Standard Health Record

ConditionPresenceStatementProfile

 

The official URL for this profile is:

http://standardhealthrecord.org/fhir/StructureDefinition/cimi-statement-ConditionPresenceStatement

A condition that is or may be present in a subject. 'Condition' is interpreted broadly and could be a disorder, abnormality, problem, injury, complaint, functionality, illness, disease, ailment, sickness, affliction, upset, difficulty, disorder, symptom, worry, or trouble.

In CIMI terms, it is an archetype of ClinicalStatement that combines a ConditionTopic with the ConditionPresenceContext context. The core attributes of ClinicalStatement are not included here because of mapping difficulties to FHIR DomainResource.

This profile builds on US Core Condition (a.k.a Problem) Profile.

This profile was published on Wed Aug 22 00:00:00 EDT 2018 as a draft by The MITRE Corporation: Standard Health Record Collaborative.

Summary

Mandatory: 0 element (2 nested mandatory elements)
Prohibited: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

SHR Mapping Source

This structure represents the following SHR mapping definition:

cimi.statement.ConditionPresenceStatement maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition:
  _Entry.CreationTime maps to assertedDate
  SubjectOfInformation maps to subject
  SourceOfInformation.EntityOrRole maps to asserter 
  ConditionTopic.Category maps to category
  ConditionTopic.TopicCode maps to code
  constrain bodySite to 0..0
  ConditionTopic.AnatomicalLocation maps to http://hl7.org/fhir/StructureDefinition/condition-targetBodySite 
  ConditionPresenceContext.Encounter maps to context
  ConditionPresenceContext.ClinicalStatus maps to clinicalStatus
  ConditionPresenceContext.VerificationStatus maps to verificationStatus
  ConditionPresenceContext.Onset maps to onset[x]
  ConditionPresenceContext.Abatement maps to abatement[x]
  ConditionPresenceContext.Severity maps to severity
  ConditionPresenceContext.Stage maps to stage
  ConditionPresenceContext.Stage.CodeableConcept maps to stage.summary
  ConditionPresenceContext.Stage.StageDetail maps to stage.assessment

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition SHR ConditionPresenceStatement Profile
... condition-targetBodySite 0..*Reference(BodySite)Extension
URL: http://hl7.org/fhir/StructureDefinition/condition-targetBodySite
... cimi-element-Annotation-extension 0..*AnnotationProfileSHR Annotation Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-element-Annotation-extension
... cimi-core-RecordStatus-extension 0..1CodeableConceptProfileSHR RecordStatus Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-RecordStatus-extension
... cimi-core-Recorded-extension 0..1(Complex)SHR Recorded Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Recorded-extension
... cimi-core-Signed-extension 0..1(Complex)SHR Signed Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Signed-extension
... cimi-core-Cosigned-extension 0..*(Complex)SHR Cosigned Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Cosigned-extension
... cimi-core-Verified-extension 0..*(Complex)SHR Verified Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Verified-extension
... clinicalStatus 1..1
... category CodeableConceptProfileBinding: SHR ConditionCategoryVS ValueSet (required)
... severity CodeableConceptProfileBinding: Condition/Diagnosis Severity (required)
... code CodeableConceptProfile
... bodySite 0..0
... subject Reference(SHR Patient Profile)
... context Reference(SHR Encounter Profile)
... onset[x] dateTime, AgeProfile, Period, RangeProfile, string
... abatement[x] dateTime, AgeProfile, boolean, Period, RangeProfile, string
... assertedDate 1..1
... asserter Reference(SHR Practitioner Profile | SHR Patient Profile | SHR RelatedPerson Profile)
... stage
.... summary CodeableConceptProfile
.... assessment 0..1Reference(SHR EvaluationResultRecorded Profile)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*SHR ConditionPresenceStatement Profile
us-core-1: A code in Condition.category SHOULD be from US Core Condition Category Codes value set.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
... condition-targetBodySite 0..*Reference(BodySite)Extension
URL: http://hl7.org/fhir/StructureDefinition/condition-targetBodySite
... cimi-element-Annotation-extension 0..*AnnotationProfileSHR Annotation Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-element-Annotation-extension
... cimi-core-RecordStatus-extension 0..1CodeableConceptProfileSHR RecordStatus Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-RecordStatus-extension
... cimi-core-Recorded-extension 0..1(Complex)SHR Recorded Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Recorded-extension
... cimi-core-Signed-extension 0..1(Complex)SHR Signed Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Signed-extension
... cimi-core-Cosigned-extension 0..*(Complex)SHR Cosigned Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Cosigned-extension
... cimi-core-Verified-extension 0..*(Complex)SHR Verified Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Verified-extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI1..1codeactive | recurrence | inactive | remission | resolved
Binding: Condition Clinical Status Codes (required)
... verificationStatus ?!SΣI1..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding: ConditionVerificationStatus (required)
... category S1..*CodeableConceptProfileproblem-list-item | encounter-diagnosis
Binding: SHR ConditionCategoryVS ValueSet (required)
... severity 0..1CodeableConceptProfileSubjective severity of condition
Binding: Condition/Diagnosis Severity (required)
... code SΣ1..1CodeableConceptProfileIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (extensible)
... subject SΣ1..1Reference(SHR Patient Profile)Who has the condition?
... context Σ0..1Reference(SHR Encounter Profile)Encounter or episode when condition first asserted
... onset[x] Σ0..1dateTime, AgeProfile, Period, RangeProfile, stringEstimated or actual date, date-time, or age
... abatement[x] I0..1dateTime, AgeProfile, boolean, Period, RangeProfile, stringIf/when in resolution/remission
... assertedDate Σ1..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(SHR Practitioner Profile | SHR Patient Profile | SHR RelatedPerson Profile)Person who asserts this condition
... stage I0..1BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... summary I0..1CodeableConceptProfileSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment I0..1Reference(SHR EvaluationResultRecorded Profile)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example)
.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Summary

