Path | Short | Definition | Comments |
---|---|---|---|
Detailed information about conditions, problems or diagnoses | A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. | ||
identifier | External Ids for this condition | 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. | This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). 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. |
clinicalStatus | active | recurrence | relapse | inactive | remission | resolved | The clinical status of the condition. | 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. |
verificationStatus | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | The verification status to support the clinical status of the condition. | 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. |
category | problem-list-item | encounter-diagnosis | A category assigned to the condition. | The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. |
severity | Subjective severity of condition | A subjective assessment of the severity of the condition as evaluated by the clinician. | Coding of the severity with a terminology is preferred, where possible. |
code | Identification of the condition, problem or diagnosis | Identification of the condition, problem or diagnosis. | |
bodySite | Anatomical location, if relevant | The anatomical location where this condition manifests itself. | 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](extension-bodysite.html). May be a summary code, or a reference to a very precise definition of the location, or both. |
subject | Who has the condition? | Indicates the patient or group who the condition record is associated with. | |
encounter | Encounter created as part of | The Encounter during which this Condition was created or to which the creation of this record is tightly associated. | 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". |
onset[x] | Estimated or actual date, date-time, or age | Estimated or actual date or date-time the condition began, in the opinion of the clinician. | Age is generally used when the patient reports an age at which the Condition began to occur. |
abatement[x] | When in resolution/remission | 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. | 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. |
recordedDate | Date record was first recorded | The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date. | |
recorder | Who recorded the condition | Individual who recorded the record and takes responsibility for its content. | |
asserter | Person who asserts this condition | Individual who is making the condition statement. | |
stage | Stage/grade, usually assessed formally | Clinical stage or grade of a condition. May include formal severity assessments. | |
stage.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
stage.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
stage.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
stage.summary | Simple summary (disease specific) | A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. | |
stage.assessment | Formal record of assessment | Reference to a formal record of the evidence on which the staging assessment is based. | |
stage.type | Kind of staging | The kind of staging, such as pathological or clinical staging. | |
evidence | Supporting evidence | Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. | The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. |
evidence.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
evidence.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
evidence.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
evidence.code | Manifestation/symptom | A manifestation or symptom that led to the recording of this condition. | |
evidence.detail | Supporting information found elsewhere | Links to other relevant information, including pathology reports. | |
note | Additional information about the Condition | Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. |
Condition is one of the event resources in the FHIR workflow specification.
This resource is used to record detailed information about a condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. The condition could be a point in time diagnosis in context of an encounter, it could be an item on the practitioner’s Problem List, or it could be a concern that doesn’t exist on the practitioner’s Problem List. Often times, a condition is about a clinician's assessment and assertion of a particular aspect of a patient's state of health. It can be used 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 a practitioner considers harmful, potentially harmful and may be investigated and managed (problem), or other health issue/situation that may require ongoing monitoring and/or management (health issue/concern).
The condition resource may be used to record a certain health state of a patient which does not normally present a negative outcome, e.g. pregnancy. The condition resource may be used to record a condition following a procedure, such as the condition of Amputee-BKA following an amputation procedure.
While conditions are frequently a result of a clinician's assessment and assertion of a particular aspect of a patient's state of health, conditions can also be expressed by the patient, related person, or any care team member. A clinician may have a concern about a patient condition (e.g. anorexia) that the patient is not concerned about. Likewise, the patient may have a condition (e.g. hair loss) that does not rise to the level of importance such that it belongs on a practitioner’s Problem List.
For example, each of the following conditions could rise to the level of importance such that it belongs on a problem or concern list due to its direct or indirect impact on the patient’s health. These examples may also be represented using other resources, such as FamilyMemberHistory, Observation, or Procedure.
The condition resource may be referenced by other resources as "reasons" for an action (e.g. MedicationRequest, Procedure, ServiceRequest, etc.)
