FHIR Release 3 (STU)

This page is part of the FHIR Specification (v3.0.2: STU 3). 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

9.2.6 Resource Condition - Detailed Descriptions

Detailed Descriptions for the elements in the Condition resource.

Condition
Definition

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

Control 1..1
Invariants Defined on this element
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error (expression : verificationStatus='entered-in-error' or clinicalStatus.exists(), xpath: f:verificationStatus/@value='entered-in-error' or exists(f:clinicalStatus))
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (expression : abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive', xpath: not(exists(*[starts-with(local-name(.), 'abatement')])) or f:clinicalStatus/@value=('resolved', 'remission', 'inactive'))
Condition.identifier
Definition

This records identifiers associated with this condition that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

Note This is a business identifer, not a resource identifier (see discussion)
Control 0..*
Requirements

Need to allow connection to a wider workflow.

Summary true
Condition.clinicalStatus
Definition

The clinical status of the condition.

Control 0..1
Summary true
Comments

This element is labeled as a modifier because the status contains codes that mark the condition as not currently valid or of concern.

Invariants Affect this element
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error (expression : verificationStatus='entered-in-error' or clinicalStatus.exists(), xpath: f:verificationStatus/@value='entered-in-error' or exists(f:clinicalStatus))
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (expression : abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive', xpath: not(exists(*[starts-with(local-name(.), 'abatement')])) or f:clinicalStatus/@value=('resolved', 'remission', 'inactive'))
Condition.verificationStatus
Definition

The verification status to support the clinical status of the condition.

Control 0..1
Default Value unknown
Summary true
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.

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.

Invariants Affect this element
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error (expression : verificationStatus='entered-in-error' or clinicalStatus.exists(), xpath: f:verificationStatus/@value='entered-in-error' or exists(f:clinicalStatus))
Condition.category
Definition

A category assigned to the condition.

Control 0..*
Comments

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

Condition.severity
Definition

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

Control 0..1
Comments

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

Condition.code
Definition

Identification of the condition, problem or diagnosis.

Control 0..1
Requirements

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

Alternate Names type
Summary true
Condition.bodySite
Definition

The anatomical location where this condition manifests itself.

Control 0..*
Summary true
Comments

Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension body-site-instance. May be a summary code, or a reference to a very precise definition of the location, or both.

Condition.subject
Definition

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

Control 1..1
Requirements

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

Alternate Names patient
Summary true
Condition.context
Definition

Encounter during which the condition was first asserted.

Control 0..1
Alternate Names encounter
Summary true
Comments

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".

Condition.onset[x]
Definition

Estimated or actual date or date-time the condition began, in the opinion of the clinician.

Control 0..1
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
Comments

Age is generally used when the patient reports an age at which the Condition began to occur.

Condition.abatement[x]
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" - Conditions are never really resolved, but they can abate.

Control 0..1
[x] Note See Choice of Data Types for further information about how to use [x]
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.

Invariants Affect this element
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (expression : abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive', xpath: not(exists(*[starts-with(local-name(.), 'abatement')])) or f:clinicalStatus/@value=('resolved', 'remission', 'inactive'))
Condition.assertedDate
Definition

The date on which the existance of the Condition was first asserted or acknowledged.

Control 0..1
Summary true
Comments

The assertedDate represents the date when this particular Condition record was created in the EHR, not the date of the most recent update in terms of when severity, abatement, etc. were specified. The date of the last record modification can be retrieved from the resource metadata.

Condition.asserter
Definition

Individual who is making the condition statement.

Control 0..1
Summary true
Condition.stage
Definition

Clinical stage or grade of a condition. May include formal severity assessments.

Control 0..1
Invariants Defined on this element
con-1: Stage SHALL have summary or assessment (expression : summary.exists() or assessment.exists(), xpath: exists(f:summary) or exists(f:assessment))
Condition.stage.summary
Definition

A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.

Control 0..1
Invariants Affect this element
con-1: Stage SHALL have summary or assessment (expression : summary.exists() or assessment.exists(), xpath: exists(f:summary) or exists(f:assessment))
Condition.stage.assessment
Definition

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

Control 0..*
Invariants Affect this element
con-1: Stage SHALL have summary or assessment (expression : summary.exists() or assessment.exists(), xpath: exists(f:summary) or exists(f:assessment))
Condition.evidence
Definition

Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed.

Control 0..*
Comments

The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.

Invariants Defined on this element
con-2: evidence SHALL have code or details (expression : code.exists() or detail.exists(), xpath: exists(f:code) or exists(f:detail))
Condition.evidence.code
Definition

A manifestation or symptom that led to the recording of this condition.

Control 0..*
Summary true
Invariants Affect this element
con-2: evidence SHALL have code or details (expression : code.exists() or detail.exists(), xpath: exists(f:code) or exists(f:detail))
Condition.evidence.detail
Definition

Links to other relevant information, including pathology reports.

Control 0..*
Summary true
Invariants Affect this element
con-2: evidence SHALL have code or details (expression : code.exists() or detail.exists(), xpath: exists(f:code) or exists(f:detail))
Condition.note
Definition

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

Control 0..*

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