Condition
A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern
Scope and Usage
This resource is used to record detailed information about a condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. The condition could be a point in time diagnosis in context of an encounter, it could be an item on the practitioner’s Problem List, or it could be a concern that doesn’t exist on the practitioner’s Problem List. Oftentimes, a condition is about a clinician's assessment and assertion of a particular aspect of a patient's state of health. It can be used to record information about a disease/illness identified from application of clinical reasoning over the pathologic and pathophysiologic findings (diagnosis), or identification of health issues/situations that a practitioner considers harmful, potentially harmful and may be investigated and managed (problem), or other health issue/situation that may require ongoing monitoring and/or management (health issue/concern).
The condition resource may be used to record a certain health state of a patient which does not normally present a negative outcome, e.g. pregnancy. The condition resource may be used to record a condition following a procedure, such as the condition of Amputee-BKA following an amputation procedure.
While conditions are frequently a result of a clinician's assessment and assertion of a particular aspect of a patient's state of health, conditions can also be expressed by the patient, related person, or any care team member. A clinician may have a concern about a patient condition (e.g. anorexia) that the patient is not concerned about. Likewise, the patient may have a condition (e.g. hair loss) that does not rise to the level of importance such that it belongs on a practitioner’s Problem List.
For example, each of the following conditions could rise to the level of importance such that it belongs on a problem or concern list due to its direct or indirect impact on the patient’s health:
- Unemployed
- Without transportation (or other barriers)
- Susceptibility to falls
- Exposure to communicable disease
- Family History of cardiovascular disease
- Fear of cancer
- Cardiac pacemaker
- Amputee-BKA
- Risk of Zika virus following travel to a country
- Former smoker
- Travel to a country planned (that warrants immunizations)
- Motor Vehicle Accident
- Patient has had coronary bypass graft
Resource content
These are different views on this resource:
PH_Condition (Condition) | I | Condition | |
id | Σ | 0..1 | string |
meta | Σ | 0..1 | Meta |
implicitRules | Σ ?! | 0..1 | uri |
language | 0..1 | codeBinding | |
text | 0..1 | Narrative | |
contained | 0..* | Resource | |
extension | I | 0..* | Extension |
extOrganization | I | 0..* | Extension(Reference(Organization)) |
modifierExtension | ?! I | 0..* | Extension |
identifier | Σ | 0..* | Identifier |
clinicalStatus | Σ ?! I | 0..1 | CodeableConceptBinding |
verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding |
category | 0..* | CodeableConceptBinding | |
severity | 0..1 | CodeableConceptBinding | |
code | Σ | 0..1 | CodeableConcept |
bodySite | Σ | 0..* | CodeableConcept |
subject | Σ I | 1..1 | Reference(Patient | Group) |
encounter | Σ I | 0..1 | Reference(Encounter) |
onset[x] | Σ | 0..1 | |
onsetDateTime | dateTime | ||
onsetAge | Age | ||
onsetPeriod | Period | ||
onsetRange | Range | ||
onsetString | string | ||
abatement[x] | I | 0..0 | |
recordedDate | Σ | 0..1 | dateTime |
recorder | Σ I | 0..0 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
asserter | Σ I | 0..0 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
stage | I | 0..0 | BackboneElement |
evidence | I | 0..0 | BackboneElement |
note | 0..* | Annotation |
Condition | |
Definition | A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. |
Cardinality | 0...* |
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Condition.id | |
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. |
Cardinality | 0...1 |
Type | string |
Summary | True |
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
Condition.meta | |
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. |
Cardinality | 0...1 |
Type | Meta |
Summary | True |
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Condition.implicitRules | |
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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Cardinality | 0...1 |
Type | uri |
Modifier | True |
Summary | True |
Comments | 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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
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Condition.language | |
Definition | The base language in which the resource is written. |
Cardinality | 0...1 |
Type | code |
Binding | A human language. |
Comments | 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). |
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Condition.text | |
Definition | A human-readable narrative that contains a summary of the resource and can 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. |
Cardinality | 0...1 |
Type | Narrative |
Alias | narrative, html, xhtml, display |
Comments | 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 information is added later. |
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Condition.contained | |
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. |
Cardinality | 0...* |
Type | Resource |
Alias | inline resources, anonymous resources, contained resources |
Comments | 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. |
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Condition.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, user content |
Comments | 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. |
Slicing | Unordered, Open, by url(Value) |
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Condition.extension:extOrganization | |
Definition | Health facility where the encounter was |
Cardinality | 0...* |
Type | Extension(Reference(Organization)) |
Alias | extensions, user content |
