| IB-Problema (Condition) | I | | Condition | There are no (further) constraints on this element Element idShort description Detailed information about conditions, problems or diagnoses Definition A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
Condition Constraints- dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty() - dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative
contained.text.empty() - dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() - dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
contained.where(('#'+id in %resource.descendants().reference).not()).empty() - con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive' - con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error
verificationStatus='entered-in-error' or clinicalStatus.exists()
- rim: Entity. Role, or Act
- sct-concept: < 243796009 |Situation with explicit context|:
246090004 |Associated finding| =
((< 404684003 |Clinical finding| MINUS
<< 420134006 |Propensity to adverse reactions| MINUS
<< 473010000 |Hypersensitivity condition| MINUS
<< 79899007 |Drug interaction| MINUS
<< 69449002 |Drug action| MINUS
<< 441742003 |Evaluation finding| MINUS
<< 307824009 |Administrative status| MINUS
<< 385356007 |Tumor stage finding|) OR
< 272379006 |Event|)
- v2: PPR message
- rim: Observation[classCode=OBS, moodCode=EVN, code=ASSERTION, value<Diagnosis]
- w5: clinical.general
|
| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idShort description Logical id of this artifact Definition 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.
id Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
|
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idShort description Metadata about the resource Definition 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.
Meta Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
|
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idShort description A set of rules under which this content was created Definition 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.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
|
| language | | 0..1 | codeBinding | There are no (further) constraints on this element Element idShort description Language of the resource content Definition 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).
code Binding A human language. Common Languages (extensible)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
|
| text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idShort description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition 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.
Narrative Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- rim: N/A
- rim: Act.text?
|
| contained | | 0..* | Resource | There are no (further) constraints on this element Element idShort description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition 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.
Resource Mappings- rim: Entity. Role, or Act
- rim: N/A
|
| extension | I | 0..* | Extension | Element idShort description Additional Content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. 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.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| jerarquia | I | 1..1 | Extension(Coding)Binding | Element idCondition.extension:jerarquia Primario | Secundario Alternate names extensions, user content Definition Un problema de salud se considera primario cuando no es consecuencia directa de otro problema de salud o se desconoce esa relación y secundario cuando se conoce esa relación. Ejemplo: Una neumonía podría ser un problema de salud primario, en cuyo contexto la fiebre, la tos y el dolor pleurítico serían problemas de salud secundarios. A su vez una neumonía podría ser un pro-blema secundario a una neoplasia con obstrucción bronquial.
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.
Extension(Coding) Extension URL http://example.org/fhir/StructureDefinition/IB-Jerarquia Binding ?? (required) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| atributosComunes | I | 1..1 | Extension(Complex) | Element idCondition.extension:atributosComunes Atributos Comunes Alternate names extensions, user content Definition Atributos Comunes: ID Paciente, Tipo Elemento, Fecha y Hora registro, Sistema que envía, Autor.
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.
Extension(Complex) Extension URL http://example.org/fhir/StructureDefinition/IB-AtributosComunes Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.modifierExtension Extensions that cannot be ignored Alternate names extensions, user content Definition 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.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idShort description External Ids for this condition Definition 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.
Identifier Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
- rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
- servd: Identifier
- rim: .id
- w5: id
|
| clinicalStatus | Σ ?! I | 1..1 | codeBinding | Element idShort description active | recurrence | inactive | remission | resolved Definition Afirmación sobre la situación actual del problema de salud.
PDTE: confirmar estados remission y recurrence
This element is labeled as a modifier because the status contains codes that mark the condition as not currently valid or of concern.
code Binding The clinical status of the condition or diagnosis. Condition Clinical Status Codes (required)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- sct-concept: < 303105007 |Disease phases|
- v2: PRB-14 / DG1-6
- rim: Observation ACT
.inboundRelationship[typeCode=COMP].source[classCode=OBS, code="clinicalStatus", moodCode=EVN].value
- w5: status
|
| verificationStatus | Σ ?! I | 1..1 | codeBinding | Element idCondition.verificationStatus provisional | differential | confirmed | refuted | entered-in-error | unknown Definition El nivel de certeza de la identificación del problema de salud.
PDTE: mapeos Sospecha y Probable a Provisional y que hacer con: refuted, entered-in-error, unknown, differential
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.
code Binding The verification status to support or decline the clinical status of the condition or diagnosis. ConditionVerificationStatus (required)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- sct-concept: < 410514004 |Finding context value|
- v2: PRB-13
- rim: Observation ACT
.inboundRelationship[typeCode=COMP].source[classCode=OBS, code="verificationStatus", moodCode=EVN].value
- sct-attr: 408729009
- w5: status
|
| category | | 1..1 | CodeableConceptBindingFixed Value | Element idShort description problem-list-item Definition Identificador del elemento Problema de Salud
The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.
