Condition (MY Core)
Defining URL | http://fhir.hie.moh.gov.my/StructureDefinition/Condition-my-core |
Version | 1.0.0 |
Name | ConditionMyCore |
Definition | A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. |
Title | Condition (MY Core) |
Status | Active as of 11-3-2022 |
Publisher | Malaysia MOH - HIE Steering Committee |
Copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
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:audit | |
Definition | Extension of the individual who recorded and updated the date |
Cardinality | 0...1 |
Type | Extension(Complex) |
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. |
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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 | 1...1 |
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.code.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.code.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.code.coding | |
Definition | A reference to a code defined by a terminology system. |
Cardinality | 0...* |
Type | Coding |
Summary | True |
Requirements | Allows for alternative encodings within a code system, and translations to other code systems. |
Comments | 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. |
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Condition.code.coding.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.code.coding.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.code.coding.system | |
Definition | The identification of the code system that defines the meaning of the symbol in the code. |
Cardinality | 0...1 |
Type | uri |
Summary | True |
Requirements | Need to be unambiguous about the source of the definition of the symbol. |
Comments | 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 reference to some definition that establishes the system clearly and unambiguously. |
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Condition.code.coding.version | |
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. |
Cardinality | 0...1 |
Type | string |
Summary | True |
Comments | 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. |
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Condition.code.coding.code | |
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). |
Cardinality | 1...1 |
Type | code |
Summary | True |
Requirements | Need to refer to a particular code in the system. |
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size |
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Condition.code.coding.display | |
Definition | A representation of the meaning of the code in the system, following the rules of the system. |
Cardinality | 1...1 |
Type | string |
Summary | True |
Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system. |
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size |
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Condition.code.coding.userSelected | |
Definition | Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). |
Cardinality | 0...1 |
Type | boolean |
Summary | True |
Requirements | 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. |
Comments | 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. |
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Condition.code.text | |
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. |
Cardinality | 1...1 |
Type | string |
Summary | True |
Requirements | 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. |
Comments | Very often the text is the same as a displayName of one of the codings. |
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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...1 |
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...1 |
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...1 |
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...* |
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...* |
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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Condition.note.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.note.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.note.author[x] | |
Definition | The individual responsible for making the annotation. |
Cardinality | 0...1 |
Type | Reference(Practitioner | Patient | RelatedPerson | Organization | http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner) |
Summary | True |
Comments | Organization is used when there's no need for specific attribution as to who made the comment. |
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Condition.note.time | |
Definition | Indicates when this particular annotation was made. |
Cardinality | 0...1 |
Type | dateTime |
Summary | True |
Invariants |
|
Mappings |
|
Condition.note.text | |
Definition | The text of the annotation in markdown format. |
Cardinality | 1...1 |
Type | markdown |
Summary | True |
Comments | Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/ |
Invariants |
|
Mappings |
|
example-condition-comorbidities
example-condition-encounter-diagnosis
example-condition-death-diagnosis