Mandatory: 0 element (2 nested mandatory elements)
Prohibited: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

SHR Mapping Source

This structure represents the following SHR mapping definition:

cimi.statement.ConditionPresenceStatement maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition:
  _Entry.CreationTime maps to assertedDate
  SubjectOfInformation maps to subject
  SourceOfInformation.EntityOrRole maps to asserter 
  ConditionTopic.Category maps to category
  ConditionTopic.TopicCode maps to code
  constrain bodySite to 0..0
  ConditionTopic.AnatomicalLocation maps to http://hl7.org/fhir/StructureDefinition/condition-targetBodySite 
  ConditionPresenceContext.Encounter maps to context
  ConditionPresenceContext.ClinicalStatus maps to clinicalStatus
  ConditionPresenceContext.VerificationStatus maps to verificationStatus
  ConditionPresenceContext.Onset maps to onset[x]
  ConditionPresenceContext.Abatement maps to abatement[x]
  ConditionPresenceContext.Severity maps to severity
  ConditionPresenceContext.Stage maps to stage
  ConditionPresenceContext.Stage.CodeableConcept maps to stage.summary
  ConditionPresenceContext.Stage.StageDetail maps to stage.assessment

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition SHR ConditionPresenceStatement Profile
... condition-targetBodySite 0..*Reference(BodySite)Extension
URL: http://hl7.org/fhir/StructureDefinition/condition-targetBodySite
... cimi-element-Annotation-extension 0..*AnnotationProfileSHR Annotation Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-element-Annotation-extension
... cimi-core-RecordStatus-extension 0..1CodeableConceptProfileSHR RecordStatus Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-RecordStatus-extension
... cimi-core-Recorded-extension 0..1(Complex)SHR Recorded Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Recorded-extension
... cimi-core-Signed-extension 0..1(Complex)SHR Signed Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Signed-extension
... cimi-core-Cosigned-extension 0..*(Complex)SHR Cosigned Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Cosigned-extension
... cimi-core-Verified-extension 0..*(Complex)SHR Verified Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Verified-extension
... clinicalStatus 1..1
... category CodeableConceptProfileBinding: SHR ConditionCategoryVS ValueSet (required)
... severity CodeableConceptProfileBinding: Condition/Diagnosis Severity (required)
... code CodeableConceptProfile
... bodySite 0..0
... subject Reference(SHR Patient Profile)
... context Reference(SHR Encounter Profile)
... onset[x] dateTime, AgeProfile, Period, RangeProfile, string
... abatement[x] dateTime, AgeProfile, boolean, Period, RangeProfile, string
... assertedDate 1..1
... asserter Reference(SHR Practitioner Profile | SHR Patient Profile | SHR RelatedPerson Profile)
... stage
.... summary CodeableConceptProfile
.... assessment 0..1Reference(SHR EvaluationResultRecorded Profile)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*SHR ConditionPresenceStatement Profile
us-core-1: A code in Condition.category SHOULD be from US Core Condition Category Codes value set.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
... condition-targetBodySite 0..*Reference(BodySite)Extension
URL: http://hl7.org/fhir/StructureDefinition/condition-targetBodySite
... cimi-element-Annotation-extension 0..*AnnotationProfileSHR Annotation Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-element-Annotation-extension
... cimi-core-RecordStatus-extension 0..1CodeableConceptProfileSHR RecordStatus Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-RecordStatus-extension
... cimi-core-Recorded-extension 0..1(Complex)SHR Recorded Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Recorded-extension