CodeableConcept Binding A category assigned to the condition. Condition Category Codes (required)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
{
"coding": [
{
"system": "http://hl7.org/fhir/ValueSet/condition-category",
"code": "problem-list-item"
}
],
"text": "problem-list-item"
}- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept: < 404684003 |Clinical finding|
- v2: 'problem' if from PRB-3. 'diagnosis' if from DG1 segment in PV1 message
- rim: .code
- w5: class
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description xml:id (or equivalent in JSON) Definition unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Note that FHIR strings may not exceed 1MB in size
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
|
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.category.extension Additional Content defined by implementations Alternate names extensions, user content Definition 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.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| coding | Σ | 1..1 | CodingBindingFixed Value | Element idCondition.category.coding Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding Binding problem-list-item Condition Category Codes (required)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
{
"system": "http://hl7.org/fhir/ValueSet/condition-category",
"code": "problem-list-item"
}- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idCondition.category.coding.id xml:id (or equivalent in JSON) Definition unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Note that FHIR strings may not exceed 1MB in size
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
|
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.category.coding.extension Additional Content defined by implementations Alternate names extensions, user content Definition 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.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| system | Σ | 1..1 | uriBindingFixed Value | Element idCondition.category.coding.system Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code.
Need to be unambiguous about the source of the definition of the symbol.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
uri Binding problem-list-item Condition Category Codes (required)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: C*E.3
- rim: ./codeSystem
- orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.category.coding.version Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: C*E.7
- rim: ./codeSystemVersion
- orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | Σ | 1..1 | codeFixed Value | Element idCondition.category.coding.code Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
Note that FHIR strings may not exceed 1MB in size
code Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: C*E.1
- rim: ./code
- orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.category.coding.display Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Note that FHIR strings may not exceed 1MB in size
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: C*E.2 - but note this is not well followed
- rim: CV.displayName
- orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idCondition.category.coding.userSelected If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
boolean Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: Sometimes implied by being first
- rim: CD.codingRationale
- orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| text | Σ | 1..1 | stringFixed Value | Element idShort description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Very often the text is the same as a displayName of one of the codings.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| severity | | 0..1 | CodeableConceptBinding | Element idShort description Subjective severity of condition Definition Una evaluación del profesional de la salud sobre la severidad del problema de salud.
PDTE: definir mapeo de campos con el arquetipo
Coding of the severity with a terminology is preferred, where possible.
CodeableConcept Binding A subjective assessment of the severity of the condition as evaluated by the clinician. Condition/Diagnosis Severity (preferred)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept: < 272141005 |Severities|
- v2: PRB-26 / ABS-3
- rim: Can be pre/post-coordinated into value. Or ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="severity"].value
- sct-attr: 246112005
- w5: grade
|
| code | Σ | 1..1 | CodeableConceptBinding | Element idShort description Identification of the condition, problem or diagnosis Alternate names type Definition Identification of the condition, problem or diagnosis.
RefSet de snomed
0..1 to account for primarily narrative only resources.
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
CodeableConcept Binding Identification of the condition or diagnosis. Condition/Problem/Diagnosis Codes (required)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept: code 246090004 |Associated finding| (< 404684003 |Clinical finding| MINUS
<< 420134006 |Propensity to adverse reactions| MINUS
<< 473010000 |Hypersensitivity condition| MINUS
<< 79899007 |Drug interaction| MINUS
<< 69449002 |Drug action| MINUS
<< 441742003 |Evaluation finding| MINUS
<< 307824009 |Administrative status| MINUS
<< 385356007 |Tumor stage finding|)
OR < 413350009 |Finding with explicit context|
OR < 272379006 |Event|
- v2: PRB-3
- rim: .value
- sct-attr: 246090004
- w5: what
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description xml:id (or equivalent in JSON) Definition unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Note that FHIR strings may not exceed 1MB in size
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
|
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idShort description Additional Content defined by implementations Alternate names extensions, user content Definition 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.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| coding | Σ | 1..1 | Coding | There are no (further) constraints on this element Element idShort description Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| text | Σ | 1..1 | string | There are no (further) constraints on this element Element idShort description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Very often the text is the same as a displayName of one of the codings.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| bodySite | Σ | 0..* | CodeableConcept | Element idShort description Anatomical location, if relevant Definition Localización anatómica estructurada para el problema de salud.
PDTE: confirmar datos del mapeo o listado de snomed
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.
CodeableConcept Binding Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Izquierdo{
"text": "Izquierdo"
}
Derecho{
"text": "Derecho"
}
Bilateral{
"text": "Bilateral"
}
Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept: < 442083009 |Anatomical or acquired body structure|
- rim: .targetBodySiteCode
- sct-attr: 363698007
|
| subject | Σ I | 1..1 | Reference(Patient) | Element idShort description Who has the condition? Alternate names patient Definition Indicates the patient or group who the condition record is associated with.
Identificador único de paciente de IB-Salut. Debe cumplir con la codificación específica de este tipo de identificador.
