Profiles & Operations > Structure Definition: Condition Profile
Profile: Condition
Canonical URL:http://ontariohealth.ca/fhir/ehr/StructureDefinition/profile-condition
Simplifier project page: Condition EHR
Derived from: Condition (R4)
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work
Differential View
| ConditionEHR (Condition) | I | Condition | There are no (further) constraints on this element Element idCondition Detailed information about conditions, problems or diagnoses DefinitionA clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
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| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idCondition.meta Metadata about the resource DefinitionThe 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.
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idCondition.implicitRules A set of rules under which this content was created DefinitionA 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. 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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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idCondition.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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| text | 0..1 | Narrative | There are no (further) constraints on this element Element idCondition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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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| contained | 0..* | Resource | There are no (further) constraints on this element Element idCondition.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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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| modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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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| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idCondition.identifier External Ids for this condition DefinitionBusiness 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. Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. 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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| clinicalStatus | S Σ I | 0..1 | CodeableConceptEHRBinding | Element idCondition.clinicalStatus Concept - reference to a terminology or just text DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text. The clinical status of the condition or diagnosis.
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| verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.verificationStatus unconfirmed | provisional | differential | confirmed | refuted | entered-in-error DefinitionThe verification status to support the clinical status of the condition. 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. The verification status to support or decline the clinical status of the condition or diagnosis.
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| category | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.category problem-list-item | encounter-diagnosis DefinitionA category assigned to the condition. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. A category assigned to the condition.
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| severity | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.severity Subjective severity of condition DefinitionA subjective assessment of the severity of the condition as evaluated by the clinician. Coding of the severity with a terminology is preferred, where possible. A subjective assessment of the severity of the condition as evaluated by the clinician.
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| code | S Σ | 1..1 | CodeableConceptEHRBinding | Element idCondition.code Concept - reference to a terminology or just text Alternate namestype DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. 0..1 to account for primarily narrative only resources. For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text. Identification of the condition or diagnosis.
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| bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCondition.bodySite Anatomical location, if relevant DefinitionThe anatomical location where this condition manifests itself. 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. Codes describing anatomical locations. May include laterality.
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| subject | S Σ | 1..1 | Reference(PatientEHR) | Element idCondition.subject Who has the condition? Alternate namespatient DefinitionIndicates the patient or group who the condition record is associated with. Group is typically used for veterinary or public health use cases.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCondition.subject.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.subject.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ I | 1..1 | string | There are no (further) constraints on this element Element idCondition.subject.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idCondition.subject.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idCondition.subject.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.subject.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| encounter | Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idCondition.encounter Encounter created as part of DefinitionThe Encounter during which this Condition was created or to which the creation of this record is tightly associated. 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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| onset[x] | S Σ | 0..1 | Element idCondition.onset[x] Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur. Unordered, Open, by $this(Type) Constraints
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| (All Slices) | There are no (further) constraints on this element | |||
| onsetAge | Age | There are no (further) constraints on this element Data type | ||
| onsetPeriod | Period | There are no (further) constraints on this element Data type | ||
| onsetRange | Range | There are no (further) constraints on this element Data type | ||
| onsetString | string | There are no (further) constraints on this element Data type | ||
| onsetDateTime | S Σ | 0..1 | dateTime | Element idCondition.onset[x]:onsetDateTime Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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| abatement[x] | I | 0..1 | There are no (further) constraints on this element Element idCondition.abatement[x] When in resolution/remission DefinitionThe 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. 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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| abatementDateTime | dateTime | There are no (further) constraints on this element Data type | ||
| abatementAge | Age | There are no (further) constraints on this element Data type | ||
| abatementPeriod | Period | There are no (further) constraints on this element Data type | ||
| abatementRange | Range | There are no (further) constraints on this element Data type | ||
| abatementString | string | There are no (further) constraints on this element Data type | ||
| recordedDate | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idCondition.recordedDate Date record was first recorded DefinitionThe recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.
