US Core Implementation Guide
6.0.0 - STU6 United States of America flag

This page is part of the US Core (v6.0.0: STU6) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: US Core Condition Encounter Diagnosis Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis Version: 6.0.0
Active as of 2022-04-20 Computable Name: USCoreConditionEncounterDiagnosisProfile

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The US Core Condition Encounter Diagnosis Profile is based upon the core FHIR Condition Resource and meets the U.S. Core Data for Interoperability (USCDI) v2 Encounter Diagnosis requirements. In version 5.0.0, The US Core Condition Profile has been split into the US Core Condition Encounter Diagnosis Profile and US Core Condition Problems and Health Concerns Profile. To promote interoperability and adoption through common implementation, this profile defines constraints and extensions on the Condition resource for the minimal set of data to record, search, and fetch information about an encounter diagnosis. It identifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains the way the elements are used when using this profile. It provides the floor for standards development for specific use cases.

Example Usage Scenarios:

The following are example usage scenarios for this profile:

  • Query for a Patient’s current or historical encounter diagnosis
  • Record or update a Patient’s encounter diagnosis

Mandatory and Must Support Data Elements

The following data-elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each Condition Must Have:

  1. a category code of ‘encounter-diagnosis’
  2. a code that identifies the condition
  3. a patient

Each Condition Must Support:

  1. a clinical status of the condition (e.g., active or resolved)
  2. a verification status
  3. an encounter
  4. a date of diagnosis*
  5. abatement date (in other words, date of resolution or remission)
  6. a date when recorded*

*see guidance below

Profile Specific Implementation Guidance:

  • For Problems and Health Concerns use the US Core Condition Problems and Health Concerns Profile.
  • For USCDI v2+ the applicable vocabulary standards for Encounter Diagnosis are SNOMED CT and ICD-10-CM. For general guidance on extensible binding to coded data, review this section in the General Requirements page.
    • The US Core Condition Codes supports ICD-9-CM for historical purposes only. ICD-10-CM is available and SHOULD be used as the primary code for current encounter diagnoses.
  • The encounter SHOULD always be referenced in Condition.encounter.
  • To search for an encounter diagnosis, query for Conditions that reference the Encounter of interest and have a category of encounter-diagnosis. An example search is shown in the Quick Start section below.
  • *There is no single element in Condition that represents the date of diagnosis. It may be the assertedDate Extension, Condition.onsetDate, or Condition.recordedDate.
    • Although all three are marked as Must Support, the server is not required to support all.
    • A server SHALL support Condition.recordedDate.
    • A server SHALL support at least one of assertedDate Extension and Condition.onsetDate. A server may support both, which means they support all 3 dates.
    • The client application SHALL support all three elements.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... assertedDate S0..1dateTime(USCDI) Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... clinicalStatus S0..1CodeableConcept(USCDI) active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus S0..1CodeableConcept(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S1..*CodeableConcept(USCDI) category codes
Slice: Unordered, Open by pattern:$this
.... category:us-core S1..1CodeableConcept(USCDI) encounter-diagnosis
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: encounter-diagnosis
... code S1..1CodeableConcept(USCDI) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

... subject S1..1Reference(US Core Patient Profile)(USCDI) Who has the condition?
... encounter S0..1Reference(US Core Encounter Profile)(USCDI) Encounter created as part of
... onset[x] S0..1(USCDI) Estimated or actual date, date-time, or age
.... onsetDateTimedateTime S
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] S0..1(USCDI) When in resolution/remission
.... abatementDateTimedateTime S
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate S0..1dateTime(USCDI) Date record was first recorded

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.codeextensibleUSCoreConditionCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... assertedDate S0..1dateTime(USCDI) Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... clinicalStatus ?!SΣC0..1CodeableConcept(USCDI) active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC0..1CodeableConcept(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S1..*CodeableConcept(USCDI) category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:us-core S1..1CodeableConcept(USCDI) encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: encounter-diagnosis
... code SΣ1..1CodeableConcept(USCDI) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) Who has the condition?
... encounter SΣ0..1Reference(US Core Encounter Profile)(USCDI) Encounter created as part of
... onset[x] SΣ0..1(USCDI) Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
... abatement[x] SC0..1(USCDI) When in resolution/remission
.... abatementDateTimedateTime
... recordedDate SΣ0..1dateTime(USCDI) Date record was first recorded

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.category:us-coreextensiblePattern: encounter-diagnosis
Condition.codeextensibleUSCoreConditionCodes

