HdBe-Problem
Profile | Description | Status | URL |
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HdBe-Problem | A problem describes a situation with regard to an individual’s health and/or welfare. This situation can be described by the person involved (the patient) themselves (in the form of a complaint), or by their healthcare provider (in the form of a diagnosis, for example). The situation can form cause for diagnostic or therapeutic policy. A problem includes all kinds of medical or nursing information that represents a health problem. A problem can represent various types of health problems: A complaint, finding by patient: a subjective, negatively experienced observation of the patient’s health. Examples: stomach ache, amnesia A symptom: an observation by or about the patient which may indicate a certain disease. Examples: fever, blood in stool, white spots on the roof of the mouth; A diagnosis: medical interpretation of complaints and findings. Examples: Diabetes Mellitus type II, pneumonia, hemolytic-uremic syndrome. A functional limitation: a reduction of functional options. Examples: reduced mobility, help required for dressing. A complication: Every diagnosis seen by the healthcare provider as an unforeseen and undesired result of medical action. Examples: post-operative wound infections, loss of hearing through the use of antibiotics. | draft | https://fhir.healthdata.be/StructureDefinition/HdBe-Problem |
Condition | I | Condition | Element IdCondition Problem Alternate namesProbleem 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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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 | Σ ?! I | 0..1 | CodeableConceptBinding | Element IdCondition.clinicalStatus ProblemStatus Alternate namesProbleemStatus DefinitionThe problem status describes the condition of the problem:
The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. Use ConceptMap ProblemStatus_to_ConditionClinicalStatusCodes to translate terminology from the functional model to profile terminology in ValueSet ConditionClinicalStatusCodes. ConditionClinicalStatusCodes (required)Permitted Values ProblemStatus_to_ConditionClinicalStatusCodes Constraints
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verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding | Element IdCondition.verificationStatus VerificationStatus Alternate namesVerificatieStatus DefinitionClinical status of the problem or the diagnosis. 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. Use ConceptMap VerificationStatus_to_ConditionVerificationStatus to translate terminology from the functional model to profile terminology in ValueSet ConditionVerificationStatus. ConditionVerificationStatus (required)Permitted Values VerificationStatus_to_ConditionVerificationStatus Constraints
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coding | Σ | 0..* | Coding | Element IdCondition.verificationStatus.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Value) Constraints
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verificationStatusCodelist | Σ | 1..1 | CodingBinding | Element IdCondition.verificationStatus.coding:verificationStatusCodelist Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. In addition to a coding from this ValueSet, the corresponding coding from the FHIR base ValueSet SHALL be communicated. The ConceptMap https://fhir.healthdata.be/ConceptMap/VerificationStatus-to-ConditionVerificationStatus can be used to relate these two ValueSets.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.verificationStatus.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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category | 0..* | CodeableConceptBinding | 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. Unordered, Open, by $this(Value) BindingA category assigned to the condition. ConditionCategoryCodes (extensible)Constraints
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problemType | 0..1 | CodeableConceptBinding | Element IdCondition.category:problemType ProblemType Alternate namesProbleemType DefinitionThe type of problem; see the concept description. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. A category assigned to the condition. ProblemType (required)Constraints
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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. Condition/DiagnosisSeverity (preferred)Constraints
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code | Σ | 0..1 | CodeableConceptBinding | Element IdCondition.code ProblemName Alternate namestype, ProbleemNaam DefinitionThe problem name defines the problem. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Identification of the condition or diagnosis. ProblemName (extensible)Constraints
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extension | I | 0..* | Extension | Element IdCondition.code.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) Constraints
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furtherSpecificationProblemName | I | 0..1 | Extension(string) | Element IdCondition.code.extension:furtherSpecificationProblemName Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.healthdata.be/StructureDefinition/ext-Problem.FurtherSpecificationProblemName Constraints
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url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdCondition.code.extension:furtherSpecificationProblemName.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. System.String Fixed Valuehttps://fhir.healthdata.be/StructureDefinition/ext-Problem.FurtherSpecificationProblemName
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value[x] | 0..1 | Element IdCondition.code.extension:furtherSpecificationProblemName.value[x] FurtherSpecificationProblemName Alternate namesNadereSpecificatieProbleemNaam DefinitionFurther specification of problem name when it is recorded via a thesaurus or code system in which the required level of detail is not (yet) available.
