resource Content

Condition (Resource)This records identifiers associated with this condition that are defined by business processed 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)identifier : Identifier 0..*Indicates the patient who the condition record is associated withsubject : Resource(Patient) 1..1Encounter during which the condition was first assertedencounter : Resource(Encounter) 0..1Person who takes responsibility for asserting the existence of the condition as part of the electronic recordasserter : Resource(Practitioner|Patient) 0..1Estimated or actual date the condition/problem/diagnosis was first detected/suspecteddateAsserted : date 0..1Identification of the condition, problem or diagnosiscode : CodeableConcept 1..1 <<Identification of the Condition or diagnosis.ConditionKind>>A category assigned to the condition. E.g. complaint | symptom | finding | diagnosiscategory : CodeableConcept 0..1 <<A category assigned to the condition. E.g. finding | Condition | diagnosis | concern | conditionConditionCategory>>The clinical status of the condition (this element modifies the meaning of other elements)status : code 1..1 <<The clinical status of the Condition or diagnosisConditionStatus>>The degree of confidence that this condition is correct (this element modifies the meaning of other elements)certainty : CodeableConcept 0..1 <<The degree of confidence that this condition is correctConditionCertainty>>A subjective assessment of the severity of the condition as evaluated by the clinicianseverity : CodeableConcept 0..1 <<A subjective assessment of the severity of the condition as evaluated by the clinician.ConditionSeverity>>Estimated or actual date the condition began, in the opinion of the clinicianonset[x] : date|Age 0..1The 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 abateabatement[x] : date|Age|boolean 0..1Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosisnotes : string 0..1StageA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specificsummary : CodeableConcept 0..1Reference to a formal record of the evidence on which the staging assessment is basedassessment : Resource(Any) 0..*EvidenceA manifestation or symptom that led to the recording of this conditioncode : CodeableConcept 0..1Links to other relevant information, including pathology reportsdetail : Resource(Any) 0..*LocationCode that identifies the structural locationcode : CodeableConcept 0..1Detailed anatomical location informationdetail : string 0..1RelatedItemThe type of relationship that this condition has to the related itemtype : code 1..1 <<The type of relationship between a condition and its related itemConditionRelationshipType>>Code that identifies the target of this relationship. The code takes the place of a detailed instance targetcode : CodeableConcept 0..1 <<Identification of the Condition or diagnosis.ConditionKind>>Target of the relationshiptarget : Resource(Condition|Procedure| MedicationAdministration|Immunization| MedicationStatement) 0..1Clinical stage or grade of a condition. May include formal severity assessmentsstage0..1Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmedevidence0..*The anatomical location where this condition manifests itselflocation0..*Further conditions, problems, diagnoses, procedures or events that are related in some way to this condition, or the substance that caused/triggered this ConditionrelatedItem0..*