Constraints

IdGradePath(s)DetailsRequirements
con-3best practiceConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
: clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4errorConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5errorConditionCondition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorConditionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... assertedDate S0..1dateTime(USCDI) Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣC0..1CodeableConcept(USCDI) active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC0..1CodeableConcept(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S1..*CodeableConcept(USCDI) category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:us-core S1..1CodeableConcept(USCDI) encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: encounter-diagnosis
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ1..1CodeableConcept(USCDI) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) Who has the condition?
... encounter SΣ0..1Reference(US Core Encounter Profile)(USCDI) Encounter created as part of
... onset[x] SΣ0..1(USCDI) Estimated or actual date, date-time, or age
.... onsetDateTimedateTime S
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] SC0..1(USCDI) When in resolution/remission
.... abatementDateTimedateTime S
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate SΣ0..1dateTime(USCDI) Date record was first recorded
... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
... asserter Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Person who asserts this condition
... stage C0..*BackboneElementStage/grade, usually assessed formally
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary C0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C0..*BackboneElementSupporting evidence
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣC0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.category:us-coreextensiblePattern: encounter-diagnosis
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codeextensibleUSCoreConditionCodes
Condition.bodySiteexampleSNOMEDCTBodyStructures
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleManifestationAndSymptomCodes

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Condition

Summary

Mandatory: 3 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element Condition.category is sliced based on the value of pattern:$this

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... assertedDate S0..1dateTime(USCDI) Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... clinicalStatus S0..1CodeableConcept(USCDI) active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus S0..1CodeableConcept(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S1..*CodeableConcept(USCDI) category codes
Slice: Unordered, Open by pattern:$this
.... category:us-core S1..1CodeableConcept(USCDI) encounter-diagnosis
Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: encounter-diagnosis
... code S1..1CodeableConcept(USCDI) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

... subject S1..1Reference(US Core Patient Profile)(USCDI) Who has the condition?
... encounter S0..1Reference(US Core Encounter Profile)(USCDI) Encounter created as part of
... onset[x] S0..1(USCDI) Estimated or actual date, date-time, or age
.... onsetDateTimedateTime S
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] S0..1(USCDI) When in resolution/remission
.... abatementDateTimedateTime S
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate S0..1dateTime(USCDI) Date record was first recorded

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.codeextensibleUSCoreConditionCodes

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... assertedDate S0..1dateTime(USCDI) Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... clinicalStatus ?!SΣC0..1CodeableConcept(USCDI) active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC0..1CodeableConcept(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S1..*CodeableConcept(USCDI) category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:us-core S1..1CodeableConcept(USCDI) encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: encounter-diagnosis
... code SΣ1..1CodeableConcept(USCDI) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) Who has the condition?
... encounter SΣ0..1Reference(US Core Encounter Profile)(USCDI) Encounter created as part of
... onset[x] SΣ0..1(USCDI) Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
... abatement[x] SC0..1(USCDI) When in resolution/remission
.... abatementDateTimedateTime
... recordedDate SΣ0..1dateTime(USCDI) Date record was first recorded

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.category:us-coreextensiblePattern: encounter-diagnosis
Condition.codeextensibleUSCoreConditionCodes

Constraints

IdGradePath(s)DetailsRequirements
con-3best practiceConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
: clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4errorConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5errorConditionCondition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorConditionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... assertedDate S0..1dateTime(USCDI) Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣC0..1CodeableConcept(USCDI) active | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC0..1CodeableConcept(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... Slices for category S1..*CodeableConcept(USCDI) category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:us-core S1..1CodeableConcept(USCDI) encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: encounter-diagnosis
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ1..1CodeableConcept(USCDI) Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) Who has the condition?
... encounter SΣ0..1Reference(US Core Encounter Profile)(USCDI) Encounter created as part of
... onset[x] SΣ0..1(USCDI) Estimated or actual date, date-time, or age
.... onsetDateTimedateTime S
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] SC0..1(USCDI) When in resolution/remission
.... abatementDateTimedateTime S
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate SΣ0..1dateTime(USCDI) Date record was first recorded
... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
... asserter Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Person who asserts this condition
... stage C0..*BackboneElementStage/grade, usually assessed formally
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary C0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C0..*BackboneElementSupporting evidence
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣC0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.category:us-coreextensiblePattern: encounter-diagnosis
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codeextensibleUSCoreConditionCodes
Condition.bodySiteexampleSNOMEDCTBodyStructures
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleManifestationAndSymptomCodes

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Condition

Summary

Mandatory: 3 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element Condition.category is sliced based on the value of pattern:$this

 

Other representations of profile: CSV, Excel, Schematron

Notes:


Quick Start


Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

  • The syntax used to describe the interactions is described here.