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valueString | string | There are no (further) constraints on this element Data Type | ||
coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdCondition.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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bodySite | Σ | 0..1 | HdBe AnatomicalLocation | Element IdCondition.bodySite Location / ProblemAnatomicalLocation Alternate namesLocatie, ProbleemAnatomischeLocatie DefinitionAnatomical location which is the focus of the problem. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
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subject | Σ I | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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encounter | Σ I | 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] | 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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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 | Σ | 0..1 | dateTime | Element IdCondition.onset[x]:onsetDateTime ProblemStartDate Alternate namesProbleemBeginDatum DefinitionOnset of the symptom, complaint, functional limitation, complication or date of diagnosis. A ‘vague’ date, such as only the year or the month and the year, is permitted. 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 | 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. Unordered, Open, by $this(Type) Constraints
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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 | ||
abatementDateTime | I | 0..1 | dateTime | Element IdCondition.abatement[x]:abatementDateTime ProblemEndDate Alternate namesProbleemEindDatum DefinitionDate on which the disorder to which the problem applies, is considered not to be present anymore.This datum needs not to be the same as the date of the change in problem status. A ‘vague’ date, such as only the year or the month and the year, is permitted. 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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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 I | 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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asserter | Σ I | 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. 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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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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing condition stages (e.g. Cancer stages). ConditionStage (example)Constraints
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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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing the kind of condition staging (e.g. clinical or pathological). ConditionStageType (example)Constraints
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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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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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes that describe the manifestation or symptoms of a condition. ManifestationAndSymptomCodes (example)Constraints
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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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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note | 0..1 | 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. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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author[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdCondition.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
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authorString | string | There are no (further) constraints on this element Data Type | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Data Type Reference(Practitioner | Patient | RelatedPerson | Organization) | ||
time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdCondition.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
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text | Σ | 1..1 | markdown | Element IdCondition.note.text Comment Alternate namesToelichting DefinitionComment by the one who determined or updated the Problem. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
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Condition | I | Condition | Element IdCondition Problem Alternate namesProbleem 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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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 | Σ ?! I | 0..1 | CodeableConceptBinding | Element IdCondition.clinicalStatus ProblemStatus Alternate namesProbleemStatus DefinitionThe problem status describes the condition of the problem:
The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. Use ConceptMap ProblemStatus_to_ConditionClinicalStatusCodes to translate terminology from the functional model to profile terminology in ValueSet ConditionClinicalStatusCodes. ConditionClinicalStatusCodes (required)Permitted Values ProblemStatus_to_ConditionClinicalStatusCodes Constraints
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verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding | Element IdCondition.verificationStatus VerificationStatus Alternate namesVerificatieStatus DefinitionClinical status of the problem or the diagnosis. 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. Use ConceptMap VerificationStatus_to_ConditionVerificationStatus to translate terminology from the functional model to profile terminology in ValueSet ConditionVerificationStatus. ConditionVerificationStatus (required)Permitted Values VerificationStatus_to_ConditionVerificationStatus Constraints
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coding | Σ | 0..* | Coding | Element IdCondition.verificationStatus.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Value) Constraints
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verificationStatusCodelist | Σ | 1..1 | CodingBinding | Element IdCondition.verificationStatus.coding:verificationStatusCodelist Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. In addition to a coding from this ValueSet, the corresponding coding from the FHIR base ValueSet SHALL be communicated. The ConceptMap https://fhir.healthdata.be/ConceptMap/VerificationStatus-to-ConditionVerificationStatus can be used to relate these two ValueSets.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.verificationStatus.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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category | 0..* | CodeableConceptBinding | 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. Unordered, Open, by $this(Value) BindingA category assigned to the condition. ConditionCategoryCodes (extensible)Constraints
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problemType | 0..1 | CodeableConceptBinding | Element IdCondition.category:problemType ProblemType Alternate namesProbleemType DefinitionThe type of problem; see the concept description. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. A category assigned to the condition. ProblemType (required)Constraints
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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. Condition/DiagnosisSeverity (preferred)Constraints
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code | Σ | 0..1 | CodeableConceptBinding | Element IdCondition.code ProblemName Alternate namestype, ProbleemNaam DefinitionThe problem name defines the problem. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Identification of the condition or diagnosis. ProblemName (extensible)Constraints
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extension | I | 0..* | Extension | Element IdCondition.code.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) Constraints
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furtherSpecificationProblemName | I | 0..1 | Extension(string) | Element IdCondition.code.extension:furtherSpecificationProblemName Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.healthdata.be/StructureDefinition/ext-Problem.FurtherSpecificationProblemName Constraints
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url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdCondition.code.extension:furtherSpecificationProblemName.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. System.String Fixed Valuehttps://fhir.healthdata.be/StructureDefinition/ext-Problem.FurtherSpecificationProblemName
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value[x] | 0..1 | Element IdCondition.code.extension:furtherSpecificationProblemName.value[x] FurtherSpecificationProblemName Alternate namesNadereSpecificatieProbleemNaam DefinitionFurther specification of problem name when it is recorded via a thesaurus or code system in which the required level of detail is not (yet) available.
