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Resource Condition - Content 4.5

Use to record detailed information about conditions, problems or diagnoses recognized by a clinician. There are many uses including: recording a Diagnosis during an Encounter; populating a problem List or a Summary Statement, such as a Discharge Summary.

The resource name as it appears in a RESTful URL is [root]/condition/

This resource is used to record detailed information about a specific issue with the health state of a patient. It is intended for use for issues that have been identified as relevant for tracking and reporting purposes or where there's a need to capture a concrete diagnosis or the gathering of data such as signs and symptoms. There are situations where the same information might appear as both an observation as well as a condition. For example, the appearance of a rash or an instance of a fever are signs and symptoms that would typically be captured using the Observation resource. However, a pattern of ongoing fevers or a persistent or severe rash requiring treatment might be captured as a condition. The Condition resource specifically excludes AdverseReactions and AllergyIntolerances as those are handled with their own resources.

Conditions are frequently referenced by other resources as "reasons" for an action (Prescription, Procedure, DiagnosticOrder, etc.)

The conditions represented in this resources are sometimes described as "Problems", and kept as part of a problem list.

Resource Content 4.5.1

<Condition xmlns="http://hl7.org/fhir">
 <!-- from Resource: extension, narrative, and contained -->
 <subject><!-- 1..1 Resource(Patient) Subject of this condition --></subject>
 <encounter><!-- 0..1 Resource(Encounter) Encounter during which the condition was first asserted --></encounter>
 <asserter><!-- 0..1 Resource(Practitioner|Patient) Person who asserts this condition --></asserter>
 <dateAsserted value="[date]"/><!-- 0..1 When first detected/suspected/entered -->
 <code><!-- 1..1 CodeableConcept Identification of the condition, problem or diagnosis --></code>
 <category><!-- 0..1 CodeableConcept E.g. complaint | symptom | finding | diagnosis --></category>
 <status value="[code]"/><!-- 1..1 provisional | working | confirmed | refuted -->
 <certainty><!-- 0..1 CodeableConcept Degree of confidence --></certainty>
 <severity><!-- 0..1 CodeableConcept Subjective severity of condition --></severity>
 <onset[x]><!-- 0..1 date|Age Estimated or actual date, or age --></onset[x]>
 <abatement[x]><!-- 0..1 date|Age|boolean If/when in resolution/remission --></abatement[x]>
 <stage>  <!-- 0..1 Stage/grade, usually assessed formally -->
  <summary><!-- 0..1 CodeableConcept Simple summary (disease specific) --></summary>
  <assessment><!-- 0..* Resource(Any) Formal record of assessment --></assessment>
 </stage>
 <evidence>  <!-- 0..* Supporting evidence -->
  <code><!-- 0..1 CodeableConcept Manifestation/symptom --></code>
  <detail><!-- 0..* Resource(Any) Supporting information found elsewhere --></detail>
 </evidence>
 <location>  <!-- 0..* Anatomical location, if relevant -->
  <code><!-- 0..1 CodeableConcept Location - may include laterality --></code>
  <detail value="[string]"/><!-- 0..1 Precise location details -->
 </location>
 <relatedItem>  <!-- 0..* Causes or precedents for this Condition -->
  <type value="[code]"/><!-- 1..1 due-to | follows -->
  <code><!-- 0..1 CodeableConcept Relationship target by means of a predefined code --></code>
  <target><!-- 0..1 Resource(Condition|Procedure|Substance) Relationship target resource --></target>
 </relatedItem>
 <notes value="[string]"/><!-- 0..1 Additional information about the Condition -->
</Condition>

Alternate definitions: Schema/Schematron, Resource Profile

Terminology Bindings 4.5.1.1

Path	Definition	Type	Reference
Condition.code	Identification of the Condition or diagnosis.	Example	http://hl7.org/fhir/vs/condition-code
Condition.category	A category assigned to the condition. E.g. finding | Condition | diagnosis | concern | condition	Incomplete	http://hl7.org/fhir/vs/condition-category
Condition.status	The clinical status of the Condition or diagnosis	Fixed	http://hl7.org/fhir/condition-status
Condition.certainty	The degree of confidence that this condition is correct	Example	http://hl7.org/fhir/vs/condition-certainty
Condition.severity	A subjective assessment of the severity of the condition as evaluated by the clinician.	Example	http://hl7.org/fhir/vs/condition-severity
Condition.relatedItem.type	The type of relationship between a condition and its related item	Fixed	http://hl7.org/fhir/condition-relationship-type
Condition.relatedItem.code	Identification of issue that is a cause or a precedent of a Condition or diagnosis.	Example	http://hl7.org/fhir/vs/condition-code

Constraints 4.5.1.2

• Inv-1: On Condition.stage: Stage must have summary or assessment (xpath on f:Condition/f:stage: exists(f:summary) or exists(f:assessment))
• Inv-2: On Condition.evidence: evidence must have code or details (xpath on f:Condition/f:evidence: exists(f:code) or exists(f:detail))
• Inv-3: On Condition.location: location must have code or details (xpath on f:Condition/f:location: exists(f:code) or exists(f:detail))
• Inv-4: On Condition.relatedItem: Relationship must have either a code or a target (xpath on f:Condition/f:relatedItem: exists(f:code) != exists(f:target))

Use of Condition.code 4.5.1.3

Many of the code systems used for coding conditions will provide codes that define not only the condition itself, but may also specify a particular stage, location, or causality as part of the code. This is particularly true if SNOMED-CT is used for the condition, and especially if expressions are allowed.

When the Condition.code specifies additional properties of the condition, the other properties are not given a value - instead, the value must be understood from the Condition.code.

Search Parameters 4.5.2

Search Parameters for RESTful searches. The standard parameters also apply. See Searching for more information.

Name / Type	Description	Paths
_id : token	The logical resource id associated with the resource (must be supported by all servers)
asserter : reference	Person who asserts this condition	Condition.asserter
category : token	the category of the condition	Condition.category
code : token	code for the condition	Condition.code
date-asserted : date	When first detected/suspected/entered	Condition.dateAsserted
encounter : reference	Encounter during which the condition was first asserted	Condition.encounter
evidence : token	Manifestation/symptom	Condition.evidence.code
location : token	Location - may include laterality	Condition.location.code
onset : date	when the Condition started (if started on a date)	Condition.onset[x]
related-code : token	Relationship target by means of a predefined code	Condition.relatedItem.code
related-item : reference	Relationship target resource	Condition.relatedItem.target
severity : token	the severity of the condition	Condition.severity
stage : token	Simple summary (disease specific)	Condition.stage.summary
status : token	the status of the condition	Condition.status
subject : reference	Subject of this condition	Condition.subject