... cimi-core-Signed-extension 0..1(Complex)SHR Signed Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Signed-extension
... cimi-core-Cosigned-extension 0..*(Complex)SHR Cosigned Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Cosigned-extension
... cimi-core-Verified-extension 0..*(Complex)SHR Verified Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/cimi-core-Verified-extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI1..1codeactive | recurrence | inactive | remission | resolved
Binding: Condition Clinical Status Codes (required)
... verificationStatus ?!SΣI1..1codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding: ConditionVerificationStatus (required)
... category S1..*CodeableConceptProfileproblem-list-item | encounter-diagnosis
Binding: SHR ConditionCategoryVS ValueSet (required)
... severity 0..1CodeableConceptProfileSubjective severity of condition
Binding: Condition/Diagnosis Severity (required)
... code SΣ1..1CodeableConceptProfileIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (extensible)
... subject SΣ1..1Reference(SHR Patient Profile)Who has the condition?
... context Σ0..1Reference(SHR Encounter Profile)Encounter or episode when condition first asserted
... onset[x] Σ0..1dateTime, AgeProfile, Period, RangeProfile, stringEstimated or actual date, date-time, or age
... abatement[x] I0..1dateTime, AgeProfile, boolean, Period, RangeProfile, stringIf/when in resolution/remission
... assertedDate Σ1..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(SHR Practitioner Profile | SHR Patient Profile | SHR RelatedPerson Profile)Person who asserts this condition
... stage I0..1BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... summary I0..1CodeableConceptProfileSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment I0..1Reference(SHR EvaluationResultRecorded Profile)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example)
.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, TTL), Schema: XML Schematron

 

Terminology Bindings

PathNameConformanceValueSet
Condition.languageCommon LanguagesextensibleCommon Languages
Condition.clinicalStatusCondition Clinical Status CodesrequiredCondition Clinical Status Codes
Condition.verificationStatusConditionVerificationStatusrequiredConditionVerificationStatus
Condition.categorySHR ConditionCategoryVS ValueSetrequiredConditionCategoryVS
Condition.severityCondition/Diagnosis SeverityrequiredCondition/Diagnosis Severity
Condition.codeProblem Value SetextensibleProblem Value Set
Condition.stage.summaryCondition StageexampleCondition Stage
Condition.evidence.codeManifestation and Symptom CodesexampleManifestation and Symptom Codes

 

Constraints

IdPathDetailsRequirements
dom-2ConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-1ConditionIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-4ConditionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-3ConditionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
con-4ConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive'
con-3ConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error
: verificationStatus='entered-in-error' or clinicalStatus.exists()
us-core-1ConditionA code in Condition.category SHOULD be from US Core Condition Category Codes value set.
: where(category in 'http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category').exists()
ele-1Condition.stageAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
con-1Condition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
ele-1Condition.evidenceAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
con-2Condition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()