DwCondition

Purpose

The purpose of this resource to provide a current and past clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. This will be used to convey both encounter diagnosis as well as problem list items from the patient profile and these will be differentiated by category.

idS Σ1..1id
id0..1string
extensionC0..*Extension
versionIdΣ0..1id
lastUpdatedS Σ0..1instant
sourceS Σ0..1uri
profileΣ0..*canonical(StructureDefinition)
securityS Σ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
textS0..1Narrative
contained0..*Resource
extensionC0..*Extension
modifierExtension?! C0..*Extension
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemS Σ1..1uri
valueS Σ1..1string
periodΣ C0..1Period
assignerΣ C0..1Reference(Organization)
clinicalStatusS Σ ?! C0..1CodeableConceptBinding
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ0..1uri
versionΣ0..1string
codeΣ0..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
categoryS0..*CodeableConceptBinding
severityS0..1CodeableConceptBinding
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ0..1code
id0..1string
id0..1string
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueCodecode
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueMarkdownmarkdown
valueStringstring
url1..1uriFixed Value
value0..1System.String
userSelectedΣ0..1boolean
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ0..1code
id0..1string
id0..1string
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueCodecode
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueMarkdownmarkdown
valueStringstring
url1..1uriFixed Value
value0..1System.String
userSelectedΣ0..1boolean
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ0..1code
id0..1string
id0..1string
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueCodecode
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueMarkdownmarkdown
valueStringstring
url1..1uriFixed Value
value0..1System.String
userSelectedΣ0..1boolean
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ0..1code
id0..1string
id0..1string
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueCodecode
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueMarkdownmarkdown
valueStringstring
url1..1uriFixed Value
value0..1System.String
userSelectedΣ0..1boolean
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ0..1code
id0..1string
id0..1string
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueCodecode
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueMarkdownmarkdown
valueStringstring
url1..1uriFixed Value
value0..1System.String
userSelectedΣ0..1boolean
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ0..1code
id0..1string
id0..1string
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueCodecode
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueMarkdownmarkdown
valueStringstring
url1..1uriFixed Value
value0..1System.String
userSelectedΣ0..1boolean
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ0..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
bodySiteΣ0..*CodeableConcept
subjectS Σ C1..1Reference(DwPatient)
encounterS Σ C0..1Reference(DwEncounter)
onsetAgeAge
onsetDateTimedateTime
onsetPeriodPeriod
onsetRangeRange
onsetStringstring
abatementAgeAge
abatementDateTimedateTime
abatementPeriodPeriod
abatementRangeRange
abatementStringstring
recordedDateS Σ0..1dateTime
recorderS Σ C0..1Reference(DwPatient | DwPractitioner | DwPractitionerRole)
asserterΣ C0..1Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
summaryC0..1CodeableConcept
assessmentC0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
codeΣ C0..*CodeableConcept
detailΣ C0..*Reference(Resource)
noteS0..*Annotation

Usage note

  • clinicalStatus

  • Clinic status for the |FHIR|MA|PSS|CHR| |- |Active|Current||| |Inactive|Past||| |Remission|Remission||| |Resolved|Past with outcome value "recovered" documented|||

  • condition.code - code slices allows for multiple diagnosis codes to accomodate multiple codes and various clinical workflows. This will be provided when it is documented

    • SNOMED
    • ICD9
    • ICD10
    • ENCODE
  • onset - Depending on the EMR source dateTime, Age, or string will be provided.

    • MedAccess - onset.DateTime
    • PSS - onset.DateTime, onsetAge or onset.string
  • condition.abatement - The resolved date is provided for conditions identified as resolved. Depending on the EMR source format may vary

    • MedAccess - onset.DateTime
    • PSS - onset.DateTime, onsetAge or onset.string
  • condition.note - Additional comments and notes associated to the condition documented in the profile.

Bundle

Condition

Examples

Example EMR
Acute Bronchitis CHR
Type 2 Diabetes Mellitus CHR
Acute Upper Respiratory Infection MA
Essential Hypertension MA

Medical History — CHR UI Navigation

The following table shows where each FHIR element comes from in CHR: the UI path a clinician follows to enter or view the data.

