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Condition

The SHR Condition domain contains basic definitions used to capture information about problems, concerns, complaints, and disorders.

Abatement

The end, remission or resolution. C1880019

Value:  GeneralizedTemporalContext A generalized indicator of a dateTime or an age when an event happened.

AcademicProblem [Entry]

A problem with learning or behavior in a learning environment. C0000873

Based On Condition

Value:  CodeableConcept must be from TBD
A set of codes drawn from different coding systems, representing the same concept.
BodySite not used A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
Category must be from ConditionCategoryVS
1 or more A class or division of people or things having particular shared characteristics
Subject required The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
ClinicalStatus must be from http://hl7.org/fhir/ValueSet/condition-clinical
required A flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).
BodySiteOrCode 0 or more A body site entity or a body site code.
Onset optional The beginning or first appearance of a mental or physical disorder.
Abatement optional The end, remission or resolution.
WhenClinicallyRecognized optional The time at which a condition or condition was first identified in a healthcare context.
Preexisting optional If the problem or condition existed before the current episode of care.
Severity must be from http://hl7.org/fhir/ValueSet/condition-severity
optional Degree of harshness or extent of a symptom, disorder, or condition.
Criticality must be from http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality
optional The potential clinical harm associated with a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.
Stage optional The relative advancement in the course of a disease.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
FindingStatus optional Indicates whether the finding is preliminary, amended, final, etc..
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ClinicalStatus

A flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).

Value:  code

Condition [Entry]

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. C0348080

Based On SpecializedFinding

Value:  CodeableConcept from http://hl7.org/fhir/us/core/ValueSet/us-core-problem
(if covered)
A set of codes drawn from different coding systems, representing the same concept.
Category must be from ConditionCategoryVS
1 or more A class or division of people or things having particular shared characteristics
Subject required The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
ClinicalStatus must be from http://hl7.org/fhir/ValueSet/condition-clinical
required A flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).
BodySiteOrCode 0 or more A body site entity or a body site code.
Onset optional The beginning or first appearance of a mental or physical disorder.
Abatement optional The end, remission or resolution.
WhenClinicallyRecognized optional The time at which a condition or condition was first identified in a healthcare context.
Preexisting optional If the problem or condition existed before the current episode of care.
Severity must be from http://hl7.org/fhir/ValueSet/condition-severity
optional Degree of harshness or extent of a symptom, disorder, or condition.
Criticality must be from http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality
optional The potential clinical harm associated with a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.
Stage optional The relative advancement in the course of a disease.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
FindingStatus optional Indicates whether the finding is preliminary, amended, final, etc..
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ConditionAbsent [Entry]

A finding that a condition is or was not present in the subject at a certain time, not necessarily the time the information is gathered. no disease present (C0277541)

Based On Observation

Value:  CodeableConcept from http://hl7.org/fhir/us/core/ValueSet/us-core-problem
(if covered)
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is C027754
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
ObservationComponent 0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

Criticality

The potential clinical harm associated with a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality. Criticality (C3858539)

Value:  code

DiseaseProgression [Entry]

A finding related to the current trend of a disease. This concept is most often used for chronic and incurable diseases where the status and trendline of the disease is an important determinant of therapy and prognosis. The specific disorder being evaluated must be cited in the AssessmentFocus as a reference to a Condition. Progression (C0421176)

Based On Observation

Value:  CodeableConcept must be from ProgressionVS
A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is Progression (C0421176)
required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
FocalSubject should be from ConditionVS
optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference must be a Condition
optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
Evidence must be from ProgressionEvidenceTypeVS
0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category
(if covered)
0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Specimen optional Sample for analysis
Device optional A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ReferenceRange 0 or more The usual or acceptable range for a test result.
ObservationComponent 0 or more A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
Members required Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

Injury [Entry]

Damage inflicted on the body by an external force. C3263722

Based On Condition

Value:  CodeableConcept from http://hl7.org/fhir/us/core/ValueSet/us-core-problem
(if covered)
A set of codes drawn from different coding systems, representing the same concept.
Setting optional Description of the place or type of surroundings where something is positioned or where an event takes place.
Location optional A position, site, or point in space where something can be found.
Category must be from ConditionCategoryVS
1 or more A class or division of people or things having particular shared characteristics
Subject required The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
ClinicalStatus must be from http://hl7.org/fhir/ValueSet/condition-clinical
required A flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).
BodySiteOrCode 0 or more A body site entity or a body site code.
Onset optional The beginning or first appearance of a mental or physical disorder.
Abatement optional The end, remission or resolution.
WhenClinicallyRecognized optional The time at which a condition or condition was first identified in a healthcare context.
Preexisting optional If the problem or condition existed before the current episode of care.
Severity must be from http://hl7.org/fhir/ValueSet/condition-severity
optional Degree of harshness or extent of a symptom, disorder, or condition.
Criticality must be from http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality
optional The potential clinical harm associated with a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.
Stage optional The relative advancement in the course of a disease.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
FindingStatus optional Indicates whether the finding is preliminary, amended, final, etc..
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

MentalHealthCondition [Entry]

A condition relating to a person’s psychological and emotional well-being. C1446377

Based On Condition

Value:  CodeableConcept must be from DSMVS
A set of codes drawn from different coding systems, representing the same concept.
Category must be from ConditionCategoryVS
1 or more A class or division of people or things having particular shared characteristics
Subject required The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
ClinicalStatus must be from http://hl7.org/fhir/ValueSet/condition-clinical
required A flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).
BodySiteOrCode 0 or more A body site entity or a body site code.
Onset optional The beginning or first appearance of a mental or physical disorder.
Abatement optional The end, remission or resolution.
WhenClinicallyRecognized optional The time at which a condition or condition was first identified in a healthcare context.
Preexisting optional If the problem or condition existed before the current episode of care.
Severity must be from http://hl7.org/fhir/ValueSet/condition-severity
optional Degree of harshness or extent of a symptom, disorder, or condition.
Criticality must be from http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality
optional The potential clinical harm associated with a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.
Stage optional The relative advancement in the course of a disease.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
FindingStatus optional Indicates whether the finding is preliminary, amended, final, etc..
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

Onset

The beginning or first appearance of a mental or physical disorder. C0277793

Value:  GeneralizedTemporalContext A generalized indicator of a dateTime or an age when an event happened.

Preexisting

If the problem or condition existed before the current episode of care.

Value:  CodeableConcept must be from YesNoUnknownVS
A set of codes drawn from different coding systems, representing the same concept.

Severity

Degree of harshness or extent of a symptom, disorder, or condition. C0392364

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

Stage

The relative advancement in the course of a disease. C0699749

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

WhenClinicallyRecognized

The time at which a condition or condition was first identified in a healthcare context.

Value:  GeneralizedTemporalContext A generalized indicator of a dateTime or an age when an event happened.