DSTU2

This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

4.3 Resource Condition - Content

Patient Care Work Group Maturity Level: 2 Compartments: Encounter, Patient, Practitioner

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.

4.3.1 Scope and Usage

Used to record detailed information pertinent to a clinician's assessment and assertion of a particular aspect of a person's state of health. Examples of condition include problems, diagnoses, concerns, issues. There are many uses of condition which include:

recording a problem, diagnosis, health concern or health issue during an encounter
the use of such information to populate a problem list of a summary statement such as a discharge summary

This resource is used to record detailed information about a clinician's assessment and assertion of a particular aspect of a patient's state of health. It is intended for use to record information about a disease/illness identified from application of clinical reasoning over the pathologic and pathophysiologic findings (diagnosis), or identification of health issues/situations that require ongoing monitoring and/or management (health issue/concern), or identification of health issues/situations considered harmful, potentially harmful and required to be investigated and managed (problems).

The condition resource may also be used to record certain health state of a patient which does not normally present negative outcome (until complications are predicted or detected), e.g. pregnancy. Examples of complications of pregnancy include: hyperemesis gravidarum, preeclampsia, eclampsia - which are captured as problems/diagnoses.

4.3.2 Boundaries and Relationships

The condition resource may be referenced by other resources as "reasons" for an action (e.g. MedicationOrder, Procedure, DiagnosticOrder, etc.)

This resource is not to be used to record information about subjective and objective information that might lead to the recording of a Condition. Such signs and symptoms that are typically captured using the Observation resource; although in some cases a persistent symptom, e.g. fever, headache may be captured as a condition before a definitive diagnosis can be discerned by a clinician.

The condition resource also specifically excludes AllergyIntoelrance as those are handled with their own resource.

This resource is referenced by CarePlan, ClinicalImpression, DiagnosticOrder, Encounter, EpisodeOfCare, Goal, MedicationOrder, MedicationStatement, Procedure, ProcedureRequest, RiskAssessment and VisionPrescription

Structure

Name	Flags	Card.	Type	Description & Constraints doco
.. Condition	Σ		DomainResource	Detailed information about conditions, problems or diagnoses
... identifier	Σ	0..*	Identifier	External Ids for this condition
... patient	Σ	1..1	Reference(Patient)	Who has the condition?
... encounter	Σ	0..1	Reference(Encounter)	Encounter when condition first asserted
... asserter	Σ	0..1	Reference(Practitioner \| Patient)	Person who asserts this condition
... dateRecorded	Σ	0..1	date	When first entered
... code	Σ	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Condition/Problem/Diagnosis Codes (Example)
... category	Σ	0..1	CodeableConcept	complaint \| symptom \| finding \| diagnosis Condition Category Codes (Preferred)
... clinicalStatus	?! Σ	0..1	code	active \| relapse \| remission \| resolved Condition Clinical Status Codes (Preferred)
... verificationStatus	?! Σ	1..1	code	provisional \| differential \| confirmed \| refuted \| entered-in-error \| unknown ConditionVerificationStatus (Required)
... severity	Σ	0..1	CodeableConcept	Subjective severity of condition Condition/Diagnosis Severity (Preferred)
... onset[x]	Σ	0..1		Estimated or actual date, date-time, or age
.... onsetDateTime			dateTime
.... onsetQuantity			Age
.... onsetPeriod			Period
.... onsetRange			Range
.... onsetString			string
... abatement[x]	Σ	0..1		If/when in resolution/remission
.... abatementDateTime			dateTime
.... abatementQuantity			Age
.... abatementBoolean			boolean
.... abatementPeriod			Period
.... abatementRange			Range
.... abatementString			string
... stage	Σ I	0..1	BackboneElement	Stage/grade, usually assessed formally Stage SHALL have summary or assessment
.... summary	Σ I	0..1	CodeableConcept	Simple summary (disease specific) Condition Stage (Example)
.... assessment	Σ I	0..*	Reference(ClinicalImpression \| DiagnosticReport \| Observation)	Formal record of assessment
... evidence	Σ I	0..*	BackboneElement	Supporting evidence evidence SHALL have code or details
.... code	Σ I	0..1	CodeableConcept	Manifestation/symptom Manifestation and Symptom Codes (Example)
.... detail	Σ I	0..*	Reference(Any)	Supporting information found elsewhere
... bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant SNOMED CT Body Structures (Example)
... notes	Σ	0..1	string	Additional information about the Condition
doco Documentation for this format