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valueString | string | There are no (further) constraints on this element Data Type | ||
coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdCondition.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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bodySite | Σ | 0..1 | HdBe AnatomicalLocation | Element IdCondition.bodySite Location / ProblemAnatomicalLocation Alternate namesLocatie, ProbleemAnatomischeLocatie DefinitionAnatomical location which is the focus of the problem. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
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subject | Σ I | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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encounter | Σ I | 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] | 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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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 | Σ | 0..1 | dateTime | Element IdCondition.onset[x]:onsetDateTime ProblemStartDate Alternate namesProbleemBeginDatum DefinitionOnset of the symptom, complaint, functional limitation, complication or date of diagnosis. A ‘vague’ date, such as only the year or the month and the year, is permitted. 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 | 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. Unordered, Open, by $this(Type) Constraints
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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 | ||
abatementDateTime | I | 0..1 | dateTime | Element IdCondition.abatement[x]:abatementDateTime ProblemEndDate Alternate namesProbleemEindDatum DefinitionDate on which the disorder to which the problem applies, is considered not to be present anymore.This datum needs not to be the same as the date of the change in problem status. A ‘vague’ date, such as only the year or the month and the year, is permitted. 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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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 I | 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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asserter | Σ I | 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. 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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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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing condition stages (e.g. Cancer stages). ConditionStage (example)Constraints
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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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing the kind of condition staging (e.g. clinical or pathological). ConditionStageType (example)Constraints
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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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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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes that describe the manifestation or symptoms of a condition. ManifestationAndSymptomCodes (example)Constraints
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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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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note | 0..1 | 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. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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author[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdCondition.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
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authorString | string | There are no (further) constraints on this element Data Type | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Data Type Reference(Practitioner | Patient | RelatedPerson | Organization) | ||
time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdCondition.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
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text | Σ | 1..1 | markdown | Element IdCondition.note.text Comment Alternate namesToelichting DefinitionComment by the one who determined or updated the Problem. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
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Condition | I | Condition | Element IdCondition Problem Alternate namesProbleem 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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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 | Σ ?! I | 0..1 | CodeableConceptBinding | Element IdCondition.clinicalStatus ProblemStatus Alternate namesProbleemStatus DefinitionThe problem status describes the condition of the problem:
The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. Use ConceptMap ProblemStatus_to_ConditionClinicalStatusCodes to translate terminology from the functional model to profile terminology in ValueSet ConditionClinicalStatusCodes. ConditionClinicalStatusCodes (required)Permitted Values ProblemStatus_to_ConditionClinicalStatusCodes Constraints
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verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding | Element IdCondition.verificationStatus VerificationStatus Alternate namesVerificatieStatus DefinitionClinical status of the problem or the diagnosis. 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. Use ConceptMap VerificationStatus_to_ConditionVerificationStatus to translate terminology from the functional model to profile terminology in ValueSet ConditionVerificationStatus. ConditionVerificationStatus (required)Permitted Values VerificationStatus_to_ConditionVerificationStatus Constraints
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coding | Σ | 0..* | Coding | Element IdCondition.verificationStatus.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Value) Constraints
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verificationStatusCodelist | Σ | 1..1 | CodingBinding | Element IdCondition.verificationStatus.coding:verificationStatusCodelist Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. In addition to a coding from this ValueSet, the corresponding coding from the FHIR base ValueSet SHALL be communicated. The ConceptMap https://fhir.healthdata.be/ConceptMap/VerificationStatus-to-ConditionVerificationStatus can be used to relate these two ValueSets.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.verificationStatus.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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category | 0..* | CodeableConceptBinding | 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. Unordered, Open, by $this(Value) BindingA category assigned to the condition. ConditionCategoryCodes (extensible)Constraints
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problemType | 0..1 | CodeableConceptBinding | Element IdCondition.category:problemType ProblemType Alternate namesProbleemType DefinitionThe type of problem; see the concept description. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. A category assigned to the condition. ProblemType (required)Constraints
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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. Condition/DiagnosisSeverity (preferred)Constraints
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code | Σ | 0..1 | CodeableConceptBinding | Element IdCondition.code ProblemName Alternate namestype, ProbleemNaam DefinitionThe problem name defines the problem. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Identification of the condition or diagnosis. ProblemName (extensible)Constraints
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extension | I | 0..* | Extension | Element IdCondition.code.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) Constraints
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furtherSpecificationProblemName | I | 0..1 | Extension(string) | Element IdCondition.code.extension:furtherSpecificationProblemName Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.healthdata.be/StructureDefinition/ext-Problem.FurtherSpecificationProblemName Constraints
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url | 1..1 | System.StringFixed Value | There are no (further) constraints on this element Element IdCondition.code.extension:furtherSpecificationProblemName.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. System.String Fixed Valuehttps://fhir.healthdata.be/StructureDefinition/ext-Problem.FurtherSpecificationProblemName
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value[x] | 0..1 | Element IdCondition.code.extension:furtherSpecificationProblemName.value[x] FurtherSpecificationProblemName Alternate namesNadereSpecificatieProbleemNaam DefinitionFurther specification of problem name when it is recorded via a thesaurus or code system in which the required level of detail is not (yet) available.
