Standard Health Record FHIR Implementation Guide

SHR Condition Profile

 

The official URL for this profile is:

http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Condition

A disorder, abnormality, problem, injury, complaint, risk, functionality, concern, illness, disease, ailment, sickness, affliction, upset, difficulty, disorder, symptom, worry, or trouble. A ConditionPresent finding implies the existence of a condition as an entity. 'Condition' is interpreted broadly to cover states of existence - things the patient is or has.

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

This profile was published on Tue Feb 27 00:00:00 EST 2018 as a draft by The MITRE Corporation: Standard Health Record Collaborative.

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

Summary

Mandatory: 0 element (2 nested mandatory elements)

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:

shr.condition.Condition maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition:
  RelatedEncounter maps to context
  Informant maps to asserter
  Subject maps to subject
  _Entry.CreationTime maps to assertedDate
  CodeableConcept maps to code
  Category maps to category
  ClinicalStatus maps to clinicalStatus
  Onset maps to onset[x]
  Abatement maps to abatement[x]
  BodySiteOrCode.CodeableConcept maps to bodySite   
  BodySiteOrCode.BodySite maps to http://hl7.org/fhir/StructureDefinition/body-structure
  Severity maps to severity
  Stage maps to stage
  Stage.CodeableConcept maps to stage.summary
  Evidence maps to evidence

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition SHR Condition Profile
... clinicalStatus 1..1
... category Binding: SHR ConditionCategoryVS ValueSet (required)
... severity Binding: Condition/Diagnosis Severity (required)
... code
... bodySite Binding: SHR BodySiteVS ValueSet (required)
... subject Reference(SHR Patient Profile)
... context Reference(SHR EncounterPerformed Profile)
... onset[x] dateTime, SHR Age Profile, SHR GestationalAge Profile, Period
... abatement[x] dateTime, SHR Age Profile, SHR GestationalAge Profile, Period
... assertedDate 1..1
... asserter Reference(SHR Patient Profile), Reference(SHR RelatedPerson Profile)
... extension 0..1?? http://hl7.org/fhir/StructureDefinition/body-structureURL: http://hl7.org/fhir/StructureDefinition/body-structure
... shr-base-Author-extension 0..1(Complex)SHR Author Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Author-extension
... shr-finding-FocalSubject-extension 0..1CodeableConceptSHR FocalSubject Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FocalSubject-extension
... shr-finding-FocalSubjectReference-extension 0..1(Complex)SHR FocalSubjectReference Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FocalSubjectReference-extension
... shr-finding-FindingMethod-extension 0..1CodeableConceptSHR FindingMethod Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FindingMethod-extension
... shr-finding-FindingStatus-extension 0..1CodeableConceptSHR FindingStatus Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FindingStatus-extension
Binding: ObservationStatus (required)
... shr-condition-WhenClinicallyRecognized-extension 0..1(Complex)SHR WhenClinicallyRecognized Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-WhenClinicallyRecognized-extension
... shr-condition-Preexisting-extension 0..1CodeableConceptSHR Preexisting Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Preexisting-extension
Binding: SHR YesNoUnknownVS ValueSet (required)
... shr-condition-Criticality-extension 0..1codeSHR Criticality Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Criticality-extension
.... valueCode Binding: AllergyIntoleranceCriticality (required)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*SHR Condition 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..1?? http://hl7.org/fhir/StructureDefinition/body-structureURL: http://hl7.org/fhir/StructureDefinition/body-structure
... shr-base-Author-extension 0..1(Complex)SHR Author Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Author-extension
... shr-finding-FocalSubject-extension 0..1CodeableConceptSHR FocalSubject Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FocalSubject-extension
... shr-finding-FocalSubjectReference-extension 0..1(Complex)SHR FocalSubjectReference Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FocalSubjectReference-extension
... shr-finding-FindingMethod-extension 0..1CodeableConceptSHR FindingMethod Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FindingMethod-extension
... shr-finding-FindingStatus-extension 0..1CodeableConceptSHR FindingStatus Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FindingStatus-extension
Binding: ObservationStatus (required)
... shr-condition-WhenClinicallyRecognized-extension 0..1(Complex)SHR WhenClinicallyRecognized Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-WhenClinicallyRecognized-extension
... shr-condition-Preexisting-extension 0..1CodeableConceptSHR Preexisting Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Preexisting-extension
Binding: SHR YesNoUnknownVS ValueSet (required)
... shr-condition-Criticality-extension 0..1codeSHR Criticality Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Criticality-extension
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Criticality-extension"
.... valueCode 1..1codeValue of extension
Binding: AllergyIntoleranceCriticality (required)
... 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..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: SHR ConditionCategoryVS ValueSet (required)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (required)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (extensible)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SHR BodySiteVS ValueSet (required)
... subject SΣ1..1Reference(SHR Patient Profile)Who has the condition?
... context Σ0..1Reference(SHR EncounterPerformed Profile)Encounter or episode when condition first asserted
... onset[x] Σ0..1dateTime, SHR Age Profile, SHR GestationalAge Profile, PeriodEstimated or actual date, date-time, or age
... abatement[x] I0..1dateTime, SHR Age Profile, SHR GestationalAge Profile, PeriodIf/when in resolution/remission
... assertedDate Σ1..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(SHR Patient Profile), Reference(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..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment I0..*Reference(ClinicalImpression), Reference(DiagnosticReport), Reference(Observation)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)