Comments | This is an extension |
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Condition.modifierExtension | |
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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Cardinality | 0...* |
Type | Extension |
Modifier | True |
Alias | extensions, user content |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Comments | 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. |
Slicing | Unordered, Open, by url(Value) |
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Condition.identifier | |
Definition | Business identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server. |
Cardinality | 0...* |
Type | Identifier |
Summary | True |
Requirements | Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. |
Comments | This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. |
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Condition.clinicalStatus | |
Definition | The clinical status of the condition. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | The clinical status of the condition or diagnosis. |
Modifier | True |
Summary | True |
Comments | The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. |
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Condition.verificationStatus | |
Definition | The verification status to support the clinical status of the condition. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | The verification status to support or decline the clinical status of the condition or diagnosis. |
Modifier | True |
Summary | True |
Comments | verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. |
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Condition.category | |
Definition | A category assigned to the condition. |
Cardinality | 0...* |
Type | CodeableConcept |
Binding | A category assigned to the condition. |
Comments | The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. |
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Condition.severity | |
Definition | A subjective assessment of the severity of the condition as evaluated by the clinician. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | A subjective assessment of the severity of the condition as evaluated by the clinician. |
Comments | Coding of the severity with a terminology is preferred, where possible. |
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Condition.code | |
Definition | Identification of the condition, problem or diagnosis. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Identification of the condition or diagnosis. |
Summary | True |
Alias | type |
Requirements | 0..1 to account for primarily narrative only resources. |
Comments | 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. |
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Condition.bodySite | |
Definition | The anatomical location where this condition manifests itself. |
Cardinality | 0...* |
Type | CodeableConcept |
Binding | Codes describing anatomical locations. May include laterality. |
Summary | True |
Comments | 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 bodySite. May be a summary code, or a reference to a very precise definition of the location, or both. |
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Condition.subject | |
Definition | Indicates the patient or group who the condition record is associated with. |
Cardinality | 1...1 |
Type | Reference(Patient | Group) |
Summary | True |
Alias | patient |
Requirements | Group is typically used for veterinary or public health use cases. |
Comments | 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. |
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Condition.encounter | |
Definition | The Encounter during which this Condition was created or to which the creation of this record is tightly associated. |
Cardinality | 0...1 |
Type | Reference(Encounter) |
Summary | True |
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. 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". |
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Condition.onset[x] | |
Definition | Estimated or actual date or date-time the condition began, in the opinion of the clinician. |
Cardinality | 0...1 |
Type | dateTime |
Summary | True |
Comments | Age is generally used when the patient reports an age at which the Condition began to occur. |
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Condition.abatement[x] | |
Definition | 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. |
Cardinality | 0...0 |
Type | dateTime |
Comments | 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. |
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Condition.recordedDate | |
Definition | The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date. |
Cardinality | 0...1 |
Type | dateTime |
Summary | True |
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Condition.recorder | |
Definition | Individual who recorded the record and takes responsibility for its content. |
Cardinality | 0...0 |
Type | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
Summary | True |
Comments | 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. |
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Condition.asserter | |
Definition | Individual who is making the condition statement. |
Cardinality | 0...0 |
Type | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
Summary | True |
Comments | 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. |
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Condition.stage | |
Definition | Clinical stage or grade of a condition. May include formal severity assessments. |
Cardinality | 0...0 |
Type | BackboneElement |
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Condition.stage.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Cardinality | 0...1 |
Type | string |
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Condition.stage.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, user content |
Comments | 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. |