UML Diagram

XML Template

<Condition xmlns="http://hl7.org/fhir"> doco 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier  External Ids for this condition  --></identifier>
 <patient><!-- 1..1 Reference(Patient) Who has the condition?  --></patient>
 <encounter><!-- 0..1 Reference(Encounter) Encounter when condition first asserted  --></encounter>
 <asserter><!-- 0..1 Reference(Practitioner|Patient) Person who asserts this condition  --></asserter>
 <dateRecorded value="[date ]"/><!-- 0..1 When first entered  -->
 <code><!-- 1..1 CodeableConcept  Identification of the condition, problem or diagnosis  --></code>
 <category><!-- 0..1 CodeableConcept  complaint | symptom | finding | diagnosis  --></category>
 <clinicalStatus value="[code ]"/><!-- 0..1 active | relapse | remission | resolved  -->
 <verificationStatus value="[code ]"/><!-- 1..1 provisional | differential | confirmed | refuted | entered-in-error | unknown  -->
 <severity><!-- 0..1 CodeableConcept  Subjective severity of condition  --></severity>
 <onset[x]><!-- 0..1 dateTime|Quantity(Age)|Period|Range|string  Estimated or actual date, date-time, or age  --></onset[x]>
 <abatement[x]><!-- 0..1 dateTime|Quantity(Age)|boolean|Period|Range|string  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..* Reference(ClinicalImpression|DiagnosticReport|Observation) Formal record of assessment  --></assessment>
 </stage>
 <evidence> <!-- 0..* Supporting evidence -->
 <code><!-- ?? 0..1 CodeableConcept  Manifestation/symptom  --></code>
 <detail><!-- ?? 0..* Reference(Any) Supporting information found elsewhere  --></detail>
 </evidence>
 <bodySite><!-- 0..* CodeableConcept  Anatomical location, if relevant  --></bodySite>
 <notes value="[string ]"/><!-- 0..1 Additional information about the Condition  -->
</Condition>

JSON Template

{doco 
 "resourceType" : "Condition",
 // from Resource: id, meta, implicitRules, and language
 // from DomainResource: text, contained, extension, and modifierExtension
 "identifier" : [{ Identifier  }], // External Ids for this condition 
 "patient" : { Reference(Patient) }, // R! Who has the condition? 
 "encounter" : { Reference(Encounter) }, // Encounter when condition first asserted 
 "asserter" : { Reference(Practitioner|Patient) }, // Person who asserts this condition 
 "dateRecorded" : "<date >", // When first entered 
 "code" : { CodeableConcept  }, // R! Identification of the condition, problem or diagnosis 
 "category" : { CodeableConcept  }, // complaint | symptom | finding | diagnosis 
 "clinicalStatus" : "<code >", // active | relapse | remission | resolved 
 "verificationStatus" : "<code >", // R! provisional | differential | confirmed | refuted | entered-in-error | unknown 
 "severity" : { CodeableConcept  }, // Subjective severity of condition 
 // onset[x]: Estimated or actual date, date-time, or age. One of these 5:
 "onsetDateTime" : "<dateTime >",
 "onsetQuantity" : { Quantity(Age) },
 "onsetPeriod" : { Period  },
 "onsetRange" : { Range  },
 "onsetString" : "<string >",
 // abatement[x]: If/when in resolution/remission. One of these 6:
 "abatementDateTime" : "<dateTime >",
 "abatementQuantity" : { Quantity(Age) },
 "abatementBoolean" : <boolean >,
 "abatementPeriod" : { Period  },
 "abatementRange" : { Range  },
 "abatementString" : "<string >",
 "stage" : { // Stage/grade, usually assessed formally 
 "summary" : { CodeableConcept  }, // C? Simple summary (disease specific) 
 "assessment" : [{ Reference(ClinicalImpression|DiagnosticReport|Observation) }] // C? Formal record of assessment 
 },
 "evidence" : [{ // Supporting evidence 
 "code" : { CodeableConcept  }, // C? Manifestation/symptom 
 "detail" : [{ Reference(Any) }] // C? Supporting information found elsewhere 
 }],
 "bodySite" : [{ CodeableConcept  }], // Anatomical location, if relevant 
 "notes" : "<string >" // Additional information about the Condition 
}