<StructureDefinition xmlns="http://hl7.org/fhir"> <id value="Condition-my-core" /> <meta> <versionId value="1" /> <lastUpdated value="2024-03-06T09:34:02.0518571+00:00" /> </meta> <text> <status value="generated" /> --- We have skipped the narrative for better readability of the resource --- </text> <url value="http://fhir.hie.moh.gov.my/StructureDefinition/Condition-my-core" /> <version value="1.0.0" /> <name value="ConditionMyCore" /> <title value="Condition (MY Core)" /> <status value="active" /> <date value="2024-03-13T01:41:41.3395961+00:00" /> <publisher value="Malaysia MOH - HIE Steering Committee" /> <description value="This profile represents the constraints applied to the Condition resource by MY Core FHIR Implementation Guide and describes the minimum expectations for the Patient resource when used in the MY Core composition or in one of the referred resources." /> <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:audit"> <path value="Condition.extension" /> <sliceName value="audit" /> <short value="Extension of the individual who recorded and updated the date" /> <definition value="Extension of the individual who recorded and updated the date" /> <max value="1" /> <type> <code value="Extension" /> <profile value="http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core" /> </type> <isModifier value="false" /> </element> <element id="Condition.category"> <path value="Condition.category" /> <min value="1" /> <max value="1" /> <binding> <strength value="required" /> <valueSet value="http://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core" /> </binding> </element> <element id="Condition.code.coding.code"> <path value="Condition.code.coding.code" /> <min value="1" /> </element> <element id="Condition.code.coding.display"> <path value="Condition.code.coding.display" /> <min value="1" /> </element> <element id="Condition.code.text"> <path value="Condition.code.text" /> <min value="1" /> </element> <element id="Condition.note.author[x]"> <path value="Condition.note.author[x]" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Practitioner" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/RelatedPerson" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Organization" /> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner" /> <aggregation value="referenced" /> </type> <type> <code value="string" /> </type> </element> </differential> </StructureDefinition>
{ "resourceType": "StructureDefinition", "id": "Condition-my-core", "meta": { "versionId": "1", "lastUpdated": "2024-03-06T09:34:02.0518571+00:00" }, "text": { "status": "generated", --- We have skipped the narrative for better readability of the resource --- }, "url": "http://fhir.hie.moh.gov.my/StructureDefinition/Condition-my-core", "version": "1.0.0", "name": "ConditionMyCore", "title": "Condition (MY Core)", "status": "active", "date": "2024-03-13T01:41:41.3395961+00:00", "publisher": "Malaysia MOH - HIE Steering Committee", "description": "This profile represents the constraints applied to the Condition resource by MY Core FHIR Implementation Guide and describes the minimum expectations for the Patient resource when used in the MY Core composition or in one of the referred resources.", "fhirVersion": "4.0.1", "kind": "resource", "abstract": false, "type": "Condition", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Condition", "derivation": "constraint", "differential": { "element": [ { "id": "Condition.extension:audit", "path": "Condition.extension", "sliceName": "audit", "short": "Extension of the individual who recorded and updated the date", "definition": "Extension of the individual who recorded and updated the date", "max": "1", "type": [ { "code": "Extension", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core" ] } ], "isModifier": false }, { "id": "Condition.category", "path": "Condition.category", "min": 1, "max": "1", "binding": { "strength": "required", "valueSet": "http://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core" } }, { "id": "Condition.code.coding.code", "path": "Condition.code.coding.code", "min": 1 }, { "id": "Condition.code.coding.display", "path": "Condition.code.coding.display", "min": 1 }, { "id": "Condition.code.text", "path": "Condition.code.text", "min": 1 }, { "id": "Condition.note.author[x]", "path": "Condition.note.author[x]", "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner" ], "aggregation": [ "referenced" ] }, { "code": "string" } ] } ] } }
Snapshot
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 |
audit | I | 0..1 | Extension(Complex) |
modifierExtension | ?! I | 0..* | Extension |
identifier | Σ | 0..* | Identifier |
clinicalStatus | Σ ?! I | 0..1 | CodeableConceptBinding |
verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding |
category | 1..1 | CodeableConceptBinding | |
severity | 0..1 | CodeableConceptBinding | |
code | Σ | 0..1 | CodeableConcept |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | Σ | 0..* | Coding |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | Σ | 0..1 | uri |
version | Σ | 0..1 | string |
code | Σ | 1..1 | code |
display | Σ | 1..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 1..1 | string |
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..1 | |
abatementDateTime | dateTime | ||
abatementAge | Age | ||
abatementPeriod | Period | ||
abatementRange | Range | ||
abatementString | string | ||
recordedDate | Σ | 0..1 | dateTime |
recorder | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
asserter | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
stage | I | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
summary | I | 0..1 | CodeableConcept |
assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) |
type | 0..1 | CodeableConcept | |
evidence | I | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
code | Σ I | 0..* | CodeableConcept |
detail | Σ I | 0..* | Reference(Resource) |
note | 0..* | Annotation | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
author[x] | Σ | 0..1 | |
authorString | string | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization | http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner) | ||