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| recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | There are no (further) constraints on this element Element idCondition.recorder Who recorded the condition DefinitionIndividual who recorded the record and takes responsibility for its content. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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| asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | There are no (further) constraints on this element Element idCondition.asserter Person who asserts this condition DefinitionIndividual who is making the condition statement. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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| stage | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idCondition.stage Stage/grade, usually assessed formally DefinitionClinical stage or grade of a condition. May include formal severity assessments.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCondition.stage.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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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| summary | I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCondition.stage.summary Simple summary (disease specific) DefinitionA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. Codes describing condition stages (e.g. Cancer stages).
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| assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | There are no (further) constraints on this element Element idCondition.stage.assessment Formal record of assessment DefinitionReference to a formal record of the evidence on which the staging assessment is based. Reference(ClinicalImpression | DiagnosticReport | Observation) Constraints
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| type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCondition.stage.type Kind of staging DefinitionThe kind of staging, such as pathological or clinical staging. Codes describing the kind of condition staging (e.g. clinical or pathological).
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| evidence | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idCondition.evidence Supporting evidence DefinitionSupporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCondition.evidence.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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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| code | Σ I | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCondition.evidence.code Manifestation/symptom DefinitionA manifestation or symptom that led to the recording of this condition. Codes that describe the manifestation or symptoms of a condition.
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| detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idCondition.evidence.detail Supporting information found elsewhere DefinitionLinks to other relevant information, including pathology reports.
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| note | 0..* | Annotation | There are no (further) constraints on this element Element idCondition.note Additional information about the Condition DefinitionAdditional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.
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Hybrid View
| ConditionEHR (Condition) | I | Condition | There are no (further) constraints on this element Element idCondition Detailed information about conditions, problems or diagnoses DefinitionA clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
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| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idCondition.meta Metadata about the resource DefinitionThe 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.
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idCondition.implicitRules A set of rules under which this content was created DefinitionA 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. 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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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idCondition.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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| text | 0..1 | Narrative | There are no (further) constraints on this element Element idCondition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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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| contained | 0..* | Resource | There are no (further) constraints on this element Element idCondition.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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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| modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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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| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idCondition.identifier External Ids for this condition DefinitionBusiness 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. Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. 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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| clinicalStatus | S Σ I | 0..1 | CodeableConceptEHRBinding | Element idCondition.clinicalStatus Concept - reference to a terminology or just text DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text. The clinical status of the condition or diagnosis.
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| verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.verificationStatus unconfirmed | provisional | differential | confirmed | refuted | entered-in-error DefinitionThe verification status to support the clinical status of the condition. 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. The verification status to support or decline the clinical status of the condition or diagnosis.
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| category | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.category problem-list-item | encounter-diagnosis DefinitionA category assigned to the condition. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. A category assigned to the condition.
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| severity | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.severity Subjective severity of condition DefinitionA subjective assessment of the severity of the condition as evaluated by the clinician. Coding of the severity with a terminology is preferred, where possible. A subjective assessment of the severity of the condition as evaluated by the clinician.
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| code | S Σ | 1..1 | CodeableConceptEHRBinding | Element idCondition.code Concept - reference to a terminology or just text Alternate namestype DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. 0..1 to account for primarily narrative only resources. For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text. Identification of the condition or diagnosis.
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| bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCondition.bodySite Anatomical location, if relevant DefinitionThe anatomical location where this condition manifests itself. 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. Codes describing anatomical locations. May include laterality.