Structure

Name	Flags	Card.	Type	Description & Constraints doco
.. Condition	Σ		DomainResource	Detailed information about conditions, problems or diagnoses
... identifier	Σ	0..*	Identifier	External Ids for this condition
... patient	Σ	1..1	Reference(Patient)	Who has the condition?
... encounter	Σ	0..1	Reference(Encounter)	Encounter when condition first asserted
... asserter	Σ	0..1	Reference(Practitioner \| Patient)	Person who asserts this condition
... dateRecorded	Σ	0..1	date	When first entered
... code	Σ	1..1	CodeableConcept	Identification of the condition, problem or diagnosis Condition/Problem/Diagnosis Codes (Example)
... category	Σ	0..1	CodeableConcept	complaint \| symptom \| finding \| diagnosis Condition Category Codes (Preferred)
... clinicalStatus	?! Σ	0..1	code	active \| relapse \| remission \| resolved Condition Clinical Status Codes (Preferred)
... verificationStatus	?! Σ	1..1	code	provisional \| differential \| confirmed \| refuted \| entered-in-error \| unknown ConditionVerificationStatus (Required)
... severity	Σ	0..1	CodeableConcept	Subjective severity of condition Condition/Diagnosis Severity (Preferred)
... onset[x]	Σ	0..1		Estimated or actual date, date-time, or age
.... onsetDateTime			dateTime
.... onsetQuantity			Age
.... onsetPeriod			Period
.... onsetRange			Range
.... onsetString			string
... abatement[x]	Σ	0..1		If/when in resolution/remission
.... abatementDateTime			dateTime
.... abatementQuantity			Age
.... abatementBoolean			boolean
.... abatementPeriod			Period
.... abatementRange			Range
.... abatementString			string
... stage	Σ I	0..1	BackboneElement	Stage/grade, usually assessed formally Stage SHALL have summary or assessment
.... summary	Σ I	0..1	CodeableConcept	Simple summary (disease specific) Condition Stage (Example)
.... assessment	Σ I	0..*	Reference(ClinicalImpression \| DiagnosticReport \| Observation)	Formal record of assessment
... evidence	Σ I	0..*	BackboneElement	Supporting evidence evidence SHALL have code or details
.... code	Σ I	0..1	CodeableConcept	Manifestation/symptom Manifestation and Symptom Codes (Example)
.... detail	Σ I	0..*	Reference(Any)	Supporting information found elsewhere
... bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant SNOMED CT Body Structures (Example)
... notes	Σ	0..1	string	Additional information about the Condition
doco Documentation for this format

UML Diagram

XML Template

<Condition xmlns="http://hl7.org/fhir"> doco 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier  External Ids for this condition  --></identifier>
 <patient><!-- 1..1 Reference(Patient) Who has the condition?  --></patient>
 <encounter><!-- 0..1 Reference(Encounter) Encounter when condition first asserted  --></encounter>
 <asserter><!-- 0..1 Reference(Practitioner|Patient) Person who asserts this condition  --></asserter>
 <dateRecorded value="[date ]"/><!-- 0..1 When first entered  -->
 <code><!-- 1..1 CodeableConcept  Identification of the condition, problem or diagnosis  --></code>
 <category><!-- 0..1 CodeableConcept  complaint | symptom | finding | diagnosis  --></category>
 <clinicalStatus value="[code ]"/><!-- 0..1 active | relapse | remission | resolved  -->
 <verificationStatus value="[code ]"/><!-- 1..1 provisional | differential | confirmed | refuted | entered-in-error | unknown  -->
 <severity><!-- 0..1 CodeableConcept  Subjective severity of condition  --></severity>
 <onset[x]><!-- 0..1 dateTime|Quantity(Age)|Period|Range|string  Estimated or actual date, date-time, or age  --></onset[x]>
 <abatement[x]><!-- 0..1 dateTime|Quantity(Age)|boolean|Period|Range|string  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..* Reference(ClinicalImpression|DiagnosticReport|Observation) Formal record of assessment  --></assessment>
 </stage>
 <evidence> <!-- 0..* Supporting evidence -->
 <code><!-- ?? 0..1 CodeableConcept  Manifestation/symptom  --></code>
 <detail><!-- ?? 0..* Reference(Any) Supporting information found elsewhere  --></detail>
 </evidence>
 <bodySite><!-- 0..* CodeableConcept  Anatomical location, if relevant  --></bodySite>
 <notes value="[string ]"/><!-- 0..1 Additional information about the Condition  -->
</Condition>