time | Σ | 0..1 | dateTime |
text | Σ | 1..1 | markdown |
Diff
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 |
audit | I | 0..1 | Extension(Complex) |
modifierExtension | ?! I | 0..* | Extension |
identifier | Σ | 0..* | Identifier |
clinicalStatus | Σ ?! I | 0..1 | CodeableConceptBinding |
verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding |
category | 1..1 | CodeableConceptBinding | |
severity | 0..1 | CodeableConceptBinding | |
code | Σ | 0..1 | CodeableConcept |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | Σ | 0..* | Coding |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | Σ | 0..1 | uri |
version | Σ | 0..1 | string |
code | Σ | 1..1 | code |
display | Σ | 1..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 1..1 | string |
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..1 | |
abatementDateTime | dateTime | ||
abatementAge | Age | ||
abatementPeriod | Period | ||
abatementRange | Range | ||
abatementString | string | ||
recordedDate | Σ | 0..1 | dateTime |
recorder | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
asserter | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
stage | I | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
summary | I | 0..1 | CodeableConcept |
assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) |
type | 0..1 | CodeableConcept | |
evidence | I | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
code | Σ I | 0..* | CodeableConcept |
detail | Σ I | 0..* | Reference(Resource) |
note | 0..* | Annotation | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
author[x] | Σ | 0..1 | |
authorString | string | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization | http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner) | ||
time | Σ | 0..1 | dateTime |
text | Σ | 1..1 | markdown |
Hybrid
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 |
audit | I | 0..1 | Extension(Complex) |
modifierExtension | ?! I | 0..* | Extension |
identifier | Σ | 0..* | Identifier |
clinicalStatus | Σ ?! I | 0..1 | CodeableConceptBinding |
verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding |
category | 1..1 | CodeableConceptBinding | |
severity | 0..1 | CodeableConceptBinding | |
code | Σ | 0..1 | CodeableConcept |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | Σ | 0..* | Coding |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | Σ | 0..1 | uri |
version | Σ | 0..1 | string |
code | Σ | 1..1 | code |
display | Σ | 1..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 1..1 | string |
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..1 | |
abatementDateTime | dateTime | ||
abatementAge | Age | ||
abatementPeriod | Period | ||
abatementRange | Range | ||
abatementString | string | ||
recordedDate | Σ | 0..1 | dateTime |
recorder | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
asserter | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
stage | I | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
summary | I | 0..1 | CodeableConcept |
assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) |
type | 0..1 | CodeableConcept | |
evidence | I | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
code | Σ I | 0..* | CodeableConcept |
detail | Σ I | 0..* | Reference(Resource) |
note | 0..* | Annotation | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
author[x] | Σ | 0..1 | |
authorString | string | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization | http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner) | ||
time | Σ | 0..1 | dateTime |
text | Σ | 1..1 | markdown |
This profile is derived from the base FHIR Condition resource.
Requirements
This structure defines these element as mandatory requirement:
- A category (
category
) - The code
code.coding.code
,code.coding.display
andcode.text
must all exist.- The code system
code.coding.system
is not specified as it may be of ICD-10, ICD-11 or other local or international code system. Currently HIE scope is to allow Continuation Of Care (COC) between facility (record sharing) as one of the main functional priority indiscriminate of code system.
- The code system
- A subject referenced (
subject
)
Extension
This structure includes the following extension:
Type of Condition
Currently there are 4 different types of condition defined in HIE;
- Comorbidities
problem-list-item
- Encounter Diagnosis
encounter-diagnosis
- Death Diagnosis
death-certificate
- Dental Alert
dental-alert
The category is defined from category e.g.:
condition.coding.code="problem-list-item"
Comorbidities
In clinical context, the term "comorbid" has three definitions:
- to indicate a medical condition existing simultaneously but independently with another condition in a patient.
- to indicate a medical condition in a patient that causes, is caused by, or is otherwise related to another condition in the same patient.
- to indicate two or more medical conditions existing simultaneously regardless of their causal relationship.
In HIE context, comorbidities are condition that are independant of an encounter e.g. a chronic illness such as diabetes mellitus or asthma that clinician should take into consideration when attending a despite not being the main condition of the patient visit
Condition defined as comorbidities requires:
- The category as "problem-list-item"
category.coding.code="problem-list-item"
wherecategory.coding.system="http://terminology.hl7.org/CodeSystem/condition-category"
. - The code
code.coding.code
,code.coding.display
andcode.text
must all exist. - A subject referenced (
subject
).
