AU Core Implementation Guide
0.4.1-preview - Preview
This page is part of the AU Core (v0.4.1-preview: QA Preview) based on FHIR (HL7® FHIR® Standard) R4. . For a full list of available versions, see the Directory of published versions
Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-condition | Version: 0.4.1-preview | |||
Standards status: Draft | Maturity Level: 1 | Computable Name: AUCoreCondition | ||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2022+; Licensed Under Creative Commons No Rights Reserved. |
This profile sets minimum expectations for a Condition resource to record, search, and fetch problems, diagnoses, and health concerns associated with a patient. It is based on the AU Base Condition profile and identifies the additional mandatory core elements, extensions, vocabularies and value sets that SHALL be present in the Condition resource when conforming to this profile. It provides the floor for standards development for specific uses cases in an Australian context.
The following are supported usage scenarios for this profile:
A resource conforming to this profile is conformant to:
problem-list-item
is suppliedencounter-diagnosis
is suppliedConformance in reverse is not guaranteed, i.e. a resource conforming to International Patient Access, International Patient Summary, or US Core MAY NOT conform to AU Core.
Condition.category
provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.Condition.code.text
and/or Condition.code.coding.display
so that requesters can display the condition even if the requester does not recognise the code supplied.Condition.code
contains the identification of the condition, problem or diagnosis which may include body site information. Where a system has information not supported by the coding in Condition.code.coding
(e.g. body site, laterality and other qualification of condition coding terms) that information SHOULD be supplied in Condition.code.text
Condition.clinicalStatus
Condition.code
:
Condition.code
SHOULD use the code SNOMED CT 160245001 |No current problems or disability (situation)|Condition.code
and Condition.verificationStatus
of “confirmed” or “unconfirmed”Input is requested on how to exchange 'free text' medical history i.e. are these always Condition and/or Procedure resources? Please comment on HL7 Jira FHIR-43846.
Input is requested on how a diagnosis type (e.g. Comorbidity, Complication) would be represented in AU Core Condition. Please comment on HL7 Jira FHIR-43847.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from AUBaseCondition
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context au-core-cond-05: Clinical status shall be present if verification status is not entered-in-error | ||||||
clinicalStatus | SOC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved
| ||||||
verificationStatus | SO | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
| ||||||
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis
| ||||||
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
| ||||||
code | SO | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
| ||||||
bodySite | C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT | ||||||
subject | SO | 1..1 | Reference(AU Core Patient) | Who has the condition?
| ||||||
onset[x] | SO | 0..1 | Estimated or actual date, date-time, or age
| |||||||
onsetDateTime | dateTime | |||||||||
onsetAge | Age | |||||||||
onsetPeriod | Period | |||||||||
onsetRange | Range | |||||||||
abatement[x] | SO | 0..1 | When in resolution/remission
| |||||||
abatementDateTime | dateTime | |||||||||
abatementAge | Age | |||||||||
abatementPeriod | Period | |||||||||
abatementRange | Range | |||||||||
note | SO | 0..* | Annotation | Additional information about the Condition
| ||||||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | |
Condition.code | extensible | ClinicalCondition https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 | |
Condition.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
Id | Grade | Path(s) | Details | Requirements |
au-core-cond-02 | error | Condition.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
au-core-cond-05 | error | Condition | Clinical status shall be present if verification status is not entered-in-error : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error au-core-cond-05: Clinical status shall be present if verification status is not entered-in-error | ||||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
clinicalStatus | ?!SOΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||
verificationStatus | ?!SOΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
| ||||||
code | SOΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
| ||||||
bodySite | ΣC | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT | ||||||
subject | SOΣ | 1..1 | Reference(AU Core Patient) | Who has the condition?
| ||||||
onset[x] | SOΣ | 0..1 | Estimated or actual date, date-time, or age
| |||||||
onsetDateTime | dateTime | |||||||||
onsetAge | Age | |||||||||
onsetPeriod | Period | |||||||||
onsetRange | Range | |||||||||
abatement[x] | SOC | 0..1 | When in resolution/remission
| |||||||
abatementDateTime | dateTime | |||||||||
abatementAge | Age | |||||||||
abatementPeriod | Period | |||||||||
abatementRange | Range | |||||||||
note | SO | 0..* | Annotation | Additional information about the Condition
| ||||||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | |
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | |
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | |
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | |
Condition.code | extensible | ClinicalCondition https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 | |
Condition.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
Id | Grade | Path(s) | Details | Requirements |
au-core-cond-02 | error | Condition.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
au-core-cond-05 | error | Condition | Clinical status shall be present if verification status is not entered-in-error : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If 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-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error au-core-cond-05: Clinical status shall be present if verification status is not entered-in-error | ||||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||
contained | 0..* | Resource | Contained, inline Resources | |||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||||
clinicalStatus | ?!SOΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||
verificationStatus | ?!SOΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
| ||||||
code | SOΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
| ||||||
bodySite | ΣC | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT | ||||||
subject | SOΣ | 1..1 | Reference(AU Core Patient) | Who has the condition?
