Release 4 5 Preview #3
This page is part of the FHIR Specification (v4.0.1: R4 - Mixed Normative and STU ). This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Patient Care Work Group Maturity Level : 3   Trial Use Security Category : Patient Compartments : Encounter , Patient , Practitioner , RelatedPerson

Detailed Descriptions for the elements in the Condition resource.

Condition
Element Id Condition
Definition

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

Cardinality 0..*
Type DomainResource
Invariants
Defined on this element
con-3 Guideline Condition.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() verificationStatus='entered-in-error' or category.select($this='problem-list-item').empty()
This is (only) a best practice guideline because:

Most systems will expect a clinicalStatus to be valued for problem-list-items that are managed over time, but might not need a clinicalStatus for point in time encounter-diagnosis.

con-4 Rule If 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-5 Rule Condition.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()
Condition.identifier
Element Id Condition.identifier
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.

Note This is a business identifier, not a resource identifier (see discussion )
Cardinality 0..*
Type Identifier
Requirements

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

Summary true
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.

Condition.clinicalStatus
Element Id Condition.clinicalStatus
Definition

The clinical status of the condition.

Cardinality 0..1
Terminology Binding Condition Clinical Status Codes ( Required )
Type CodeableConcept
Is Modifier true (Reason: This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.)
Summary true
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.

Invariants
Affect this element
con-3 Guideline Condition.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() verificationStatus='entered-in-error' or category.select($this='problem-list-item').empty()
This is (only) a best practice guideline because:

Most systems will expect a clinicalStatus to be valued for problem-list-items that are managed over time, but might not need a clinicalStatus for point in time encounter-diagnosis.

con-4 Rule If 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-5 Rule Condition.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()
Condition.verificationStatus
Element Id Condition.verificationStatus
Definition

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

Cardinality 0..1
Terminology Binding ConditionVerificationStatus ( Required )
Type CodeableConcept
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.)
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. 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.

Invariants
Affect this element
con-3 Guideline Condition.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() verificationStatus='entered-in-error' or category.select($this='problem-list-item').empty()
This is (only) a best practice guideline because:

Most systems will expect a clinicalStatus to be valued for problem-list-items that are managed over time, but might not need a clinicalStatus for point in time encounter-diagnosis.

con-5 Rule Condition.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()
Condition.category
Element Id Condition.category
Definition

A category assigned to the condition.

Cardinality 0..*
Terminology Binding Condition Category Codes ( Extensible )
Type CodeableConcept
Comments

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

Condition.severity
Element Id Condition.severity
Definition

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

Cardinality 0..1
Terminology Binding Condition/Diagnosis Severity ( Preferred )
Type CodeableConcept
Comments

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

Condition.code
Element Id Condition.code
Definition

Identification of the condition, problem or diagnosis.

Cardinality 0..1
Terminology Binding Condition/Problem/Diagnosis Codes ( Example )
Type CodeableConcept
Requirements

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

Alternate Names type
Summary true
Condition.bodySite
Element Id Condition.bodySite
Definition

The anatomical location where this condition manifests itself.

Cardinality 0..*
Terminology Binding SNOMED CT Body Structures ( Example )
Type CodeableConcept
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 bodySite . May be a summary code, or a reference to a very precise definition of the location, or both.

Condition.subject
Element Id Condition.subject
Definition

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

Cardinality 1..1
Type Reference ( Patient | Group )
Patterns Reference(Patient,Group): Common patterns = Participant
Requirements

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

Alternate Names patient
Summary true
Condition.encounter
Element Id Condition.encounter
Definition

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

Cardinality 0..1
Type Reference ( Encounter )
Summary true
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".

Condition.onset[x]
Element Id Condition.onset[x]
Definition

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

Cardinality 0..1
Type dateTime | Age | Period | Range | string
[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. 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.

Condition.abatement[x]
Element Id 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 Some conditions, such as chronic conditions, are never really resolved, but they can abate.

Cardinality 0..1
Type dateTime | Age | Period | Range | string
[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 Rule If 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()
Condition.recordedDate
Element Id Condition.recordedDate
Definition

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

Cardinality 0..1
Type dateTime
Summary true
Condition.recorder
Element Id Condition.recorder
Definition

Individual who recorded the record and takes responsibility for its content.

Cardinality 0..1
Type Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson )
Patterns Reference(Practitioner,PractitionerRole,Patient,RelatedPerson): Common patterns = Participant
Summary true
Condition.asserter
Element Id Condition.asserter
Definition

Individual who or device that is making the condition statement.

Cardinality 0..1
Type Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson | Device )
Patterns Reference(Practitioner,PractitionerRole,Patient,RelatedPerson,Device): Common patterns = Participant
Summary true
Condition.stage
Element Id Condition.stage
Definition

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

Cardinality 0..*
Invariants
Defined on this element
con-1 Rule Stage SHALL have summary or assessment summary.exists() or assessment.exists()
Condition.stage.summary
Element Id Condition.stage.summary
Definition

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

Cardinality 0..1
Terminology Binding Condition Stage ( Example )
Type CodeableConcept
Invariants
Affect this element
con-1 Rule Stage SHALL have summary or assessment summary.exists() or assessment.exists()
Condition.stage.assessment
Element Id Condition.stage.assessment
Definition

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

Cardinality 0..*
Type Reference ( ClinicalImpression | DiagnosticReport | Observation )
Patterns Reference(ClinicalImpression,DiagnosticReport,Observation): Common patterns = Event
Invariants
Affect this element
con-1 Rule Stage SHALL have summary or assessment summary.exists() or assessment.exists()
Condition.stage.type
Element Id Condition.stage.type
Definition

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

Cardinality 0..1
Terminology Binding Condition Stage Type ( Example )
Type CodeableConcept
Condition.evidence
Element Id Condition.evidence
Definition

Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition.

Cardinality 0..*
Comments

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.

Invariants
Defined on this element
con-2 Rule evidence SHALL have code or details code.exists() or detail.exists()
Condition.evidence.code
Element Id Condition.evidence.code
Definition

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

Cardinality 0..*
Terminology Binding Manifestation and Symptom Codes ( Example )
Type CodeableConcept
Summary true
Invariants
Affect this element
con-2 Rule evidence SHALL have code or details code.exists() or detail.exists()
Condition.evidence.detail
Element Id Condition.evidence.detail
Definition

Links to other relevant information, including pathology reports.

Cardinality 0..*
Type Reference ( Any )
Summary true
Invariants
Affect this element
con-2 Rule evidence SHALL have code or details code.exists() or detail.exists()
Condition.note
Element Id Condition.note
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