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shr.condition

The SHR Condition domain contains definitions used to capture assessments, diagnoses, and judgments related to problems reported or experienced by a subject.

BodyStructureAbsenceStatement [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 ConditionAbsenceStatement

StatementTopic must be a BodyStructureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
StatementContext must be a AbsenceContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SubjectOfInformation required The person or thing that this entry relates to, usually the Person of Record (see Entry). 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, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

BodyStructurePresenceStatement [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 ConditionPresenceStatement

StatementTopic must be a BodyStructureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
SourceOfInformation must be a PatientOrPractitionerOrRelatedPerson
optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
StatementContext must be a ConditionPresenceContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). 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, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

BodyStructureTopic [Abstract]

Presence (or absence) of a distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. C1268086

Based On ConditionTopic

Value:  CodeableConcept must be from AnatomicalLocationVS
A set of codes drawn from different coding systems, representing the same concept.
TopicCode is C1268086
required The concept representing the finding or action that is the topic of the statement. For action topics, the TopicCode represents the action being described. For findings, the TopicCode represents the 'question' or property being investigated. For evaluation result findings, the TopicCode contains a concept for an observable entity, such as systolic blood pressure. For assertion findings, the TopicCode contains a code representing the condition, allergy, or other item being asserted. In all cases, the TopicCode describes the topic independent of the context of the action or the finding.
Morphology optional The kind of structure being represented. This can define both normal and abnormal morphologies.
Category must be from ConditionCategoryVS
1 or more A class or division of people or things having particular shared characteristics
AnatomicalLocation 0 or more A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.
FindingMethod optional The technique used to create the finding; for example, the specific imaging technique, lab test code, or assessment vehicle. CIMI Alignment: In CIMI V0.0.4, this attribute was called 'method'. The value set binding reflects CIMI's preference for LOINC codes.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.

DiseaseProgression [Entry]

A finding related to the current trend of a particular existing 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 Focus_Reference or Focus_CodeableConcept as a reference to a Condition. Progression (C0421176)

Based On EvaluationResultRecorded

ProgressionEvidence 0 or more The type of evidence considered in determining disease progression.
StatementTopic must be a EvaluationResultTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
         where  EvaluationResultTopic
StatementContext must be a EvaluationResultRecordedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
         where  EvaluationResultRecordedContext
SubjectOfInformation required The person or thing that this entry relates to, usually the Person of Record (see Entry). 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, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

Morphology

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

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

ProgressionEvidence

The type of evidence considered in determining disease progression.

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