Comorbidities Sample Data
{ "resourceType": "Condition", "id": "example-condition-pl", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/Condition-my-core" ] }, "extension": [ { "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core", "extension": [ { "url": "lastUpdater", "valueReference": { "display": "SAIFULDAULAH BIN MOHD HAFIZ NGOO" } } ] } ], "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active", "display": "Active" } ] }, "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-category", "code": "problem-list-item", "display": "Comorbidities Item" } ] } ], "code": { "coding": [ { "system": "http://id.who.int/icd/entity/119724091", "code": "5A11", "display": "Type 2 diabetes mellitus" } ], "text": "Type 2 diabetes mellitus" }, "subject": { "reference": "Patient/219ac63e-91c7-4db8-93ab-4c9892ecbfb6" }, "recordedDate": "2023-09-12T13:23:45+08:00", "recorder": { "type": "PractitionerRole", "display": "SAIFULDAULAH BIN MOHD HAFIZ NGOO" }, "note": [ { "authorReference": { "display": "SAIFULDAULAH BIN MOHD HAFIZ NGOO" }, "time": "2023-09-12T13:23:45+08:00", "text": "<p>Patient on OHA x2years</p><p><br></p><p>T metformin 2tab BD</p>" } ] }
Encounter Diagnosis
FHIR defines Encounter Diagnosis as a point in time diagnosis (e.g. from a physician or nurse) in context of an encounter.
Condition defined as encounter diagnosis requires:
- The category as "encounter-diagnosis"
category.coding.code="encounter-diagnosis"
wherecategory.coding.system="http://terminology.hl7.org/CodeSystem/condition-category"
. - The code
code.coding.code
,code.coding.display
andcode.text
must all exist. - A subject referenced (
subject
). - An encounter referenced (
encounter
).
As encounter diagnosis Condition is directly related to an Encounter, the related Encounter is required to:
- Reference the Condition
Encounter.diagnosis.condition.reference
. - Define the role of the Condition in relation to the Diagnosis
Encounter.diagnosis.use.coding.code
based on CodeSystemDiagnosisRole (MY Core). - If multiple Encounter Diagnosis exist, each condition will be an array of its own under Encounter.diagnosis
Encounter Diagnosis Sample Data
{ "resourceType": "Condition", "id": "example-condition-ed", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/Condition-my-core" ] }, "extension": [ { "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core", "extension": [ { "url": "lastUpdater", "valueReference": { "display": "LIANA" } } ] } ], "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active", "display": "active" } ] }, "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-category", "code": "encounter-diagnosis", "display": "Encounter Diagnosis" } ] } ], "code": { "coding": [ { "system": "http://id.who.int/icd/release/11/2022-02/mms/383352795", "code": "1D47", "display": "Yellow fever" } ], "text": "Yellow fever" }, "subject": { "reference": "Patient/1725cc06-9544-4a10-b8e7-6fe5506d4749" }, "encounter": { "reference": "Encounter/d3162b1f-8a23-46ec-a881-b2c02f63014e" }, "recordedDate": "2023-09-18T15:25:00.000+08:00", "recorder": { "display": "LIANA" } }
Death Diagnosis
Death Diagnosis is similar to Encounter Diagnosis in that it is related to an encounter point in time diagnosis, however it is more specific to the Condition leading to the mortality of a patient.
Condition defined as death diagnosis requires:
- The category as "death-certificate"
category.coding.code="death-certificate"
wherecategory.coding.system="http://fhir.hie.moh.gov.my/CodeSystem/condition-category-my-core"
- The code
code.coding.code
,code.coding.display
andcode.text
must all exist. - A subject referenced (
subject
). - An encounter referenced (
encounter
).