This resource is referenced by CarePlan, MedicationPrescription and Procedure

<Condition xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: extension, modifierExtension, language, text, and contained -->
 <identifier><!-- 0..* Identifier External Ids for this condition --></identifier>
 <subject><!-- 1..1 Resource(Patient) Who has the condition? --></subject>
 <encounter><!-- 0..1 Resource(Encounter) Encounter when condition first asserted --></encounter>
 <asserter><!-- 0..1 Resource(Practitioner|Patient) Person who asserts this condition --></asserter>
 <dateAsserted value="[date]"/><!-- 0..1 When first detected/suspected/entered -->
 <code><!-- 1..1 CodeableConcept Identification of the condition, problem or diagnosis --></code>
 <category><!-- 0..1 CodeableConcept E.g. complaint | symptom | finding | diagnosis --></category>
 <status value="[code]"/><!-- 1..1 provisional | working | confirmed | refuted -->
 <certainty><!-- 0..1 CodeableConcept Degree of confidence --></certainty>
 <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity>
 <onset[x]><!-- 0..1 date|Age Estimated or actual date, or age --></onset[x]>
 <abatement[x]><!-- 0..1 date|Age|boolean If/when in resolution/remission --></abatement[x]>
 <stage>  <!-- 0..1 Stage/grade, usually assessed formally -->
  <summary><!-- ?? 0..1 CodeableConcept Simple summary (disease specific) --></summary>
  <assessment><!-- ?? 0..* Resource(Any) Formal record of assessment --></assessment>
 </stage>
 <evidence>  <!-- 0..* Supporting evidence -->
  <code><!-- ?? 0..1 CodeableConcept Manifestation/symptom --></code>
  <detail><!-- ?? 0..* Resource(Any) Supporting information found elsewhere --></detail>
 </evidence>
 <location>  <!-- 0..* Anatomical location, if relevant -->
  <code><!-- ?? 0..1 CodeableConcept Location - may include laterality --></code>
  <detail value="[string]"/><!-- ?? 0..1 Precise location details -->
 </location>
 <relatedItem>  <!-- 0..* Causes or precedents for this Condition -->
  <type value="[code]"/><!-- 1..1 due-to | following -->
  <code><!-- ?? 0..1 CodeableConcept Relationship target by means of a predefined code --></code>
  <target><!-- ?? 0..1 Resource(Condition|Procedure|MedicationAdministration|
    Immunization|MedicationStatement) Relationship target resource --></target>
 </relatedItem>
 <notes value="[string]"/><!-- 0..1 Additional information about the Condition -->
</Condition>

Alternate definitions: Schema/Schematron, Resource Profile

4.5.2.1 Terminology Bindings

PathDefinitionTypeReference
Condition.code
Condition.relatedItem.code 		Identification of the Condition or diagnosis.Examplehttp://hl7.org/fhir/vs/condition-code
Condition.category A category assigned to the condition. E.g. finding | Condition | diagnosis | concern | conditionIncompletehttp://hl7.org/fhir/vs/condition-category
Condition.status The clinical status of the Condition or diagnosisFixedhttp://hl7.org/fhir/condition-status
Condition.certainty The degree of confidence that this condition is correctExamplehttp://hl7.org/fhir/vs/condition-certainty
Condition.severity A subjective assessment of the severity of the condition as evaluated by the clinician.Examplehttp://hl7.org/fhir/vs/condition-severity
Condition.relatedItem.type The type of relationship between a condition and its related itemFixedhttp://hl7.org/fhir/condition-relationship-type

4.5.2.2 Constraints

4.5.2.3 Use of Condition.code

Many of the code systems used for coding conditions will provide codes that define not only the condition itself, but may also specify a particular stage, location, or causality as part of the code. This is particularly true if SNOMED-CT is used for the condition, and especially if expressions are allowed.

When the Condition.code specifies additional properties of the condition, the other properties are not given a value - instead, the value must be understood from the Condition.code.

4.5.3 Search Parameters

Search parameters for this resource. The standard parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
_idtokenThe logical resource id associated with the resource (must be supported by all servers)
_languagetokenThe language of the resource
asserterreferencePerson who asserts this conditionCondition.asserter
(Patient, Practitioner)
categorytokenThe category of the conditionCondition.category
codetokenCode for the conditionCondition.code
date-asserteddateWhen first detected/suspected/enteredCondition.dateAsserted
encounterreferenceEncounter when condition first assertedCondition.encounter
(Encounter)
evidencetokenManifestation/symptomCondition.evidence.code
locationtokenLocation - may include lateralityCondition.location.code
onsetdateWhen the Condition started (if started on a date)Condition.onset[x]
related-codetokenRelationship target by means of a predefined codeCondition.relatedItem.code
related-itemreferenceRelationship target resourceCondition.relatedItem.target
(Condition, MedicationAdministration, Procedure, MedicationStatement, Immunization)
severitytokenThe severity of the conditionCondition.severity
stagetokenSimple summary (disease specific)Condition.stage.summary
statustokenThe status of the conditionCondition.status
subjectreferenceWho has the condition?Condition.subject
(Patient)
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