type: resource-definitionsresource: Condition

Condition Definitions

Condition

Detailed information about conditions, problems or diagnoses

Definition: A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

Cardinality: 0..*

Constraints: con-3 | error | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission. | abatement.exists() implies (clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='inactive' or code='resolved' or code='remission')).exists()); con-4 | error | bodyStructure SHALL only be present if Condition.bodySite is not present | bodySite.exists() implies bodyStructure.empty()

Condition.identifier

External Ids for this condition

Definition: Business 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.

Comments: 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.

Requirements: Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers.

Cardinality: 0..*

Type: Identifier

Summary: true

Mappings: w5=FiveWs.identifier; rim=.id

Condition.clinicalStatus

Definition: The clinical status of the condition.

Comments: 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. clinicalStatus is required since it is a modifier element. For conditions that are problems list items, the clinicalStatus should not be unknown. For conditions that are not problem list items, the clinicalStatus may be unknown. For example, conditions derived from a claim are point in time, so those conditions may have a clinicalStatus of unknown

Conditions: con-3

Cardinality: 1..1

Type: CodeableConcept

Binding: required:condition-clinical

Summary: true

Is Modifier: true (Reason: This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.)

Mappings: w5=FiveWs.status; sct-concept=< 303105007 |Disease phases|; v2=PRB-14; rim=Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="clinicalStatus", moodCode=EVN].value

Condition.verificationStatus

Definition: The verification status to support the clinical status of the condition. The verification status pertains to the condition, itself, not to any specific condition attribute.

Comments: 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.

Cardinality: 0..1

Type: CodeableConcept

Binding: required:condition-ver-status

Summary: true

Is Modifier: true (Reason: This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.)

Mappings: w5=FiveWs.status; sct-concept=< 410514004 |Finding context value|; v2=PRB-13; rim=Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="verificationStatus", moodCode=EVN].value; sct-attr=408729009

Condition.category

problem-list-item | encounter-diagnosis

Definition: A category assigned to the condition.

Comments: The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:condition-category

Mappings: w5=FiveWs.class; sct-concept=< 404684003 |Clinical finding|; v2='problem' if from PRB-3. 'diagnosis' if from DG1 segment in PV1 message; rim=.code

Condition.severity

Subjective severity of condition

Definition: A subjective assessment of the severity of the condition as evaluated by the clinician.

Comments: Coding of the severity with a terminology is preferred, where possible.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:condition-severity

Mappings: w5=FiveWs.grade; sct-concept=< 272141005 |Severities|; v2=PRB-26 / ABS-3; rim=Can be pre/post-coordinated into value. Or ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="severity"].value; sct-attr=246112005

Condition.code

Identification of the condition, problem or diagnosis

Definition: Identification of the condition, problem or diagnosis.

Requirements: 0..1 to account for primarily narrative only resources.

Aliases: type

Cardinality: 0..1

Type: CodeableConcept

Binding: example:condition-code

Summary: true

Condition.bodySite

Anatomical location, if relevant

Definition: The anatomical location where this condition manifests itself.

Comments: Only used if not implicit in code found in Condition.code.

Conditions: con-4

Cardinality: 0..*

Type: CodeableConcept

Binding: example:body-site

Summary: true

Mappings: sct-concept=< 442083009 |Anatomical or acquired body structure|; rim=.targetBodySiteCode; sct-attr=363698007

Condition.bodyStructure

Anatomical body structure

Definition: Indicates the body structure on the subject's body where this condition manifests itself.

Comments: Should be consistent with Condition.code. Cannot be used if Condition.bodySite is used.

Conditions: con-4

Cardinality: 0..1

Type: Reference(BodyStructure)

Mappings: rim=targetSiteCode

Condition.subject

Who has the condition?

Definition: Indicates the patient or group who the condition record is associated with.

Requirements: Group is typically used for veterinary or public health use cases.

Aliases: patient

Cardinality: 1..1

Type: Reference(Patient, Group)

Summary: true

Mappings: w5=FiveWs.subject; v2=PID-3; rim=.participation[typeCode=SBJ].role[classCode=PAT]

Condition.encounter

The Encounter during which this Condition was created

Definition: The Encounter during which this Condition was created or to which the creation of this record is tightly associated.

Comments: 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".

Cardinality: 0..1

Type: Reference(Encounter)

Summary: true

Mappings: w5=FiveWs.context; v2=PV1-19 (+PV1-54); rim=.inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]

Condition.onset[x]

Estimated or actual date, date-time, or age

Definition: Estimated or actual date or date-time the condition, situation, or concern began, in the opinion of the clinician.

Comments: If an event has risen to a level of concern due to its direct or indirect impact on the patient's health, then the date the event occurred is the onset date of the concern. Age is generally used when the patient reports an age at which the Condition began to occur. Period is generally used to convey an imprecise onset that occurred within the time period. For example, Period is not intended to convey the transition period before the chronic bronchitis or COPD condition was diagnosed, but Period can be used to convey an imprecise diagnosis date. Range is generally used to convey an imprecise age range (e.g. 4 to 6 years old). Because a Condition.code can represent multiple levels of granularity and can be modified over time, the onset and abatement dates can have ambiguity whether those dates apply to the current Condition.code or an earlier representation of that Condition.code. For example, if the Condition.code was initially documented as severe asthma, then it is ambiguous whether the onset and abatement dates apply to asthma (overall in that subject's lifetime) or when asthma transitioned to become severe.