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:

shr.condition.Condition maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition:
  RelatedEncounter maps to context
  Informant maps to asserter
  Subject maps to subject
  _Entry.CreationTime maps to assertedDate
  CodeableConcept maps to code
  Category maps to category
  ClinicalStatus maps to clinicalStatus
  Onset maps to onset[x]
  Abatement maps to abatement[x]
  BodySiteOrCode.CodeableConcept maps to bodySite   
  BodySiteOrCode.BodySite maps to http://hl7.org/fhir/StructureDefinition/body-structure
  Severity maps to severity
  Stage maps to stage
  Stage.CodeableConcept maps to stage.summary
  Evidence maps to evidence

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition SHR Condition Profile
... clinicalStatus 1..1
... category Binding: SHR ConditionCategoryVS ValueSet (required)
... severity Binding: Condition/Diagnosis Severity (required)
... code
... bodySite Binding: SHR BodySiteVS ValueSet (required)
... subject Reference(SHR Patient Profile)
... context Reference(SHR EncounterPerformed Profile)
... onset[x] dateTime, SHR Age Profile, SHR GestationalAge Profile, Period
... abatement[x] dateTime, SHR Age Profile, SHR GestationalAge Profile, Period
... assertedDate 1..1
... asserter Reference(SHR Patient Profile), Reference(SHR RelatedPerson Profile)
... extension 0..1?? http://hl7.org/fhir/StructureDefinition/body-structureURL: http://hl7.org/fhir/StructureDefinition/body-structure
... shr-base-Author-extension 0..1(Complex)SHR Author Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Author-extension
... shr-finding-FocalSubject-extension 0..1CodeableConceptSHR FocalSubject Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FocalSubject-extension
... shr-finding-FocalSubjectReference-extension 0..1(Complex)SHR FocalSubjectReference Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FocalSubjectReference-extension
... shr-finding-FindingMethod-extension 0..1CodeableConceptSHR FindingMethod Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FindingMethod-extension
... shr-finding-FindingStatus-extension 0..1CodeableConceptSHR FindingStatus Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FindingStatus-extension
Binding: ObservationStatus (required)
... shr-condition-WhenClinicallyRecognized-extension 0..1(Complex)SHR WhenClinicallyRecognized Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-WhenClinicallyRecognized-extension
... shr-condition-Preexisting-extension 0..1CodeableConceptSHR Preexisting Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Preexisting-extension
Binding: SHR YesNoUnknownVS ValueSet (required)
... shr-condition-Criticality-extension 0..1codeSHR Criticality Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Criticality-extension
.... valueCode Binding: AllergyIntoleranceCriticality (required)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*SHR Condition 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..1?? http://hl7.org/fhir/StructureDefinition/body-structureURL: http://hl7.org/fhir/StructureDefinition/body-structure
... shr-base-Author-extension 0..1(Complex)SHR Author Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-base-Author-extension
... shr-finding-FocalSubject-extension 0..1CodeableConceptSHR FocalSubject Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FocalSubject-extension
... shr-finding-FocalSubjectReference-extension 0..1(Complex)SHR FocalSubjectReference Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FocalSubjectReference-extension
... shr-finding-FindingMethod-extension 0..1CodeableConceptSHR FindingMethod Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FindingMethod-extension
... shr-finding-FindingStatus-extension 0..1CodeableConceptSHR FindingStatus Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-finding-FindingStatus-extension
Binding: ObservationStatus (required)
... shr-condition-WhenClinicallyRecognized-extension 0..1(Complex)SHR WhenClinicallyRecognized Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-WhenClinicallyRecognized-extension
... shr-condition-Preexisting-extension 0..1CodeableConceptSHR Preexisting Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Preexisting-extension
Binding: SHR YesNoUnknownVS ValueSet (required)
... shr-condition-Criticality-extension 0..1codeSHR Criticality Extension
URL: http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Criticality-extension
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://standardhealthrecord.org/fhir/StructureDefinition/shr-condition-Criticality-extension"
.... valueCode 1..1codeValue of extension
Binding: AllergyIntoleranceCriticality (required)
... 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..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: SHR ConditionCategoryVS ValueSet (required)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (required)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Problem Value Set (extensible)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SHR BodySiteVS ValueSet (required)
... subject SΣ1..1Reference(SHR Patient Profile)Who has the condition?
... context Σ0..1Reference(SHR EncounterPerformed Profile)Encounter or episode when condition first asserted
... onset[x] Σ0..1dateTime, SHR Age Profile, SHR GestationalAge Profile, PeriodEstimated or actual date, date-time, or age
... abatement[x] I0..1dateTime, SHR Age Profile, SHR GestationalAge Profile, PeriodIf/when in resolution/remission
... assertedDate Σ1..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(SHR Patient Profile), Reference(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..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example)
.... assessment I0..*Reference(ClinicalImpression), Reference(DiagnosticReport), Reference(Observation)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.extension.valueCodeAllergyIntoleranceCriticalityrequiredAllergyIntoleranceCriticality
Condition.clinicalStatusCondition Clinical Status CodesrequiredCondition Clinical Status Codes
Condition.verificationStatusConditionVerificationStatusrequiredConditionVerificationStatus
Condition.categorySHR ConditionCategoryVS ValueSetrequiredSHR ConditionCategoryVS ValueSet
Condition.severityCondition/Diagnosis SeverityrequiredCondition/Diagnosis Severity
Condition.codeProblem Value SetextensibleProblem Value Set
Condition.bodySiteSHR BodySiteVS ValueSetrequiredSHR BodySiteVS ValueSet
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()