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| subject | S Σ | 1..1 | Reference(PatientEHR) | Element idCondition.subject Who has the condition? Alternate namespatient DefinitionIndicates the patient or group who the condition record is associated with. Group is typically used for veterinary or public health use cases.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCondition.subject.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.subject.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ I | 1..1 | string | There are no (further) constraints on this element Element idCondition.subject.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idCondition.subject.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idCondition.subject.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.subject.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| encounter | Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idCondition.encounter Encounter created as part of DefinitionThe Encounter during which this Condition was created or to which the creation of this record is tightly associated. 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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| onset[x] | S Σ | 0..1 | Element idCondition.onset[x] Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur. Unordered, Open, by $this(Type) Constraints
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| (All Slices) | There are no (further) constraints on this element | |||
| onsetAge | Age | There are no (further) constraints on this element Data type | ||
| onsetPeriod | Period | There are no (further) constraints on this element Data type | ||
| onsetRange | Range | There are no (further) constraints on this element Data type | ||
| onsetString | string | There are no (further) constraints on this element Data type | ||
| onsetDateTime | S Σ | 0..1 | dateTime | Element idCondition.onset[x]:onsetDateTime Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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| abatement[x] | I | 0..1 | There are no (further) constraints on this element Element idCondition.abatement[x] When in resolution/remission DefinitionThe 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. 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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| abatementDateTime | dateTime | There are no (further) constraints on this element Data type | ||
| abatementAge | Age | There are no (further) constraints on this element Data type | ||
| abatementPeriod | Period | There are no (further) constraints on this element Data type | ||
| abatementRange | Range | There are no (further) constraints on this element Data type | ||
| abatementString | string | There are no (further) constraints on this element Data type | ||
| recordedDate | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idCondition.recordedDate Date record was first recorded DefinitionThe recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.
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| recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | There are no (further) constraints on this element Element idCondition.recorder Who recorded the condition DefinitionIndividual who recorded the record and takes responsibility for its content. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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| asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | There are no (further) constraints on this element Element idCondition.asserter Person who asserts this condition DefinitionIndividual who is making the condition statement. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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| stage | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idCondition.stage Stage/grade, usually assessed formally DefinitionClinical stage or grade of a condition. May include formal severity assessments.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCondition.stage.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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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| summary | I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCondition.stage.summary Simple summary (disease specific) DefinitionA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. Codes describing condition stages (e.g. Cancer stages).
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| assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | There are no (further) constraints on this element Element idCondition.stage.assessment Formal record of assessment DefinitionReference to a formal record of the evidence on which the staging assessment is based. Reference(ClinicalImpression | DiagnosticReport | Observation) Constraints
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| type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCondition.stage.type Kind of staging DefinitionThe kind of staging, such as pathological or clinical staging. Codes describing the kind of condition staging (e.g. clinical or pathological).
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| evidence | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idCondition.evidence Supporting evidence DefinitionSupporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCondition.evidence.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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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| code | Σ I | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCondition.evidence.code Manifestation/symptom DefinitionA manifestation or symptom that led to the recording of this condition. Codes that describe the manifestation or symptoms of a condition.
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| detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idCondition.evidence.detail Supporting information found elsewhere DefinitionLinks to other relevant information, including pathology reports.
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| note | 0..* | Annotation | There are no (further) constraints on this element Element idCondition.note Additional information about the Condition DefinitionAdditional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.
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Snapshot View
| ConditionEHR (Condition) | I | Condition | There are no (further) constraints on this element Element idCondition Detailed information about conditions, problems or diagnoses DefinitionA clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
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| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idCondition.meta Metadata about the resource DefinitionThe 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.
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idCondition.implicitRules A set of rules under which this content was created DefinitionA 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. 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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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idCondition.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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| text | 0..1 | Narrative | There are no (further) constraints on this element Element idCondition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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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| contained | 0..* | Resource | There are no (further) constraints on this element Element idCondition.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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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| modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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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| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idCondition.identifier External Ids for this condition DefinitionBusiness 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. Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. 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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| clinicalStatus | S Σ I | 0..1 | CodeableConceptEHRBinding | Element idCondition.clinicalStatus Concept - reference to a terminology or just text DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text. The clinical status of the condition or diagnosis.
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| verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.verificationStatus unconfirmed | provisional | differential | confirmed | refuted | entered-in-error DefinitionThe verification status to support the clinical status of the condition. 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. The verification status to support or decline the clinical status of the condition or diagnosis.
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| category | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.category problem-list-item | encounter-diagnosis DefinitionA category assigned to the condition. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. A category assigned to the condition.
