2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Profile: USlabReasonForStudy

The official URL for this profile is: 

http://hl7.org/fhir/Profile/cond-uslab-uslabreasonforstudy

. The Condition(s) referenced in USRealm laboratory test and reporting in ambulatory care setting. : US Laboratory Condition Profile

This profile was published on Mon, Nov 17, 2014 00:00+1100 as a draft by HL7 International - Orders and Observations WG.

Summary

Terminology Bindings

  • Condition.code must come from This value set includes all ICD-9CM and ICD-10CM concept codes

Required/Prohibited Elements

  • The element Condition is required
  • The element Condition.subject is required
  • The element Condition.code is required
  • The element Condition.code.coding is required
  • The element Condition.code.coding.code is required
  • The element Condition.code.coding.system is required
  • The element Condition.category is required
  • The element Condition.category.coding.code is required
  • The element Condition.category.coding.system is required
  • The element Condition.status is required

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

Differential View

This structure is derived from Condition.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 1..1Reason for Study or Additional Clinical Information for Laboratorian or Pathologist.
... subject S1..1patient-uslab-uslabpatient, patient-uslab-uslabphpatientPatient
... code S1..1CodeableConceptBinding: USlabReasonForStudy (required, not extensible)
.... coding S1..1
..... code S1..1
..... display S0..1
..... system S1..1
... category S1..1
.... coding S0..1
..... code S1..1
..... display S0..1
..... system S1..1
... status S1..1

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 1..1Reason for Study or Additional Clinical Information for Laboratorian or Pathologist.
... id 0..1idLogical id of this artefact
... meta 0..1MetaMetadata about the resource
... implicitRules M0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required, not extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierExternal Ids for this condition
... subject S1..1patient-uslab-uslabpatient, patient-uslab-uslabphpatientPatient
... encounter 0..1EncounterEncounter when condition first asserted
... asserter 0..1Practitioner, PatientPerson who asserts this condition
... dateAsserted 0..1dateWhen first detected/suspected/entered
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: USlabReasonForStudy (required, not extensible)
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... coding S1..1CodingCode defined by a terminology system
..... id 0..1idxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... system S1..1uriIdentity of the terminology system
..... version 0..1stringVersion of the system - if relevant
..... code 0..1codeSymbol in syntax defined by the system
..... display 0..1stringRepresentation defined by the system
..... primary 0..1booleanIf this code was chosen directly by the user
..... valueSet 0..1ValueSetSet this coding was chosen from
.... text 0..1stringPlain text representation of the concept
... category S1..1CodeableConceptE.g. complaint | symptom | finding | diagnosis
Binding: ConditionCategory (preferred, extensible)
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... coding S0..1CodingCode defined by a terminology system
..... id 0..1idxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... system S1..1uriIdentity of the terminology system
..... version 0..1stringVersion of the system - if relevant
..... code 0..1codeSymbol in syntax defined by the system
..... display 0..1stringRepresentation defined by the system
..... primary 0..1booleanIf this code was chosen directly by the user
..... valueSet 0..1ValueSetSet this coding was chosen from
.... text 0..1stringPlain text representation of the concept
... status M S1..1codeprovisional | working | confirmed | refuted
Binding: ConditionStatus (required, not extensible)
... certainty M0..1CodeableConceptDegree of confidence
Binding: ConditionCertainty (example, extensible)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: ConditionSeverity (example, extensible)
... onset[x] 0..1dateTime, AgeEstimated or actual date, date-time, or age
... abatement[x] 0..1date, Age, booleanIf/when in resolution/remission
... stage I0..1Stage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... summary I0..1CodeableConceptSimple summary (disease specific)
.... assessment I0..*AnyFormal record of assessment
... evidence I0..*Supporting evidence
con-2: evidence SHALL have code or details
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code I0..1CodeableConceptManifestation/symptom
.... detail I0..*AnySupporting information found elsewhere
... location I0..*Anatomical location, if relevant
con-3: location SHALL have code or details
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code I0..1CodeableConceptLocation - may include laterality
.... detail I0..1stringPrecise location details
... dueTo I0..*Causes for this Condition
con-4: Relationship SHALL have either a code or a target
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... codeableConcept I0..1CodeableConceptRelationship target by means of a predefined code
Binding: ConditionKind (example, extensible)
.... target I0..1Condition, Procedure, MedicationAdministration, Immunization, MedicationStatementRelationship target resource
... occurredFollowing I0..*Precedent for this Condition
con-5: Relationship SHALL have either a code or a target
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... codeableConcept I0..1CodeableConceptRelationship target by means of a predefined code
Binding: ConditionKind (example, extensible)
.... target I0..1Condition, Procedure, MedicationAdministration, Immunization, MedicationStatementRelationship target resource
... notes 0..1stringAdditional information about the Condition

XML Template

JSON Template

todo

Differential View

This structure is derived from Condition.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 1..1Reason for Study or Additional Clinical Information for Laboratorian or Pathologist.
... subject S1..1patient-uslab-uslabpatient, patient-uslab-uslabphpatientPatient
... code S1..1CodeableConceptBinding: USlabReasonForStudy (required, not extensible)
.... coding S1..1
..... code S1..1
..... display S0..1
..... system S1..1
... category S1..1
.... coding S0..1
..... code S1..1
..... display S0..1
..... system S1..1
... status S1..1