Slicing | Unordered, Open, by url(Value) |
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Condition.stage.modifierExtension | |
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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Cardinality | 0...* |
Type | Extension |
Modifier | True |
Summary | True |
Alias | extensions, user content, modifiers |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Comments | 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. |
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Condition.stage.summary | |
Definition | A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Codes describing condition stages (e.g. Cancer stages). |
Comments | 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. |
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Condition.stage.assessment | |
Definition | Reference to a formal record of the evidence on which the staging assessment is based. |
Cardinality | 0...* |
Type | Reference(ClinicalImpression | DiagnosticReport | Observation) |
Comments | 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. |
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Condition.stage.type | |
Definition | The kind of staging, such as pathological or clinical staging. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Codes describing the kind of condition staging (e.g. clinical or pathological). |
Comments | 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. |
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Condition.evidence | |
Definition | Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. |
Cardinality | 0...0 |
Type | BackboneElement |
Comments | The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. |
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Condition.evidence.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Cardinality | 0...1 |
Type | string |
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Condition.evidence.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, user content |
Comments | 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. |
Slicing | Unordered, Open, by url(Value) |
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Condition.evidence.modifierExtension | |
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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Cardinality | 0...* |
Type | Extension |
Modifier | True |
Summary | True |
Alias | extensions, user content, modifiers |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Comments | 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. |
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Condition.evidence.code | |
Definition | A manifestation or symptom that led to the recording of this condition. |
Cardinality | 0...* |
Type | CodeableConcept |
Binding | Codes that describe the manifestation or symptoms of a condition. |
Summary | True |
Comments | 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. |
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Condition.evidence.detail | |
Definition | Links to other relevant information, including pathology reports. |
Cardinality | 0...* |
Type | Reference(Resource) |
Summary | True |
Comments | 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. |
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Condition.note | |
Definition | Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. |
Cardinality | 0...* |
Type | Annotation |
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). |
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<StructureDefinition xmlns="http://hl7.org/fhir"> <url value="https://example.org/fhir/StructureDefinition/PH_Condition" /> <name value="PH_Condition" /> <status value="draft" /> <fhirVersion value="4.0.1" /> <kind value="resource" /> <abstract value="false" /> <type value="Condition" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Condition" /> <derivation value="constraint" /> <differential> <element id="Condition.extension:extOrganization"> <path value="Condition.extension" /> <sliceName value="extOrganization" /> <short value="Health facility where the encounter was" /> <definition value="Health facility where the encounter was" /> <comment value="This is an extension" /> <type> <code value="Extension" /> <profile value="https://example.org/fhir/StructureDefinition/Ext_Organization" /> </type> <isModifier value="false" /> </element> <element id="Condition.abatement[x]"> <path value="Condition.abatement[x]" /> <max value="0" /> </element> <element id="Condition.recorder"> <path value="Condition.recorder" /> <max value="0" /> </element> <element id="Condition.asserter"> <path value="Condition.asserter" /> <max value="0" /> </element> <element id="Condition.stage"> <path value="Condition.stage" /> <max value="0" /> </element> <element id="Condition.evidence"> <path value="Condition.evidence" /> <max value="0" /> </element> </differential> </StructureDefinition>
{ "resourceType": "StructureDefinition", "url": "https://example.org/fhir/StructureDefinition/PH_Condition", "name": "PH_Condition", "status": "draft", "fhirVersion": "4.0.1", "kind": "resource", "abstract": false, "type": "Condition", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Condition", "derivation": "constraint", "differential": { "element": [ { "id": "Condition.extension:extOrganization", "path": "Condition.extension", "sliceName": "extOrganization", "short": "Health facility where the encounter was", "definition": "Health facility where the encounter was", "comment": "This is an extension", "type": [ { "code": "Extension", "profile": [ "https://example.org/fhir/StructureDefinition/Ext_Organization" ] } ], "isModifier": false }, { "id": "Condition.abatement[x]", "path": "Condition.abatement[x]", "max": "0" }, { "id": "Condition.recorder", "path": "Condition.recorder", "max": "0" }, { "id": "Condition.asserter", "path": "Condition.asserter", "max": "0" }, { "id": "Condition.stage", "path": "Condition.stage", "max": "0" }, { "id": "Condition.evidence", "path": "Condition.evidence", "max": "0" } ] } }