  • Servers providing access to encounter diagnosis data can use US Core SMART Scopes for:
    • resource level scopes (for example, patient/Condition.rs)
    • granular scopes (for example, patient.Condition.rs?category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis).
  • See the General Requirements section for additional rules and expectations when a server requires status parameters.
  • See the General Guidance section for additional guidance on searching for multiple patients.

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching for all conditions including problems, health concerns, and encounter diagnosis for a patient using the patient search parameter:

    GET [base]/Condition?patient={Type/}[id]

    Example:

    1. GET [base]/Condition?patient=1137192

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient (how to search by reference)

  2. SHALL support searching using the combination of the patient and category search parameters:

    GET [base]/Condition?patient={Type/}[id]&category={system|}[code]

    Example:

    1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|problem-list-item
    2. GET [base]/Condition?patient=1032702&category=http://hl7.org/fhir/us/core/CodeSystem/condition-category|health-concern
    3. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category. (how to search by reference and how to search by token)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

  1. SHOULD support searching using the combination of the patient and clinical-status search parameters:

    GET [base]/Condition?patient={Type/}[id]&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

    Example:

    1. GET [base/Condition?patient=1032702&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and all "active" statuses (active,relapse,remission). This will exclude diagnoses and health concerns without a clinicalStatus specified. (how to search by reference and how to search by token)

  2. SHOULD support searching using the combination of the patient and category and clinical-status search parameters:

    GET [base]/Condition?patient={Type/}[id]&category={system|}[code]&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

    Example:

    1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|problem-list-item&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active,http://terminology.hl7.org/CodeSystem/condition-clinical|recurrance,http://terminology.hl7.org/CodeSystem/condition-clinical|remission

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category for all "active" statuses (active,relapse,remission). This will exclude diagnoses and health concerns without a clinicalStatus specified. (how to search by reference and how to search by token)

  3. SHOULD support searching using the combination of the patient and category and encounter search parameters:

    GET [base]/Condition?patient={Type/}[id]&category={system|}[code]&encounter={Type/}[id]

    Example:

    1. GET [base]/Condition?patient=1032702&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis&encounter=1036

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category and encounter. When category = "encounter-diagnosis" will return the encounter diagnosis for the encounter. (how to search by reference and how to search by token)

  4. SHOULD support searching using the combination of the patient and code search parameters:

    GET [base]/Condition?patient={Type/}[id]&code={system|}[code]

    Example:

    1. GET [base]/Condition?patient=1032702&code=[http://snomed.info/sct|442311008]

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and code. (how to search by reference and how to search by token)

  5. SHOULD support searching using the combination of the patient and onset-date search parameters:
    • including support for these onset-date comparators: gt,lt,ge,le
    • including optional support for AND search on onset-date (e.g.onset-date=[date]&onset-date=[date]]&...)

    GET [base]/Condition?patient={Type/}[id]&onset-date={gt|lt|ge|le}[date]{&onset-date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Condition?patient=555580&onset-date=ge2018-01-14

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)

  6. SHOULD support searching using the combination of the patient and asserted-date search parameters:
    • including support for these asserted-date comparators: gt,lt,ge,le
    • including optional support for AND search on asserted-date (e.g.asserted-date=[date]&asserted-date=[date]]&...)

    GET [base]/Condition?patient={Type/}[id]&asserted-date={gt|lt|ge|le}[date]{&asserted-date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Condition?patient=555580&asserted-date=ge2018-01-14

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)

  7. SHOULD support searching using the combination of the patient and recorded-date search parameters:
    • including support for these recorded-date comparators: gt,lt,ge,le
    • including optional support for AND search on recorded-date (e.g.recorded-date=[date]&recorded-date=[date]]&...)

    GET [base]/Condition?patient={Type/}[id]&recorded-date={gt|lt|ge|le}[date]{&recorded-date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Condition?patient=555580&recorded-date=ge2018-01-14

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)

  8. SHOULD support searching using the combination of the patient and abatement-date search parameters:
    • including support for these abatement-date comparators: gt,lt,ge,le
    • including optional support for AND search on abatement-date (e.g.abatement-date=[date]&abatement-date=[date]]&...)

    GET [base]/Condition?patient={Type/}[id]&abatement-date={gt|lt|ge|le}[date]{&abatement-date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]Condition?patient=555580&abatement-date=ge2018-01-14

    Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and date. (how to search by reference and how to search by date)