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 1..1Reason for Study or Additional Clinical Information for Laboratorian or Pathologist.
... id 0..1idLogical id of this artefact
... meta 0..1MetaMetadata about the resource
... implicitRules M0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required, not extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierExternal Ids for this condition
... subject S1..1patient-uslab-uslabpatient, patient-uslab-uslabphpatientPatient
... encounter 0..1EncounterEncounter when condition first asserted
... asserter 0..1Practitioner, PatientPerson who asserts this condition
... dateAsserted 0..1dateWhen first detected/suspected/entered
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: USlabReasonForStudy (required, not extensible)
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... coding S1..1CodingCode defined by a terminology system
..... id 0..1idxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... system S1..1uriIdentity of the terminology system
..... version 0..1stringVersion of the system - if relevant
..... code 0..1codeSymbol in syntax defined by the system
..... display 0..1stringRepresentation defined by the system
..... primary 0..1booleanIf this code was chosen directly by the user
..... valueSet 0..1ValueSetSet this coding was chosen from
.... text 0..1stringPlain text representation of the concept
... category S1..1CodeableConceptE.g. complaint | symptom | finding | diagnosis
Binding: ConditionCategory (preferred, extensible)
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... coding S0..1CodingCode defined by a terminology system
..... id 0..1idxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... system S1..1uriIdentity of the terminology system
..... version 0..1stringVersion of the system - if relevant
..... code 0..1codeSymbol in syntax defined by the system
..... display 0..1stringRepresentation defined by the system
..... primary 0..1booleanIf this code was chosen directly by the user
..... valueSet 0..1ValueSetSet this coding was chosen from
.... text 0..1stringPlain text representation of the concept
... status M S1..1codeprovisional | working | confirmed | refuted
Binding: ConditionStatus (required, not extensible)
... certainty M0..1CodeableConceptDegree of confidence
Binding: ConditionCertainty (example, extensible)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: ConditionSeverity (example, extensible)
... onset[x] 0..1dateTime, AgeEstimated or actual date, date-time, or age
... abatement[x] 0..1date, Age, booleanIf/when in resolution/remission
... stage I0..1Stage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... summary I0..1CodeableConceptSimple summary (disease specific)
.... assessment I0..*AnyFormal record of assessment
... evidence I0..*Supporting evidence
con-2: evidence SHALL have code or details
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code I0..1CodeableConceptManifestation/symptom
.... detail I0..*AnySupporting information found elsewhere
... location I0..*Anatomical location, if relevant
con-3: location SHALL have code or details
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code I0..1CodeableConceptLocation - may include laterality
.... detail I0..1stringPrecise location details
... dueTo I0..*Causes for this Condition
con-4: Relationship SHALL have either a code or a target
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... codeableConcept I0..1CodeableConceptRelationship target by means of a predefined code
Binding: ConditionKind (example, extensible)
.... target I0..1Condition, Procedure, MedicationAdministration, Immunization, MedicationStatementRelationship target resource
... occurredFollowing I0..*Precedent for this Condition
con-5: Relationship SHALL have either a code or a target
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... codeableConcept I0..1CodeableConceptRelationship target by means of a predefined code
Binding: ConditionKind (example, extensible)
.... target I0..1Condition, Procedure, MedicationAdministration, Immunization, MedicationStatementRelationship target resource
... notes 0..1stringAdditional information about the Condition

XML Template

JSON Template

todo

 

Other definitions: (todo)

Terminology Bindings

PathNameConformanceValueSet
Condition.languageLanguagerequiredhttp://tools.ietf.org/html/bcp47
Condition.codeUSlabReasonForStudyrequiredUSlabConditonCodes
Condition.categoryConditionCategorypreferred (extensible)Condition/Problem/Diagnosis Codes
Condition.statusConditionStatusrequiredConditionStatus
Condition.certaintyConditionCertaintyexample (extensible)Condition/Diagnosis Certainty
Condition.severityConditionSeverityexample (extensible)Condition/Diagnosis Severity
Condition.dueTo.codeableConceptConditionKindexample (extensible)Condition/Problem/Diagnosis Codes
Condition.occurredFollowing.codeableConceptConditionKindexample (extensible)Condition/Problem/Diagnosis Codes

Constraints

IdPathNameDetails
con-1Condition.stageStage ruleStage SHALL have summary or assessment
XPath: exists(f:summary) or exists(f:assessment)
con-2Condition.evidenceEvidenceevidence SHALL have code or details
XPath: exists(f:code) or exists(f:detail)
con-3Condition.locationLocationlocation SHALL have code or details
XPath: exists(f:code) or exists(f:detail)
con-4Condition.dueToRelationship1Relationship SHALL have either a code or a target
XPath: exists(f:code) != exists(f:target)
con-5Condition.occurredFollowingRelationship2Relationship SHALL have either a code or a target
XPath: exists(f:code) != exists(f:target)
.