If you have an issue with this template then please raise an issue in Simplifier against this IG by using the 'Propose a Change' link in the footer
Diagnoses
The Diagnoses section carries information about Diagnoses. PRSB Elements should be formatted as subheadings in any HTML sent.
Section | Description | Card. | MRO* | FHIR Target and Guidance |
---|---|---|---|---|
Diagnoses | A list of the patient's diagnoses. | 0..1 | R | Carried in the CodeableConcept of Composition.section.code FHIR element. ValueSet UKCoreCompositionSectionCode |
PRSB Element | Description | Card. | MRO* | FHIR Target and Guidance |
Diagnosis name | Confirmed diagnosis (or symptom); active diagnosis being treated. | 1 only | M | Text and if available a SNOMED CT concept carried in the CodeableConcept of the Condition.code FHIR element. See Condition List(Diagnosis code) . |
Stage | Stage of the disease, where relevant | 0 to 1 | O | Text and if available a SNOMED CT concept carried in the CodeableConcept of the Condition.stage.summary (using the CodeableContext text to hold the stage of disease text) |
Comment | Supporting text may be given covering diagnosis confirmation, active diagnosis being treated. | 0 to 1 | O | Free text. Supporting text may be given covering diagnosis confirmation, active diagnosis being treated. The section text should be repeated in the text of the Condition.note FHIR element to record Free differential and excluded diagnosis. |
* M=Mandatory R=Required O=Optional |
Example Diagnoses Section
{ "resourceType": "Composition", "meta": { "profile": [ "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition" ] }, "status": "final", "type": { "coding": [ { "system": "http://snomed.info/sct", "code": "373942005", "display": "Discharge summary" } ] }, "subject": { "reference": "urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9" }, "encounter": { "reference": "urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" }, "date": "2023-01-28T10:00:00+00:00", "author": [ { "reference": "urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f" } ], "title": "Cardiology Service Discharge Summary", "section": [ { "title": "Diagnoses", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "diagnoses", "display": "Diagnoses" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Diagnosis name</th><td>Underactive thyroid</td></tr><tr><th>Comment</th><td>Hypothyroidism (disorder) - 40930008</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Diagnosis name</th><td>Heart attack</td></tr><tr><th>Comment</th><td>Myocardial infarction (disorder) - 22298006</td></tr></tbody></table><table width=\"100%\"><tbody><tr><th>Diagnosis name</th><td>Alcohol misuse</td></tr><tr><th>Comment</th><td>Alcohol abuse (disorder) - 15167005</td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:e7fb78ed-db3a-4759-a370-0c0957f7f3bf" } ] } ] }
<Composition xmlns="http://hl7.org/fhir"> <!-- optional elements removed for readability --> <meta> <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition" /> </meta> <status value="final" /> <type> <coding> <system value="http://snomed.info/sct" /> <code value="373942005" /> <display value="Discharge summary" /> </coding> </type> <subject> <reference value="urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9" /> </subject> <encounter> <reference value="urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" /> </encounter> <date value="2023-01-28T10:00:00+00:00" /> <author> <reference value="urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f" /> </author> <title value="Cardiology Service Discharge Summary" /> <section> <title value="Diagnoses" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="diagnoses" /> <display value="Diagnoses" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Diagnosis name</th><td>Underactive thyroid</td></tr><tr><th>Comment</th><td>Hypothyroidism (disorder) - 40930008</td></tr></tbody></table><table width="100%"><tbody><tr><th>Diagnosis name</th><td>Heart attack</td></tr><tr><th>Comment</th><td>Myocardial infarction (disorder) - 22298006</td></tr></tbody></table><table width="100%"><tbody><tr><th>Diagnosis name</th><td>Alcohol misuse</td></tr><tr><th>Comment</th><td>Alcohol abuse (disorder) - 15167005</td></tr></tbody></table></div> </text> <entry> <reference value="urn:uuid:e7fb78ed-db3a-4759-a370-0c0957f7f3bf" /> </entry> </section> <!-- other sections removed for readability --> </Composition>
Example Coded Resources
This text section should be linked to a UKCore-List profiled resource. E.g.
{ "resourceType": "List", "meta": { "profile": [ "https://fhir.hl7.org.uk/StructureDefinition/UKCore-List" ] }, "identifier": [ { "system": "https://tools.ietf.org/html/rfc4122", "value": "hhhh1111" } ], "status": "current", "mode": "snapshot", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "887161000000102", "display": "Diagnoses" } ] }, "subject": { "reference": "urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9" }, "encounter": { "reference": "urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" }, "source": { "reference": "urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f" }, "entry": [ { "item": { "reference": "urn:uuid:cd3147aa-d104-4b48-8047-245db5c98827" } }, { "item": { "reference": "urn:uuid:02b5fe4f-b613-4081-a377-518412813541" } }, { "item": { "reference": "urn:uuid:fdc4a4b8-eb58-437a-a7b5-a2c898a74dfc" } } ] }
<List xmlns="http://hl7.org/fhir"> <meta> <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-List" /> </meta> <identifier> <system value="https://tools.ietf.org/html/rfc4122" /> <value value="hhhh1111" /> </identifier> <status value="current" /> <mode value="snapshot" /> <code> <coding> <system value="http://snomed.info/sct" /> <code value="887161000000102" /> <display value="Diagnoses" /> </coding> </code> <subject> <reference value="urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9" /> </subject> <encounter> <reference value="urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" /> </encounter> <source> <reference value="urn:uuid:2a32666e-84a2-4f90-a6a6-d5451ae2e32f" /> </source> <entry> <item> <reference value="urn:uuid:cd3147aa-d104-4b48-8047-245db5c98827" /> </item> </entry> <entry> <item> <reference value="urn:uuid:02b5fe4f-b613-4081-a377-518412813541" /> </item> </entry> <entry> <item> <reference value="urn:uuid:fdc4a4b8-eb58-437a-a7b5-a2c898a74dfc" /> </item> </entry> </List>
This list linked to a UKCore-Condition profiled resource. E.g.
{ "resourceType": "Condition", "meta": { "profile": [ "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Condition" ] }, "identifier": [ { "system": "https://tools.ietf.org/html/rfc4122", "value": "589de26e-27d2-405d-8344-3712a207479e" } ], "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-category", "code": "encounter-diagnosis", "display": "Encounter Diagnosis" } ] } ], "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "40930008", "display": "Hypothyroidism (disorder)" } ] }, "subject": { "reference": "urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9" }, "encounter": { "reference": "urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" } }
<Condition xmlns="http://hl7.org/fhir"> <meta> <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Condition" /> </meta> <identifier> <system value="https://tools.ietf.org/html/rfc4122" /> <value value="589de26e-27d2-405d-8344-3712a207479e" /> </identifier> <clinicalStatus> <coding> <system value="http://terminology.hl7.org/CodeSystem/condition-clinical" /> <code value="active" /> </coding> </clinicalStatus> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/condition-category" /> <code value="encounter-diagnosis" /> <display value="Encounter Diagnosis" /> </coding> </category> <code> <coding> <system value="http://snomed.info/sct" /> <code value="40930008" /> <display value="Hypothyroidism (disorder)" /> </coding> </code> <subject> <reference value="urn:uuid:2c0bca60-1873-46f7-a462-5733feaf32c9" /> </subject> <encounter> <reference value="urn:uuid:5a9f67fa-9343-40cc-8fde-0dd91822b7fd" /> </encounter> </Condition>