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valueString | string | There are no (further) constraints on this element Data Type | ||
coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdCondition.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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bodySite | Σ | 0..1 | HdBe AnatomicalLocation | Element IdCondition.bodySite Location / ProblemAnatomicalLocation Alternate namesLocatie, ProbleemAnatomischeLocatie DefinitionAnatomical location which is the focus of the problem. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
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subject | Σ I | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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encounter | Σ I | 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] | 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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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 | Σ | 0..1 | dateTime | Element IdCondition.onset[x]:onsetDateTime ProblemStartDate Alternate namesProbleemBeginDatum DefinitionOnset of the symptom, complaint, functional limitation, complication or date of diagnosis. A ‘vague’ date, such as only the year or the month and the year, is permitted. 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 | 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. Unordered, Open, by $this(Type) Constraints
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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 | ||
abatementDateTime | I | 0..1 | dateTime | Element IdCondition.abatement[x]:abatementDateTime ProblemEndDate Alternate namesProbleemEindDatum DefinitionDate on which the disorder to which the problem applies, is considered not to be present anymore.This datum needs not to be the same as the date of the change in problem status. A ‘vague’ date, such as only the year or the month and the year, is permitted. 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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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 I | 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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asserter | Σ I | 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. 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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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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing condition stages (e.g. Cancer stages). ConditionStage (example)Constraints
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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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing the kind of condition staging (e.g. clinical or pathological). ConditionStageType (example)Constraints
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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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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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes that describe the manifestation or symptoms of a condition. ManifestationAndSymptomCodes (example)Constraints
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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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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note | 0..1 | 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. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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author[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdCondition.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
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authorString | string | There are no (further) constraints on this element Data Type | ||
authorReference | Reference(Practitioner | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Data Type Reference(Practitioner | Patient | RelatedPerson | Organization) | ||
time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdCondition.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
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text | Σ | 1..1 | markdown | Element IdCondition.note.text Comment Alternate namesToelichting DefinitionComment by the one who determined or updated the Problem. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
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Mapping FHIR profile to CBB
Path | map | CBB |
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Condition | Problem | HdBe-Problem |
Condition.clinicalStatus | Problem.ProblemStatus | HdBe-Problem |
Condition.verificationStatus | Problem.VerificationStatus | HdBe-Problem |
Condition.category:problemType | Problem.ProblemType | HdBe-Problem |
Condition.code | Problem.ProblemName | HdBe-Problem |
Condition.code.extension:furtherSpecificationProblemName.value[x] | Problem.FurtherSpecificationProblemName | HdBe-Problem |
Condition.bodySite | Problem.ProblemAnatomicalLocation | HdBe-Problem |
Condition.onset[x]:onsetDateTime | Problem.ProblemStartDate | HdBe-Problem |
Condition.abatement[x]:abatementDateTime | Problem.ProblemEndDate | HdBe-Problem |
Condition.note.text | Problem.Comment | HdBe-Problem |
zib Problem difference
Concept | Category | Description |
---|---|---|
verificationStatus |
terminology | Replaced UNK value in ConceptMap VerificationStatusCodelist-to-ConditionVerificationStatus with SNOMED CT equivalent for Unknown (261665006). |
category.problemType |
terminology | Replaced value 116223007 with 263718001 in ValueSet ProblemType as it is inactive in the International SNOMED CT. |
code |
terminology | Replaced all possible Codesystems in ValueSet ProblemName with SNOMED CT and loosened binding to extensible . |
code |
textual | Removed all content about the multiple CodeSystems. |
Terminology Bindings
Path | Name | Strength | URL | ConceptMap |
---|---|---|---|---|
Condition.clinicalStatus | condition-clinical|4.0.1 | required | http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 | https://fhir.healthdata.be/ConceptMap/ProblemStatus-to-ConditionClinicalStatusCodes |
Condition.verificationStatus | condition-ver-status|4.0.1 | required | http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 | https://fhir.healthdata.be/ConceptMap/VerificationStatus-to-ConditionVerificationStatus |
Condition.verificationStatus.coding | VerificationStatus | required | https://fhir.healthdata.be/ValueSet/VerificationStatus | No bound ConceptMap |
Condition.category | ProblemType | required | https://fhir.healthdata.be/ValueSet/ProblemType | No bound ConceptMap |
Condition.code | ProblemName | extensible | https://fhir.healthdata.be/ValueSet/ProblemName | No bound ConceptMap |