This resource is not typically used to record information about subjective and objective information that might lead to the recording of a Condition resource. Such signs and symptoms 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. By contrast, headache may be captured as an Observation when it contributes to the establishment of a meningitis Condition.
Use the Observation resource when a symptom is resolved without long term management, tracking, or when a symptom contributes to the establishment of a condition.
Use Condition when a symptom requires long term management, tracking, or is used as a proxy for a diagnosis or problem that is not yet determined.
When the diagnosis is related to an allergy or intolerance, the Condition and AllergyIntolerance resources can both be used. However, to be actionable for decision support, using Condition alone is not sufficient as the allergy or intolerance condition needs to be represented as an AllergyIntolerance.
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, as well as "no known problems" or "negated" conditions (e.g., "no X" or "no history of X" - see the following section for "No Known Problems" and Negated 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.
Conditions/Problems Not Reviewed, Not Asked
When a sending system does not have any information about conditions/problems being reviewed or the statement is about conditions/problems not yet being asked, then the List resource should be used to indicate the List.emptyReason.code="notasked".
Conditions/Problems Reviewed, None Identified
Systems may use the List.emptyReason when a statement is about the full scope of the list (i.e. the patient has no conditions/problems of any type). However, it may be preferred to use a code for "no known problems" (e.g., SNOMED CT: 160245001 |No current problems or disability (situation)|), so that all condition/problem data will be available and queryable from Condition resource instances.
Also note that care should be used when adding new Condition resources to a list to ensure that any negation statements that are voided by the addition of a new record are removed from the list. E.g. If the list contains a "no known problems" record and you add a "diabetes" condition record, then be sure that you remove the "no known problems" record.
[%stu-note%] There are two primary ways of reporting "no known problems" in the current specification: using the CodeableConcept, as described above, or using the List resource with emptyReason. During the STU period, feedback is sought regarding the preferred approach.Provide feedback here. [%end-note%]
Patient Denies Condition
When the patient denies a condition, that can be annotated in the Condition.note element.
Generally, electronic records do not contain assertions of conditions that a patient does not have. There are however two exceptions:
The Condition.evidence provides the basis for whatever is present in Condition.code.
A range is used to communicate age period of subject at time of abatement.
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.
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.
To represent the role of the diagnosis within an encounter, such as admission diagnosis or discharge diagnosis, use Encounter.diagnosis.role.
To represent the numeric ranking of the diagnosis within an encounter, such as primary, secondary, or tertiary, use Encounter.diagnosis.rank.
A known issue exists with circular references between Condition and ClinicalImpression, which is due to the low maturity level of ClinicalImpression. The Patient Care work group intends to address this issue when ClinicalImpression is considered substantially complete and ready for implementation.
abatement-age | Abatement as age or age range | Condition.abatement.as(Age) | Condition.abatement.as(Range) |
abatement-date | Date-related abatements (dateTime and period) | Condition.abatement.as(dateTime) | Condition.abatement.as(Period) |
abatement-string | Abatement as a string | Condition.abatement.as(string) |
asserter | Person who asserts this condition | Condition.asserter |
body-site | Anatomical location, if relevant | Condition.bodySite |
category | The category of the condition | Condition.category |
clinical-status | The clinical status of the condition | Condition.clinicalStatus |
encounter | Encounter created as part of | Condition.encounter |
evidence | Manifestation/symptom | Condition.evidence.code |
evidence-detail | Supporting information found elsewhere | Condition.evidence.detail |
onset-age | Onsets as age or age range | Condition.onset.as(Age) | Condition.onset.as(Range) |
onset-date | Date related onsets (dateTime and Period) | Condition.onset.as(dateTime) | Condition.onset.as(Period) |
onset-info | Onsets as a string | Condition.onset.as(string) |
recorded-date | Date record was first recorded | Condition.recordedDate |
severity | The severity of the condition | Condition.severity |
stage | Simple summary (disease specific) | Condition.stage.summary |
subject | Who has the condition? | Condition.subject |
verification-status | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error | Condition.verificationStatus |