Group is typically used for veterinary or public health use cases.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Patient) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2: PID-3
- rim: .participation[typeCode=SBJ].role[classCode=PAT]
- w5: who.focus
|
| context | Σ I | 0..1 | Reference(Encounter | EpisodeOfCare) | There are no (further) constraints on this element Element idShort description Encounter or episode when condition first asserted Alternate names encounter Definition 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".
Reference(Encounter | EpisodeOfCare) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2: PV1-19 (+PV1-54)
- rim: .inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
- w5: context
|
| onsetDateTime | Σ | 1..1 | dateTimePattern | Element idCondition.onset[x]:onsetDateTime Estimated or actual date, date-time, or age Definition Fecha y hora en las cuales el problema de salud fue reconocido por un profesional de la salud. Es la fecha de mecanización en el sistema de información de la historia clínica.
Age is generally used when the patient reports an age at which the Condition began to occur.
dateTime Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: PRB-16
- rim: .effectiveTime.low or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at onset"].value
- w5: when.init
|
| abatementDateTime | I | 0..1 | dateTime | Element idCondition.abatement[x]:abatementDateTime If/when in resolution/remission Definition Fecha y hora estimadas o confirmadas en las cuales este problema de salud remitió o se resolvió, determinadas por un profesional de la salud.
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.
dateTime Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- rim: .effectiveTime.high or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at remission"].value or .inboundRelationship[typeCode=SUBJ]source[classCode=CONC, moodCode=EVN].status=completed
- w5: when.done
|
| assertedDate | Σ | 0..1 | dateTime | Element idShort description Date record was believed accurate Definition Fecha y hora estimada o confirmadas en las cuales los signos o sintomas del problema fueron observados por primera vez.
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.
dateTime Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: REL-11
- rim: .participation[typeCode=AUT].time
- w5: when.recorded
|
| asserter | Σ I | 0..1 | Reference(Practitioner | Patient | RelatedPerson) | There are no (further) constraints on this element Element idShort description Person who asserts this condition Definition Individual who is making the condition statement.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Practitioner | Patient | RelatedPerson) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2: REL-7.1 identifier + REL-7.12 type code
- rim: .participation[typeCode=AUT].role
- w5: who.author
|
| stage | I | 0..1 | BackboneElement | Element idShort description Stage/grade, usually assessed formally Definition Un problema de salud se considera primario cuando no es consecuencia directa de otro problema de salud o se desconoce esa relación y secundario cuando se conoce esa relación.
Ejemplo: Una neumonía podría ser un problema de salud primaria, en cuyo contexto la fiebre, la tos y el dolor pleurítico serían problemas de salud secundarios. A su vez una neumonía podría ser un problema secundario a una neoplasia con obstrucción bronquial.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - con-1: Stage SHALL have summary or assessment
summary.exists() or assessment.exists()
- rim: n/a
- rim: ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage/grade"]
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description xml:id (or equivalent in JSON) Definition unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Note that FHIR strings may not exceed 1MB in size
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
|
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.extension Additional Content defined by implementations Alternate names extensions, user content Definition 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.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.modifierExtension Extensions that cannot be ignored Alternate names extensions, user content, modifiers Definition 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.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| summary | I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idShort description Simple summary (disease specific) Definition A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
CodeableConcept Binding Codes describing condition stages (e.g. Cancer stages). Condition Stage (example)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept: < 254291000 |Staging and scales|
- v2: PRB-14
- rim: .value
|
| assessment | I | 1..1 | Reference(ValueSet) | Element idCondition.stage.assessment Formal record of assessment Definition Reference to a formal record of the evidence on which the staging assessment is based.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(ValueSet) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Primario{
"reference": "Primario",
"display": "Primario"
}
Secundario{
"reference": "Secundario",
"display": "Secundario"
}
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .self
|
| evidence | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idShort description Supporting evidence Definition 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.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - con-2: evidence SHALL have code or details
code.exists() or detail.exists()
- rim: n/a
- rim: .outboundRelationship[typeCode=SPRT].target[classCode=OBS, moodCode=EVN]
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description xml:id (or equivalent in JSON) Definition unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Note that FHIR strings may not exceed 1MB in size
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
|
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.extension Additional Content defined by implementations Alternate names extensions, user content Definition 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.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.modifierExtension Extensions that cannot be ignored Alternate names extensions, user content, modifiers Definition 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.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| code | Σ I | 0..* | CodeableConcept | There are no (further) constraints on this element Element idShort description Manifestation/symptom Definition A manifestation or symptom that led to the recording of this condition.
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
CodeableConcept Binding Codes that describe the manifestation or symptoms of a condition. Manifestation and Symptom Codes (example)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- sct-concept: < 404684003 |Clinical finding|
- rim: [code="diagnosis"].value
- w5: why
|
| detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idCondition.evidence.detail Supporting information found elsewhere Definition Links to other relevant information, including pathology reports.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Resource) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .self
- w5: why
|
| note | | 0..* | Annotation | Element idShort description Additional information about the Condition Definition Comments For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
Annotation Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
- rim: n/a
- v2: N/A
- rim: Act
- v2: NTE child of PRB
- rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
|