FHIR Path CHR Name CHR UI Navigation
Condition.identifier Medical History Record ID —
Condition.identifier.system — —
Condition.identifier.value — —
Condition.code Diagnoses Patients → select patient → chart → Health Profile → Medical History → Add / select entry
Condition.code.text — —
Condition.clinicalStatus Status Patients → select patient → chart → Health Profile → Medical History → Add / select entry
Condition.clinicalStatus.coding.system — —
Condition.clinicalStatus.coding.code — —
Condition.clinicalStatus.coding.display — —
Condition.clinicalStatus.coding.userSelected — —
Condition.clinicalStatus.text — —
Condition.clinicalStatus (Past) Past (checkbox) Patients → select patient → chart → Health Profile → Medical History → Add / select entry → Past checkbox
Condition.onset[x] Onset Date Patients → select patient → chart → Health Profile → Medical History → Add / select entry → Onset Date field
Condition.onset[x] (life stage) Life Stage Patients → select patient → chart → Health Profile → Medical History → Add / select entry → Additional Fields → Life Stage
Condition.abatement[x] Resolution Date Patients → select patient → chart → Health Profile → Medical History → Add / select entry → Additional Fields → Resolution Date
Condition.note (description) Description Patients → select patient → chart → Health Profile → Medical History → Add / select entry → Additional Fields → Description
Condition.note (notes) Notes Patients → select patient → chart → Health Profile → Medical History → Add / select entry → Notes field
Condition.note (life stage) Life Stage Patients → select patient → chart → Health Profile → Medical History → Add / select entry → Additional Fields → Life Stage
Condition.note (risk_factor) Risk Factor Patients → select patient → chart → Health Profile → Medical History → Add / select entry → Additional Fields → Risk Factor checkbox
Condition.id — —
Condition.meta.source — —
Condition.meta.lastUpdated — —
Condition.meta.security — —
Condition.text — —
Condition.subject — —
Condition.category Category (auto: Problem List Item) Auto-set to 'problem-list-item' — no user input
Condition.category.coding.display Category (auto: Problem List Item) Auto-set to 'Problem List Item' — no user input
Condition.category.text Category (auto: Medical History) Auto-set to 'Medical History' — no user input
Condition.category.coding.system — —
Condition.category.coding.userSelected — —
Condition.verificationStatus — —
Condition.verificationStatus.coding.system — —
Condition.verificationStatus.coding.code — —
Condition.verificationStatus.coding.display — —
Condition.recordedDate — —
Condition.recorder — —
Condition.encounter — —
Condition.severity — —
Condition.code.coding[SNOMEDCode] — —
Condition.code.coding[ICD9Code] — —
Condition.code.coding[ICD10Code] — —
Condition.code.coding[ENCODECode] — —
Condition.code.coding[ICD9CMCode] — —
Condition.code.coding[ICD9CMCode].system — —
Condition.code.coding[ICD9CMCode].code — —
Condition.code.coding[ICD9CMCode].display — —
Condition.code.coding[ICD9CMCode].userSelected — —
Condition.code.coding[ICD9CMCode].display.extension[translation] — —
Condition.code.coding[ICD9BILLCode] — —
Condition.code.coding[absentOrUnknownProblem] Category (auto: No Known Problems) Auto-created for a patient with zero condition records — no user input
Condition.code.coding[absentOrUnknownProblem].system — —
Condition.code.coding[absentOrUnknownProblem].code — —
Condition.code.coding[absentOrUnknownProblem].display — —
Condition.code.coding[absentOrUnknownProblem].userSelected — —

Encounter Diagnosis — CHR UI Navigation

The following table shows where each FHIR element comes from in CHR: the UI path a clinician follows to enter or view the data.

FHIR Path CHR Name CHR UI Navigation
Condition.identifier Encounter Diagnosis ID —
Condition.identifier.system — —
Condition.identifier.value — —
Condition.code Diagnoses Patients → select patient → chart → Encounters → open encounter → Assessment and Plan → add diagnosis
Optional "Add to medical history" toggle on the same screen also creates a linked Medical History entry — producing a second, separate Condition resource via the medical-history path for the same diagnosis
Condition.code.text — —
Condition.clinicalStatus Status (auto: Active) Auto-set to 'active' — no user input; not populated if the diagnosis is later deleted
Condition.clinicalStatus.coding.system — —
Condition.clinicalStatus.coding.code — —
Condition.clinicalStatus.coding.display — —
Condition.clinicalStatus.coding.userSelected — —
Condition.clinicalStatus.text — —
Condition.category Category (auto: Encounter Diagnosis) Auto-set to 'encounter-diagnosis' — no user input
Condition.category.coding.display Category (auto: Encounter Diagnosis) Auto-set to 'Encounter Diagnosis' — no user input
Condition.category.text Category (auto: Encounter Diagnosis) Auto-set to 'Encounter Diagnosis' — no user input
Condition.category.coding.system — —
Condition.category.coding.userSelected — —
Condition.encounter Encounter Reference Auto-linked to the current encounter — no user input
Condition.recorder Recorder Auto-set to the provider who created the encounter — no user input
Condition.asserter — —
Condition.id — —
Condition.meta.source — —
Condition.meta.lastUpdated — —
Condition.meta.security — —
Condition.text — —
Condition.subject — —
Condition.verificationStatus — —
Condition.verificationStatus.coding.system — —
Condition.verificationStatus.coding.code — —
Condition.verificationStatus.coding.display — —
Condition.recordedDate — —
Condition.onset[x] — —
Condition.abatement[x] — —
Condition.note — —
Condition.severity — —
Condition.code.coding[SNOMEDCode] — —
Condition.code.coding[ICD9Code] — —
Condition.code.coding[ICD10Code] — —
Condition.code.coding[ENCODECode] — —
Condition.code.coding[ICD9CMCode] — —
Condition.code.coding[ICD9CMCode].system — —
Condition.code.coding[ICD9CMCode].code — —
Condition.code.coding[ICD9CMCode].display — —
Condition.code.coding[ICD9CMCode].userSelected — —
Condition.code.coding[ICD9CMCode].display.extension[translation] — —
Condition.code.coding[ICD9BILLCode] — —
Condition.code.coding[absentOrUnknownProblem] — —

