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.

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).

Need to allow connection to a wider workflow.

Indicates the patient who the condition record is associated with.

Encounter during which the condition was first asserted.

Person who takes responsibility for asserting the existence of the condition as part of the electronic record.

Estimated or actual date the condition/problem/diagnosis was first detected/suspected.

Identification of the condition, problem or diagnosis.

A category assigned to the condition. E.g. complaint | symptom | finding | diagnosis.

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

The clinical status of the condition.

The degree of confidence that this condition is correct.

May be a percentage.

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.

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.

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

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

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.

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

Links to other relevant information, including pathology reports.

The anatomical location where this condition manifests itself.

May be a summary code, or a reference to a very precise definition of the location, or both.

Code that identifies the structural location.

May include laterality.

Detailed anatomical location information.

Further conditions, problems, diagnoses, procedures or events or the substance that caused/triggered this Condition.

Although a condition may be caused by a substance, this is not intended to be used to record allergies/adverse reactions to substances.

Code that identifies the target of this relationship. The code takes the place of a detailed instance target.

Target of the relationship.

Further conditions, problems, diagnoses, procedures or events or the substance that preceded this Condition.

Code that identifies the target of this relationship. The code takes the place of a detailed instance target.

Target of the relationship.

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