| ||||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||||
onset[x] | SOΣ | 0..1 | Estimated or actual date, date-time, or age
| |||||||
onsetDateTime | dateTime | |||||||||
onsetAge | Age | |||||||||
onsetPeriod | Period | |||||||||
onsetRange | Range | |||||||||
abatement[x] | SOC | 0..1 | When in resolution/remission
| |||||||
abatementDateTime | dateTime | |||||||||
abatementAge | Age | |||||||||
abatementPeriod | Period | |||||||||
abatementRange | Range | |||||||||
recordedDate | Σ | 0..1 | dateTime | Date record was first recorded | ||||||
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||||
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | ||||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment | ||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||||
evidence | C | 0..* | BackboneElement | Supporting evidence con-2: evidence SHALL have code or details | ||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: Clinical Finding (preferred) | ||||||
detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||||
note | SO | 0..* | Annotation | Additional information about the Condition
| ||||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | extensible | ClinicalCondition https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 | ||||
Condition.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 | ||||
Condition.stage.summary | example | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | example | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | preferred | ClinicalFinding https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
Id | Grade | Path(s) | Details | Requirements |
au-core-cond-02 | error | Condition.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
au-core-cond-05 | error | Condition | Clinical status shall be present if verification status is not entered-in-error : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() | |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If 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-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from AUBaseCondition
Summary
Mandatory: 2 elements
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Maturity: 1
Differential View
This structure is derived from AUBaseCondition
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context au-core-cond-05: Clinical status shall be present if verification status is not entered-in-error | ||||||
clinicalStatus | SOC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved
| ||||||
verificationStatus | SO | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
| ||||||
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis
| ||||||
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
| ||||||
code | SO | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
| ||||||
bodySite | C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT | ||||||
subject | SO | 1..1 | Reference(AU Core Patient) | Who has the condition?
| ||||||
onset[x] | SO | 0..1 | Estimated or actual date, date-time, or age
| |||||||
onsetDateTime | dateTime | |||||||||
onsetAge | Age | |||||||||
onsetPeriod | Period | |||||||||
onsetRange | Range | |||||||||
abatement[x] | SO | 0..1 | When in resolution/remission
| |||||||
abatementDateTime | dateTime | |||||||||
abatementAge | Age | |||||||||
abatementPeriod | Period | |||||||||
abatementRange | Range | |||||||||
note | SO | 0..* | Annotation | Additional information about the Condition
| ||||||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | |
Condition.code | extensible | ClinicalCondition https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 | |
Condition.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
Id | Grade | Path(s) | Details | Requirements |
au-core-cond-02 | error | Condition.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
au-core-cond-05 | error | Condition | Clinical status shall be present if verification status is not entered-in-error : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error au-core-cond-05: Clinical status shall be present if verification status is not entered-in-error | ||||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
clinicalStatus | ?!SOΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||
verificationStatus | ?!SOΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
| ||||||
code | SOΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
| ||||||
bodySite | ΣC | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT | ||||||
subject | SOΣ | 1..1 | Reference(AU Core Patient) | Who has the condition?
| ||||||
onset[x] | SOΣ | 0..1 | Estimated or actual date, date-time, or age
| |||||||
onsetDateTime | dateTime | |||||||||
onsetAge | Age | |||||||||
onsetPeriod | Period | |||||||||
onsetRange | Range | |||||||||
abatement[x] | SOC | 0..1 | When in resolution/remission
| |||||||
abatementDateTime | dateTime | |||||||||
abatementAge | Age | |||||||||
abatementPeriod | Period | |||||||||
abatementRange | Range | |||||||||
note | SO | 0..* | Annotation | Additional information about the Condition
| ||||||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | |
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | |
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | |
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | |
Condition.code | extensible | ClinicalCondition https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 | |
Condition.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
Id | Grade | Path(s) | Details | Requirements |
au-core-cond-02 | error | Condition.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
au-core-cond-05 | error | Condition | Clinical status shall be present if verification status is not entered-in-error : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If 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-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error au-core-cond-05: Clinical status shall be present if verification status is not entered-in-error | ||||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||
contained | 0..* | Resource | Contained, inline Resources | |||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||||
clinicalStatus | ?!SOΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
| ||||||
verificationStatus | ?!SOΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
| ||||||
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
| ||||||
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
| ||||||
code | SOΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
| ||||||
bodySite | ΣC | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT | ||||||
subject | SOΣ | 1..1 | Reference(AU Core Patient) | Who has the condition?