Medical History — MA UI Navigation

The following table shows where each FHIR element comes from in MA: the UI path a clinician follows to enter or view the data.

FHIR Path MA Name MA UI Navigation
Condition.code Diagnosis / Description Menu → Patients → select patient → Profile → New (Category: Medical) / select entry → Diagnosis field
Condition.clinicalStatus Status Menu → Patients → select patient → Profile → New (Category: Medical) / select entry → Status field
Condition.verificationStatus Confirmation Status Menu → Patients → select patient → Profile → New (Category: Medical) / select entry → Confirmation Status field
Condition.severity Severity Menu → Patients → select patient → Profile → New (Category: Medical) / select entry → Severity field
Condition.onset[x] Onset Date Menu → Patients → select patient → Profile → New (Category: Medical) / select entry → Onset Date field
Condition.abatement[x] Resolved Date Menu → Patients → select patient → Profile → New (Category: Medical) / select entry → Resolved Date field
Condition.note Notes Menu → Patients → select patient → Profile → New (Category: Medical) / select entry → Notes field
Condition.identifier — —
Condition.category Category (auto: Problem List Item) Auto-set to 'problem-list-item' — no user input
Condition.category.text Category (auto) Auto-computed — no user input
Condition.subject — —
Condition.encounter — —
Condition.recordedDate Recorded By Menu → Patients → select patient → Profile → New (Category: Medical) / select entry
Condition.recorder Recorded By Menu → Patients → select patient → Profile → New (Category: Medical) / select entry
Condition.asserter — —
Condition.meta.source — —
Condition.meta.lastUpdated — —
Condition.meta.security — —
Condition.code.coding[SNOMEDCode] — —
Condition.code.coding[ICD9Code] — —
Condition.code.coding[ICD10Code] — —
Condition.code.coding[ENCODECode] — —
Condition.code.coding[ICD9CMCode] — —
Condition.code.coding[ICD9BILLCode] — —
Condition.code.coding[absentOrUnknownProblem] — —

Encounter Diagnosis — MA UI Navigation

The following table shows where each FHIR element comes from in MA: the UI path a clinician follows to enter or view the data.

FHIR Path MA Name MA UI Navigation
Condition.identifier Encounter Diagnosis ID —
Condition.code Diagnoses Menu → Patients → select patient → select encounter → Diagnoses → add diagnosis code
Condition.clinicalStatus Status (auto: Active) Auto-derived: active unless encounter deleted/cancelled — no user input
Condition.category Category (auto: Encounter Diagnosis) Auto-set to 'encounter-diagnosis' — no user input
Condition.category.text Category (auto: Encounter Diagnosis) Auto-set to 'Encounter Diagnosis' — no user input
Condition.encounter Encounter Reference Auto-linked to the current encounter — no user input
Condition.recorder Recorder Auto-set from encounter task revision user — no user input
Condition.asserter Asserter Auto-set from encounter task owner or billing provider — no user input
Condition.recordedDate Recorded Date Auto-set from encounter task start date — no user input
Condition.verificationStatus — Auto-set to 'entered-in-error' if the encounter or diagnosis is deleted or cancelled — no user input
Condition.subject — —
Condition.meta.source — —
Condition.meta.lastUpdated — —
Condition.meta.security — —
Condition.severity — —
Condition.onset[x] — —
Condition.abatement[x] — —
Condition.note — —
Condition.code.coding[SNOMEDCode] — —
Condition.code.coding[ICD9Code] — —
Condition.code.coding[ICD10Code] — —
Condition.code.coding[ENCODECode] — —
Condition.code.coding[ICD9CMCode] — —
Condition.code.coding[ICD9BILLCode] — —
Condition.code.coding[absentOrUnknownProblem] — —