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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 Assertion

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.
ObservationCode is Not applicable (385432009) 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 not used Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Specimen not used Sample for analysis
Device not used 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 not used The usual or acceptable range for a test result.
NegationFlag optional A flag that indicates the meaning to be conveyed is the logical opposite of the current assertion. The assertion is negated only when the NegationIndicator is true. If absent or false, the assertion is not negated.
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
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.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
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.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical 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.

BodyStructureAbsent [Entry]

Absence of distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. The observation has a body site that allows the the structure to be located in the body. The observation identifier allows other observations of the same body structure to be related to QualitativeValueScaleVSthis observation and tracked over time.

Based On Observation

Value:  CodeableConcept must be from BodyStructureVS A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is TBD 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'.
NegationFlag is true required A flag that indicates the meaning to be conveyed is the logical opposite of the current assertion. The assertion is negated only when the NegationIndicator is true. If absent or false, the assertion is not negated.
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.
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.
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.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
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.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical 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.

BodyStructurePresent [Entry]

Presence of a distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. Body structures are continuants that allow observations of the same body structure to be related to be tracked over time.

Based On Finding

Value:  CodeableConcept must be from BodySiteVS A set of codes drawn from different coding systems, representing the same concept.
Morphology must be from http://hl7.org/fhir/ValueSet/bodystructure-code optional The kind of structure being represented. This can define both normal and abnormal morphologies.
NegationFlag not used A flag that indicates the meaning to be conveyed is the logical opposite of the current assertion. The assertion is negated only when the NegationIndicator is true. If absent or false, the assertion is not negated.
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.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical 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.

Based On Finding

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.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical 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 not present in the subject at a certain time.

Based On Assertion

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.
NegationFlag is true required A flag that indicates the meaning to be conveyed is the logical opposite of the current assertion. The assertion is negated only when the NegationIndicator is true. If absent or false, the assertion is not negated.
ObservationCode is Not applicable (385432009) 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 not used Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Specimen not used Sample for analysis
Device not used 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 not used The usual or acceptable range for a test result.
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.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
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.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical 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. C0449258

Based On Observation

Value:  CodeableConcept must be from SubjectiveProgressionVS A set of codes drawn from different coding systems, representing the same concept.
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.
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'.
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.
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.
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.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
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 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.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical 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.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical 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.

Morphology

The kind of structure being represented. This can define both normal and abnormal morphologies.

Based On ObservationComponent

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
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).
ObservationCode 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'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.

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.