Diagnoses

Also known as 'Conditions'. Under diagnoses, CTcue collects all registered diagnoses of a patient from various sources. These diagnoses are often registered using an (inter)national coding system. Examples of diagnosis descriptions are: “Carpal tunnel syndrome”, “Sleep apnea”, “Asthma, unspecified”. ICD 10 diagnoses are grouped and can be searched by main category (E11) but also by subcategory (E11.1).

Depending on the source of the diagnosis codes, they may not have been recorded by the treating physician / care provider but by medical coders that work for the administration department in the hospital. The codes are shared with insurance companies, national registries or the Ministry of Health, for example.

In the Netherlands this category does not only contain diagnosis codes that were made and registered in the hospital itself. There is a National Basic Registration Healthcare Data (Landelijke Basisregistratie Ziekenhuiszorg, LBZ) that also covers diagnoses made by care providers outside of the hospitals, these can also end up in the hospital EHR. In that case you can use the filter 'Category' to specifically zoom in on diagnoses taken from this non-EHR source.

Overview

Filter name in app	Priority	FHIR field (PFS)	Brief description	Example data
ID	Must have	Condition.identifier.value	Unique identifier for diagnosis.
Description	Must have	Condition.code.coding.display	Textual description of the diagnosis / condition.	Hypermobility syndrome; carpal tunnel syndrome; Acute endocarditis, unspecified
Diagnosis code	Must have	Condition.code.coding.code	Diagnosis code from the classification system / diagnosis code system used in the hospital.	ICD-10: M21.5, Q65 SNOMED CT: 10032006, 10143000 Diagnosis thesaurus (NL): 0000000027, 0000000038
Classification system	Must have	Condition.code.coding.system	The name of the classification system / catalogue that contains all diagnosis codes + descriptions used in the EHR.	ICD9, ICD10, SNOMED, national diagnosis thesaurus
Verification status	Could have	Condition.verificationStatus.coding.display	Indicates if it was verified the patient indeed suffers from the condition.	Verified, cancelled
Severity	Could have	Condition.severity.coding.display	Severity of the condition / diagnosis	No complications, permanent damage, recovery without surgical intervention.
Stage	Could have	Condition.stage.summary.coding.display	Stage of the diagnosis	Stable, progressive, stage 2
Age at time of event	Must have	Derived from Patient	Age of the patient, in years, when the diagnosis started.
Status	Could have	Condition.clinicalStatus.coding.display	Status of the diagnosis	Expired, active, present.
Specialism	Must have	Condition.specialism (extension)	The specialism that recorded the diagnosis in the EHR, specialism under which the diagnosis was recorded.	Gastroenterology, endocrinology, oncology
Category	Could have	Condition.category.coding.display	The condition category or the source of the diagnosis.	Complications, LBZ database, admission diagnosis
Care provider name	Could have	Derived from Condition.asserter	Name of the care provider that recorded the diagnosis.	Nurse Jane Doe, Dr. Robin Smith
Care provider position	Should have	Derived from Condition.asserter	Position of the care provider that recorded the diagnosis.	Neurologist, dietician, doctor-in-training.
Start date	Should have	Condition.onset[x].onSetPeriod.start	The date on which the condition / diagnosis was made or started.	DD-MM-YYYY hh:mm
End date	Should have	Condition.onset[x].onSetPeriod.end	If applicable, the date on which the condition / diagnosis ended i.e. the patient was cured from the diagnosis.	DD-MM-YYYY hh:mm
Recorded date	Must have	Condition.onset[x].recordedDate	Date on which the diagnosis was recorded in the (EHR) source system.	DD-MM-YYYY hh:mm