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| severity | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.severity Subjective severity of condition DefinitionA subjective assessment of the severity of the condition as evaluated by the clinician. Coding of the severity with a terminology is preferred, where possible. A subjective assessment of the severity of the condition as evaluated by the clinician.
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| code | S Σ | 1..1 | CodeableConceptEHRBinding | Element idCondition.code Concept - reference to a terminology or just text Alternate namestype DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. 0..1 to account for primarily narrative only resources. For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text. Identification of the condition or diagnosis.
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| bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCondition.bodySite Anatomical location, if relevant DefinitionThe anatomical location where this condition manifests itself. 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. Codes describing anatomical locations. May include laterality.
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| subject | S Σ | 1..1 | Reference(PatientEHR) | Element idCondition.subject Who has the condition? Alternate namespatient DefinitionIndicates the patient or group who the condition record is associated with. Group is typically used for veterinary or public health use cases.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCondition.subject.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.subject.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| reference | S Σ I | 1..1 | string | There are no (further) constraints on this element Element idCondition.subject.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idCondition.subject.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idCondition.subject.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.subject.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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| encounter | Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idCondition.encounter Encounter created as part of DefinitionThe Encounter during which this Condition was created or to which the creation of this record is tightly associated. 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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| onset[x] | S Σ | 0..1 | Element idCondition.onset[x] Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur. Unordered, Open, by $this(Type) Constraints
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| (All Slices) | There are no (further) constraints on this element | |||
| onsetAge | Age | There are no (further) constraints on this element Data type | ||
| onsetPeriod | Period | There are no (further) constraints on this element Data type | ||
| onsetRange | Range | There are no (further) constraints on this element Data type | ||
| onsetString | string | There are no (further) constraints on this element Data type | ||
| onsetDateTime | S Σ | 0..1 | dateTime | Element idCondition.onset[x]:onsetDateTime Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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| abatement[x] | I | 0..1 | There are no (further) constraints on this element Element idCondition.abatement[x] When in resolution/remission DefinitionThe 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. 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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| abatementDateTime | dateTime | There are no (further) constraints on this element Data type | ||
| abatementAge | Age | There are no (further) constraints on this element Data type | ||
| abatementPeriod | Period | There are no (further) constraints on this element Data type | ||
| abatementRange | Range | There are no (further) constraints on this element Data type | ||
| abatementString | string | There are no (further) constraints on this element Data type | ||
| recordedDate | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idCondition.recordedDate Date record was first recorded DefinitionThe recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.
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| recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | There are no (further) constraints on this element Element idCondition.recorder Who recorded the condition DefinitionIndividual who recorded the record and takes responsibility for its content. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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| asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | There are no (further) constraints on this element Element idCondition.asserter Person who asserts this condition DefinitionIndividual who is making the condition statement. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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| stage | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idCondition.stage Stage/grade, usually assessed formally DefinitionClinical stage or grade of a condition. May include formal severity assessments.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCondition.stage.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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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| summary | I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCondition.stage.summary Simple summary (disease specific) DefinitionA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. Codes describing condition stages (e.g. Cancer stages).
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| assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | There are no (further) constraints on this element Element idCondition.stage.assessment Formal record of assessment DefinitionReference to a formal record of the evidence on which the staging assessment is based. Reference(ClinicalImpression | DiagnosticReport | Observation) Constraints
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| type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCondition.stage.type Kind of staging DefinitionThe kind of staging, such as pathological or clinical staging. Codes describing the kind of condition staging (e.g. clinical or pathological).
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| evidence | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idCondition.evidence Supporting evidence DefinitionSupporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
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| id | 0..1 | string | There are no (further) constraints on this element Element idCondition.evidence.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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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| code | Σ I | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCondition.evidence.code Manifestation/symptom DefinitionA manifestation or symptom that led to the recording of this condition. Codes that describe the manifestation or symptoms of a condition.
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| detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idCondition.evidence.detail Supporting information found elsewhere DefinitionLinks to other relevant information, including pathology reports.
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| note | 0..* | Annotation | There are no (further) constraints on this element Element idCondition.note Additional information about the Condition DefinitionAdditional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.