Cardinality: 0..1

Type: dateTime, Age, Period, Range, string

Summary: true

Mappings: w5=FiveWs.init; v2=PRB-16; rim=.effectiveTime.low or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at onset"].value

Condition.abatement[x]

When in resolution/remission

Definition: The 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" - Some conditions, such as chronic conditions, are never really resolved, but they can abate.

Comments: 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. Because a Condition.code can represent multiple levels of granularity and can be modified over time, the onset and abatement dates can have ambiguity whether those dates apply to the current Condition.code or an earlier representation of that Condition.code. For example, if the Condition.code was initially documented as severe asthma, then it is ambiguous whether the onset and abatement dates apply to asthma (overall in that subject's lifetime) or when asthma transitioned to become severe. Period is generally used to convey an imprecise abatement that occurred within the time period. Range is generally used to convey an imprecise age range (e.g. 4 to 6 years old).

Conditions: con-3

Cardinality: 0..1

Type: dateTime, Age, Period, Range, string

Mappings: w5=FiveWs.done[x]; rim=.effectiveTime.high or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at remission"].value or .inboundRelationship[typeCode=SUBJ]source[classCode=CONC, moodCode=EVN].status=completed

Condition.recordedDate

Date condition was first recorded

Definition: The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.

Comments: When onset date is unknown, recordedDate can be used to establish if the condition was present on or before a given date. If the recordedDate is known and provided by a sending system, it is preferred that the receiving system preserve that recordedDate value. If the recordedDate is not provided by the sending system, the receipt timestamp is sometimes used as the recordedDate.

Cardinality: 0..1

Type: dateTime

Summary: true

Mappings: w5=FiveWs.recorded; v2=REL-11; rim=.participation[typeCode=AUT].time

Condition.recorder

Who recorded the condition

Definition: Individual who recorded the record and takes responsibility for accurately recording its content.

Comments: Because the recorder takes responsibility for accurately recording information in the record, the recorder is the most recent author. The recorder might or might not be the asserter. By contrast, the recordedDate is when the condition was first recorded.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Patient, RelatedPerson, Group)

Summary: true

Mappings: w5=FiveWs.author; rim=.participation[typeCode=AUT].role

Condition.asserter

Person or device that asserts this condition

Definition: Individual or device that is making the condition statement.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Patient, RelatedPerson, Device, Group)

Summary: true

Mappings: w5=FiveWs.source; v2=REL-7.1 identifier + REL-7.12 type code; rim=.participation[typeCode=INF].role

Condition.stage

Stage/grade, usually assessed formally

Definition: A simple summary of the stage such as "Stage 3" or "Early Onset". The determination of the stage is disease-specific, such as cancer, retinopathy of prematurity, kidney diseases, Alzheimer's, or Parkinson disease.

Cardinality: 0..*

Type: BackboneElement

Constraints: con-1 | error | Stage SHALL have summary or assessment | summary.exists() or assessment.exists()

Mappings: rim=./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage/grade"]

Condition.stage.summary

Simple summary (disease specific)

Conditions: con-1

Cardinality: 0..1

Type: CodeableConcept

Binding: example:condition-stage

Mappings: sct-concept=< 254291000 |Staging and scales|; v2=PRB-14; rim=.value

Condition.stage.assessment

Formal record of assessment

Definition: Reference to a formal record of the evidence on which the staging assessment is based.

Conditions: con-1

Cardinality: 0..*

Type: Reference(DiagnosticReport, Observation)

Mappings: rim=.self

Condition.stage.type

Kind of staging

Definition: The kind of staging, such as pathological or clinical staging.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:condition-stage-type

Mappings: rim=./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage type"]

Condition.evidence

Supporting evidence for the condition

Definition: Supporting evidence / manifestations that are the basis for determining the Condition.

Comments: Do not use Condition.evidence for causality. If it is an AdverseEvent, use AdverseEvent.suspectEntity.causality. Causality can also be pre-coordinated into the Condition.code (e.g. SNOMED 90619006 Fall in bathtub, or ICD W16. 2 Fall in (into) filled bathtub or bucket of water). Otherwise, use [[[http://hl7.org/fhir/StructureDefinition/condition-dueTo]]] extension to convey conditions, problems, diagnoses, procedures or events or the substance that caused/triggered this Condition. If the condition was confirmed, but subsequently refuted, then the evidence can be cumulative including all evidence over time. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. For example, if the Condition.code is pneumonia, then there could be an evidence list where Condition.evidence.concept = fever (CodeableConcept), Condition.evidence.concept = cough (CodeableConcept), and Condition.evidence.reference = bronchitis (reference to Condition).

Cardinality: 0..*

Type: CodeableReference

Binding: example:clinical-findings

Summary: true

Mappings: rim=.outboundRelationship[typeCode=SPRT].target[classCode=OBS, moodCode=EVN]

Condition.note

Additional information about the Condition

Definition: Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.

Cardinality: 0..*

Type: Annotation

Mappings: v2=NTE child of PRB; rim=.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value