abstractbaseDefinitioncopyrightdescriptionexperimentalfhirVersionjurisdiction
jurisdiction[0]kindnamepublisherpurposestatustitletypeurl| Left: | US Core Condition Encounter Diagnosis Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis) |
| Right: | US Core Condition Encounter Diagnosis Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis) |
| Name | Value | Comments | |
|---|---|---|---|
| abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/Condition | ||
| copyright | Used by permission of HL7 International, all rights reserved Creative Commons License | ||
| description | The US Core Condition Encounter Diagnosis Profile inherits from the FHIR [Condition](https://hl7.org/fhir/R4/condition.html) resource; refer to it for scope and usage definitions. US Core version 5.0.0 split the US Core Condition Profile into this profile and the US Core Condition Problems and Health Concerns Profile. This profile meets the requirements of the U.S. Core Data for Interoperability (USCDI) *Encounter Diagnosis* Data Element. It sets minimum expectations for the Condition resource to record, search, and fetch information about an encounter diagnosis. It specifies which core elements, extensions, vocabularies, and value sets **SHALL** be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption. | ||
| experimental | false | ||
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
| jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | USCoreConditionEncounterDiagnosisProfile | ||
| publisher | HL7 International / Cross-Group Projects | ||
| purpose | |||
| status | active | ||
| title | US Core Condition Encounter Diagnosis Profile | ||
| type | Condition | ||
| url | http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis | ||
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 Condition | C | 0..* | Condition | Detailed information about conditions, problems or diagnoses con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | C | 0..* | Condition | Detailed information about conditions, problems or diagnoses con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error | |||||||||
 id | Σ | 0..1 | id | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource | |||||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!Σ | 0..1 | uri | A set of rules under which this content was created | |||||||||
| language | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| |||||||||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored | |||||||||
| identifier | Σ | 0..* | Identifier | External Ids for this condition | Σ | 0..* | Identifier | External Ids for this condition | |||||||||
| clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ?? (required) | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ?? (required) | |||||||||
| verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ?? (required) | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ?? (required) | |||||||||
| Slices for category | S | 1..* | CodeableConcept | category codes Slice: Unordered, Open by pattern:$this Binding: ?? (extensible): A category assigned to the condition. | S | 1..* | CodeableConcept | category codes Slice: Unordered, Open by value:$this Binding: ?? (extensible): A category assigned to the condition. | |||||||||
| severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: ?? (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | 0..1 | CodeableConcept | Subjective severity of condition Binding: ?? (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: ?? (preferred): Valueset to describe the actual problem experienced by the patient
| SΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: ?? (preferred): Valueset to describe the actual problem experienced by the patient
| |||||||||
| bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: ?? (example): Codes describing anatomical locations. May include laterality. | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: ?? (example): Codes describing anatomical locations. May include laterality. | |||||||||
| subject | SΣ | 1..1 | Reference(US Core Patient Profile S | Group) | Who has the condition? | SΣ | 1..1 | Reference(US Core Patient Profile S | Group) | Who has the condition? | |||||||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Encounter created as part of | SΣ | 0..1 | Reference(US Core Encounter Profile) | Encounter created as part of | |||||||||
| onset[x] | SΣ | 0..1 | dateTime S, Age, Period, Range, string | Estimated or actual date, date-time, or age | SΣ | 0..1 | dateTime S, Age, Period, Range, string | Estimated or actual date, date-time, or age | |||||||||
| abatement[x] | SC | 0..1 | dateTime S, Age, Period, Range, string | When in resolution/remission | SC | 0..1 | dateTime S, Age, Period, Range, string | When in resolution/remission | |||||||||
| recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | SΣ | 0..1 | dateTime | Date record was first recorded | |||||||||
| recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | 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 | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | |||||||||
| stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment | C | 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 | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ?? (example): Codes describing condition stages (e.g. Cancer stages). | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ?? (example): Codes describing condition stages (e.g. Cancer stages). | |||||||||
| assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | |||||||||
| type | 0..1 | CodeableConcept | Kind of staging Binding: ?? (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | 0..1 | CodeableConcept | Kind of staging Binding: ?? (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||||||||
| evidence | C | 0..* | BackboneElement | Supporting evidence con-2: evidence SHALL have code or details | C | 0..* | BackboneElement | Supporting evidence con-2: evidence SHALL have code or details | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ?? (example): Codes that describe the manifestation or symptoms of a condition. | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ?? (example): Codes that describe the manifestation or symptoms of a condition. | |||||||||
| detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | |||||||||
| note | 0..* | Annotation | Additional information about the Condition | 0..* | Annotation | Additional information about the Condition | |||||||||||
| Documentation for this format | |||||||||||||||||