| ||||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||||
onset[x] | SOΣ | 0..1 | Estimated or actual date, date-time, or age
| |||||||
onsetDateTime | dateTime | |||||||||
onsetAge | Age | |||||||||
onsetPeriod | Period | |||||||||
onsetRange | Range | |||||||||
abatement[x] | SOC | 0..1 | When in resolution/remission
| |||||||
abatementDateTime | dateTime | |||||||||
abatementAge | Age | |||||||||
abatementPeriod | Period | |||||||||
abatementRange | Range | |||||||||
recordedDate | Σ | 0..1 | dateTime | Date record was first recorded | ||||||
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||||
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | ||||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment | ||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||||
evidence | C | 0..* | BackboneElement | Supporting evidence con-2: evidence SHALL have code or details | ||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||||
extension | 0..* | Extension | Additional content defined by implementations | |||||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: Clinical Finding (preferred) | ||||||
detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||||
note | SO | 0..* | Annotation | Additional information about the Condition
| ||||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Condition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodeshttp://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard | ||||
Condition.verificationStatus | required | ConditionVerificationStatushttp://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard | ||||
Condition.category | extensible | ConditionCategoryCodeshttp://hl7.org/fhir/ValueSet/condition-category from the FHIR Standard | ||||
Condition.severity | extensible | Condition/DiagnosisSeverityhttp://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard | ||||
Condition.code | extensible | ClinicalCondition https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 | ||||
Condition.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 | ||||
Condition.stage.summary | example | ConditionStagehttp://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard | ||||
Condition.stage.type | example | ConditionStageTypehttp://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard | ||||
Condition.evidence.code | preferred | ClinicalFinding https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 |
Id | Grade | Path(s) | Details | Requirements |
au-core-cond-02 | error | Condition.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
au-core-cond-05 | error | Condition | Clinical status shall be present if verification status is not entered-in-error : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() | |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If 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-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from AUBaseCondition
Summary
Mandatory: 2 elements
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron
Below is an overview of the mandatory and optional search parameters and combined search parameters. See the AU Core CapabilityStatements for a complete list of supported RESTful interactions for this IG.
FHIR search operations are described here and the syntax used to describe AU Core interactions is defined here.
Any search parameter defined in FHIR may be ‘allowed’ by the system unless explicitly marked as “SHALL NOT”. A few items are marked as MAY in this implementation guide to highlight their potential relevance.
Parameter(s) | Conformance | Type(s) | Requirements (when used alone or in combination) |
---|---|---|---|
patient | SHALL | reference |
The requester SHALL provide at least an id value and MAY provide both the Type and id values. The responder SHALL support both. |
patient+category | SHALL | reference +token |
|
patient+clinical-status | SHALL | reference +token |
|
patient+category+clinical-status | SHOULD | reference +token +token |
|
patient+code | SHOULD | reference +token |
|
patient.identifier | SHOULD | reference .token |
The requester SHALL provide both the system and code values. The responder SHALL support both. The requester SHOULD support search using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. The responder SHOULD support search using the using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. |
patient+onset-date | SHOULD | reference +date |
|
category | MAY | token |
The requester SHALL provide at least a code value and MAY provide both the system and code values. The responder SHALL support both. |
clinical-status | MAY | token |
The requester SHALL provide at least a code value and MAY provide both the system and code values. The responder SHALL support both. |
code | MAY | token |
The requester SHALL provide at least a code value and MAY provide both the system and code values. The responder SHALL support both. |
onset-date | MAY | date |
A requester SHALL provide a value precise to the second + time offset. A responder SHALL support a value precise to the second + time offset. |
The following search parameters and search parameter combinations SHALL be supported:
patient
search parameter:
patient.identifier
(e.g. patient.identifier=[system|][code]
)GET [base]/Condition?patient={Type/}[id]
or optionally GET [base]/Condition?patient.identifier=[system|][code]
Example:
Implementation Notes: Fetches a bundle of all Condition resources for the specified patient (how to search by reference and how to search by token)
patient
and category
search parameters:
patient.identifier
(e.g. patient.identifier=[system|][code]
)GET [base]/Condition?patient={Type/}[id]&category={system|}[code]
Example:
Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category code = encounter-diagnosis
(how to search by reference and how to search by token)
patient
and clinical-status
search parameters:
patient.identifier
(e.g. patient.identifier=[system|][code]
)GET [base]/Condition?patient={Type/}[id]&clinical-status={system|}[code]
Example:
Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and a clinical status (how to search by reference and how to search by token)
The following search parameters and search parameter combinations SHOULD be supported:
patient
and category
and clinical-status
search parameters:
patient.identifier
(e.g. patient.identifier=[system|][code]
)GET [base]/Condition?patient={Type/}[id]&category={system|}[code]&clinical-status={system|}[code]
Example:
GET [base]/Condition?patient=5678&category=http://terminology.hl7.org/CodeSystem/observation-category|encounter-diagnosis&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical | active |
Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and category and clinical-status (how to search by reference and how to search by token)
patient
and code
search parameters:
patient.identifier
(e.g. patient.identifier=[system|][code]
)code
(e.g.code={system|}[code],{system|}[code],...
)GET [base]/Condition?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and condition code(s). SHOULD support search by multiple codes. The Condition code
parameter searches Condition.code
only. (how to search by reference and how to search by token)
patient
and onset-date
search parameters:
patient.identifier
(e.g. patient.identifier=[system|][code]
onset-date
comparators: gt,lt,ge,le
onset-date
(e.g.onset-date=[date]&date=[date]]&...
)GET [base]/Condition?patient={Type/}[id]&onset-date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Condition resources for the specified patient and onset-date (how to search by reference and how to search by date)