JSON Template

{doco 
 "resourceType" : "Condition",
 // from Resource: id, meta, implicitRules, and language
 // from DomainResource: text, contained, extension, and modifierExtension
 "identifier" : [{ Identifier  }], // External Ids for this condition 
 "patient" : { Reference(Patient) }, // R! Who has the condition? 
 "encounter" : { Reference(Encounter) }, // Encounter when condition first asserted 
 "asserter" : { Reference(Practitioner|Patient) }, // Person who asserts this condition 
 "dateRecorded" : "<date >", // When first entered 
 "code" : { CodeableConcept  }, // R! Identification of the condition, problem or diagnosis 
 "category" : { CodeableConcept  }, // complaint | symptom | finding | diagnosis 
 "clinicalStatus" : "<code >", // active | relapse | remission | resolved 
 "verificationStatus" : "<code >", // R! provisional | differential | confirmed | refuted | entered-in-error | unknown 
 "severity" : { CodeableConcept  }, // Subjective severity of condition 
 // onset[x]: Estimated or actual date, date-time, or age. One of these 5:
 "onsetDateTime" : "<dateTime >",
 "onsetQuantity" : { Quantity(Age) },
 "onsetPeriod" : { Period  },
 "onsetRange" : { Range  },
 "onsetString" : "<string >",
 // abatement[x]: If/when in resolution/remission. One of these 6:
 "abatementDateTime" : "<dateTime >",
 "abatementQuantity" : { Quantity(Age) },
 "abatementBoolean" : <boolean >,
 "abatementPeriod" : { Period  },
 "abatementRange" : { Range  },
 "abatementString" : "<string >",
 "stage" : { // Stage/grade, usually assessed formally 
 "summary" : { CodeableConcept  }, // C? Simple summary (disease specific) 
 "assessment" : [{ Reference(ClinicalImpression|DiagnosticReport|Observation) }] // C? Formal record of assessment 
 },
 "evidence" : [{ // Supporting evidence 
 "code" : { CodeableConcept  }, // C? Manifestation/symptom 
 "detail" : [{ Reference(Any) }] // C? Supporting information found elsewhere 
 }],
 "bodySite" : [{ CodeableConcept  }], // Anatomical location, if relevant 
 "notes" : "<string >" // Additional information about the Condition 
}

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

4.3.3.1 Terminology Bindings

Path	Definition	Type	Reference
Condition.code	Identification of the condition or diagnosis.	Example	Condition/Problem/Diagnosis Codes
Condition.category	A category assigned to the condition.	Preferred	Condition Category Codes
Condition.clinicalStatus	The clinical status of the condition or diagnosis.	Preferred	Condition Clinical Status Codes
Condition.verificationStatus	The verification status to support or decline the clinical status of the condition or diagnosis.	Required	ConditionVerificationStatus
Condition.severity	A subjective assessment of the severity of the condition as evaluated by the clinician.	Preferred	Condition/Diagnosis Severity
Condition.stage.summary	Codes describing condition stages (e.g. Cancer stages).	Example	Condition Stage
Condition.evidence.code	Codes that describe the manifestation or symptoms of a condition.	Example	Manifestation and Symptom Codes
Condition.bodySite	Codes describing anatomical locations. May include laterality.	Example	SNOMED CT Body Structures

4.3.3.2 Constraints

con-1: On Condition.stage: Stage SHALL have summary or assessment (xpath on f:Condition/f:stage: exists(f:summary) or exists(f:assessment))
con-2: On Condition.evidence: evidence SHALL have code or details (xpath on f:Condition/f:evidence: exists(f:code) or exists(f:detail))

4.3.3.3 Use of Condition.code

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.

The Condition.code may also include such concepts as "history of X" and "good health", where it is useful or appropriate to make such assertions. It can also be used to capture "risk of" and "fear of" in addition to physical conditions.

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.

4.3.3.4 Use of Condition.evidence

The Condition.evidence provides the basis for whatever is present in Condition.code.

4.3.3.5 Use of Condition.abatementRange

A range is used to communicate age period of subject at time of abatement.

4.3.3.6 Use of Condition.asserter

If the data enterer is different from the asserter and needs to be known, this could be captured using a Provenance instance pointing to the Condition. For example, it is possible that a nurse records the condition on behalf of a physician. The physician is taking responsibility, despite the nurse entering it into the medical record.

4.3.3.7 Use of Condition.clinicalStatus

The Condition.stage and Condition.clinicalStatus may have interdependencies. For example, some "stages" of cancer, etc. will be different for a remission than for the initial occurrence.

4.3.4 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Paths

asserter reference Person who asserts this condition Condition.asserter
(Patient, Practitioner)

body-site token Anatomical location, if relevant Condition.bodySite

category token The category of the condition Condition.category

clinicalstatus token The clinical status of the condition Condition.clinicalStatus

code token Code for the condition Condition.code

date-recorded date A date, when the Condition statement was documented Condition.dateRecorded

encounter reference Encounter when condition first asserted Condition.encounter
(Encounter)

evidence token Manifestation/symptom Condition.evidence.code

identifier token A unique identifier of the condition record Condition.identifier

onset date Date related onsets (dateTime and Period) Condition.onset[x]

onset-info string Other onsets (boolean, age, range, string) Condition.onset[x]

patient reference Who has the condition? Condition.patient
(Patient)

severity token The severity of the condition Condition.severity

stage token Simple summary (disease specific) Condition.stage.summary