As death diagnosis Condition is directly related to an Encounter, the related Encounter is required to:
- Reference the Condition
Encounter.diagnosis.condition.reference
. - Define the role of the Condition in relation to the Diagnosis
Encounter.diagnosis.use.coding.code
based on CodeSystemDiagnosisRole (MY Core). - If multiple Encounter Diagnosis exist, each condition will be an array of its own under Encounter.diagnosis
Death Diagnosis Sample Data
{ "resourceType": "Condition", "id": "example-condition-dd", "meta": { "versionId": "1", "lastUpdated": "2023-09-18T15:29:16.678+08:00", "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/Condition-my-core" ] }, "text": { "status": "generated", --- We have skipped the narrative for better readability of the resource --- }, "extension": [ { "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core", "extension": [ { "url": "lastUpdater", "valueReference": { "display": "PUTERI NAJWA NABILA" } } ] } ], "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active", "display": "Active" } ] }, "category": [ { "coding": [ { "system": "http://fhir.hie.moh.gov.my/CodeSystem/condition-category-my-core", "code": "death-certificate", "display": "Death Diagnosis" } ] } ], "code": { "coding": [ { "system": "http://id.who.int/icd/release/11/2022-02/mms/2024855916", "code": "RA02", "display": "Post COVID-19 condition" } ], "text": "Post COVID-19 condition" }, "subject": { "reference": "Patient/b369e20b-9c3a-4e4e-9b0e-c51ea28a09d8" }, "encounter": { "reference": "Encounter/b2b7f688-6bc4-4356-84e8-2937df057a1a" }, "recordedDate": "2023-09-18T11:06:00.000+08:00", "recorder": { "display": "PUTERI NAJWA NABILA" } }
Dental Alert
Dental Alert are related to Condition that are highlighted/alerted by the Dental clinicians during their review. It is independant of an Encounter
Condition defined as dental alert requires:
- The category as "dental-alert"
category.coding.code="dental-alert"
wherecategory.coding.system="http://fhir.hie.moh.gov.my/CodeSystem/condition-category-my-core"
- Another category with the code based on any of the defined CodeSystemDentalAlertCode (MY Core).
- If the category is "dental-history" with
category.system="http://fhir.hie.moh.gov.my/CodeSystem/dental-alert-code-my-core"
, thencode.coding.code
must be based of CodeSystemDentalHistoryAlert (MY Core) withcode.coding.system="http://fhir.hie.moh.gov.my/CodeSystem/dental-history-alert-my-core"
- The code text
code.text
must exist. - A subject referenced (
subject
).
Dental Alert Sample Data 1
{ "resourceType": "Condition", "id": "example-condition-da-1", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/Condition-my-core" ] }, "extension": [ { "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core", "extension": [ { "url": "lastUpdater", "valueReference": { "display": "LIANA" } } ] } ], "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active", "display": "Active" } ] }, "category": [ { "coding": [ { "system": "http://fhir.hie.moh.gov.my/CodeSystem/condition-category-my-core", "code": "dental-alert", "display": "Dental Alert" } ] }, { "coding": [ { "system": "http://fhir.hie.moh.gov.my/CodeSystem/dental-alert-code-my-core", "code": "dental-history", "display": "Dental History" } ] } ], "code": { "coding": [ { "system": "http://fhir.hie.moh.gov.my/CodeSystem/dental-history-alert-my-core", "code": "7", "display": "Previous Endodontics" } ], "text": "Previous Endodontics" }, "subject": { "reference": "Patient/1725cc06-9544-4a10-b8e7-6fe5506d4749" }, "recordedDate": "2023-08-13T13:01:54+08:00", "recorder": { "display": "LIANA" } }
Dental Alert Sample Data 2
{ "resourceType": "Condition", "id": "example-condition-da-2", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/Condition-my-core" ] }, "extension": [ { "url": "http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core", "extension": [ { "url": "lastUpdater", "valueReference": { "display": "NIZAR" } } ] } ], "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active", "display": "Active" } ] }, "category": [ { "coding": [ { "system": "http://fhir.hie.moh.gov.my/CodeSystem/condition-category-my-core", "code": "dental-alert", "display": "Dental Alert" } ] }, { "coding": [ { "system": "http://fhir.hie.moh.gov.my/CodeSystem/dental-alert-code-my-core", "code": "family-medical-alert", "display": "Family Medical Alert" } ] } ], "code": { "text": "mother has congenital cavities" }, "subject": { "reference": "Patient/b4be86c9-f018-4ef5-a911-6c0c061cd018" }, "recordedDate": "2023-09-07T14:39:45+08:00", "recorder": { "display": "NIZAR" } }