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Table View
| Condition | .. | |
| Condition.clinicalStatus | CodeableConceptEHR | .. |
| Condition.code | CodeableConceptEHR | 1.. |
| Condition.subject | Reference(PatientEHR) | .. |
| Condition.subject.reference | 1.. | |
| Condition.onset[x] | .. | |
| Condition.onset[x] | dateTime | 0..1 |
JSON View
{ "resourceType": "StructureDefinition", "id": "Condition", "url": "http://ontariohealth.ca/fhir/ehr/StructureDefinition/profile-condition", "version": "1.0.0", "name": "ConditionEHR", "title": "Condition EHR", "status": "active", "description": "A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.", "fhirVersion": "4.0.1", "kind": "resource", "abstract": false, "type": "Condition", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Condition", "derivation": "constraint", "differential": { "element": [ { "id": "Condition.clinicalStatus", "path": "Condition.clinicalStatus", "type": [ { "code": "CodeableConcept", "profile": [ "http://ontariohealth.ca/fhir/ehr/StructureDefinition/CodeableConcept-oh-ehr" ] } ], "mustSupport": true }, { "id": "Condition.code", "path": "Condition.code", "min": 1, "type": [ { "code": "CodeableConcept", "profile": [ "http://ontariohealth.ca/fhir/ehr/StructureDefinition/CodeableConcept-oh-ehr" ] } ], "mustSupport": true, "binding": { "strength": "preferred", "valueSet": "https://fhir.infoway-inforoute.ca/ValueSet/clinicalfindingcode", "extension": [ { "url": "http://hl7.org/fhir/tools/StructureDefinition/additional-binding", "extension": [ { "url": "purpose", "valueCode": "candidate" }, { "url": "valueSet", "valueCanonical": "http://fhir.infoway-inforoute.ca/io/cacore/ValueSet/ICD9CM" }, { "url": "documentation", "valueMarkdown": "Any code from ICD-9 CM." }, { "url": "key", "valueId": "icd9cmBinding" } ] }, { "url": "http://hl7.org/fhir/tools/StructureDefinition/additional-binding", "extension": [ { "url": "purpose", "valueCode": "candidate" }, { "url": "valueSet", "valueCanonical": "http://fhir.infoway-inforoute.ca/io/cacore/ValueSet/ICD10CA" }, { "url": "documentation", "valueMarkdown": "Any Code from ICD-10 CA." }, { "url": "key", "valueId": "icd10caBinding" } ] }, { "url": "http://hl7.org/fhir/tools/StructureDefinition/additional-binding", "extension": [ { "url": "purpose", "valueCode": "candidate" }, { "url": "valueSet", "valueCanonical": "http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-problems-uv-ips" }, { "url": "documentation", "valueMarkdown": "Absent or Unknown Problems" }, { "url": "key", "valueId": "absentUnknownProblemsIPS" } ] } ] } }, { "id": "Condition.subject", "path": "Condition.subject", "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/ehr/StructureDefinition/profile-patient" ] } ], "mustSupport": true }, { "id": "Condition.subject.reference", "path": "Condition.subject.reference", "min": 1, "mustSupport": true }, { "id": "Condition.onset[x]", "path": "Condition.onset[x]", "slicing": { "discriminator": [ { "type": "type", "path": "$this" } ], "ordered": false, "rules": "open" }, "mustSupport": true }, { "id": "Condition.onset[x]:onsetDateTime", "path": "Condition.onset[x]", "sliceName": "onsetDateTime", "min": 0, "max": "1", "type": [ { "code": "dateTime" } ], "mustSupport": true } ] } }
Usage
The Condition profile supports the information about ordering provider associated with acCDR documents, ifa applicable.
Notes
.code
- MUST be populated if diagnosis information is sent to acCDR.
- If an ICD-10-CA or SNOMED code of the diagnosis is sent to acCDR, code.coding SHOULD be populated.
- If only a free text description of the diagnosis is sent to acCDR, code.text SHOULD be populated.
.subject
- MUST contain a reference to the patient associated to the diagnosis