AU Core Implementation Guide
2.0.0-preview - Preview

AU Core Implementation Guide - Downloaded Version 2.0.0-preview See the Directory of published versions

## Resource Profile: AU Core Condition

Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-condition | Version: 2.0.0-preview
Standards status: Trial-use | Maturity Level: 2 | 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.

See Comparison with other national and international IGs for a comparison between AU Core profiles and profiles in other implementation guides.

### Usage Scenarios

The following are supported usage scenarios for this profile:

- Query for a patient's problems, diagnoses, and health concerns
- Record or update a patient's problem, diagnosis, or health concern

### Profile Specific Implementation Guidance

- `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.
- The use of coding can vary significantly across systems, requesters need to understand that they may encounter codes they do not recognise and be prepared to handle those resources appropriately. Responders SHOULD populate `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.
- See the Representing Body Site, Which May Include Laterality section for guidance on representing a relevant body site and associated laterality.
- An active condition is represented using "active" in `Condition.clinicalStatus`
- To represent that a patient does not have a condition or history of condition, an appropriate negation code is used in `Condition.code`:
  - For indicating no known conditions or problems of any type `Condition.code` SHOULD use the code SNOMED CT 160245001 |No current problems or disability (situation)|
- Refutation is not expected to be handled except as above - an appropriate negation code in `Condition.code` and `Condition.verificationStatus` of "confirmed" or "unconfirmed"

The additional obligation for `Condition.onsetDateTime` for AU Core Responder is SHOULD:populate. There is no additional obligation for AU Core Requester, the obligation of SHALL:no-error applies.

This obligation is present in the underlying structure but due to a tooling limitation is not currently rendered in the Formal Views of Profile Content. See Zulip discussion for more information.

Usages:

- Refer to this Profile: AU Core Encounter, AU Core MedicationRequest, AU Core MedicationStatement and AU Core Procedure
- Examples for this Profile: Condition/ckd, Condition/condition-masked, Condition/noknown and Condition/uti
- CapabilityStatements using this Profile: AU Core Requester CapabilityStatement and AU Core Responder CapabilityStatement

You can also check for usages in the FHIR IG Statistics

Changes since version 1.0.0:

- The resource metadata has changed (description)

### Formal Views of Profile Content

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

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context Constraints: con-3, con-4, con-5
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
clinicalStatus | ?!SO Σ C | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
verificationStatus | ?!SO Σ C | 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.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
bodySite | Σ C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) Constraints: au-core-cond-01
subject | SO Σ | 1..1 | Reference(AU Core Patient) | Who has the condition?
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
onset[x] | SO Σ | 0..1 |  | Estimated or actual date, date-time, or age
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
onsetDateTime |  |  | dateTime S |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | SO C | 0..1 |  | When in resolution/remission
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
note | SO | 0..* | Annotation | Additional information about the Condition
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std.
Condition.severity | Base | extensible | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | extensible | Clinical Condition | ⏿1.0.2 | tx.ontoserver.csiro.au
Condition.bodySite | Base | extensible | Body Site | ⏿1.0.2 | tx.ontoserver.csiro.au

#### Constraints

Id | Grade | Path(s) | Description | Expression
au-core-cond-01 | error | Condition.bodySite | If a coded body site is provided, at least one coding shall be from SNOMED CT | `coding.exists() implies coding.where(system='http://snomed.info/sct').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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition |  | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context
clinicalStatus | SO | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
verificationStatus | SO | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
bodySite | C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) Constraints: au-core-cond-01
subject | SO | 1..1 | Reference(AU Core Patient) | Who has the condition?
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
onset[x] | SO | 0..1 |  | Estimated or actual date, date-time, or age
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
onsetDateTime |  |  | dateTime S |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | SO | 0..1 |  | When in resolution/remission
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
note | SO | 0..* | Annotation | Additional information about the Condition
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Condition.severity | Base | extensible | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | extensible | Clinical Condition | ⏿1.0.2 | tx.ontoserver.csiro.au
Condition.bodySite | Base | extensible | Body Site | ⏿1.0.2 | tx.ontoserver.csiro.au

#### Constraints

Id | Grade | Path(s) | Description | Expression
au-core-cond-01 | error | Condition.bodySite | If a coded body site is provided, at least one coding shall be from SNOMED CT | `coding.exists() implies coding.where(system='http://snomed.info/sct').exists()`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context Constraints: con-3, con-4, con-5
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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 | ?!SO Σ C | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
verificationStatus | ?!SO Σ C | 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.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
bodySite | Σ C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) Constraints: au-core-cond-01
subject | SO Σ | 1..1 | Reference(AU Core Patient) | Who has the condition?
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of
onset[x] | SO Σ | 0..1 |  | Estimated or actual date, date-time, or age
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
onsetDateTime |  |  | dateTime S |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | SO C | 0..1 |  | When in resolution/remission
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 Constraints: con-1
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 Constraints: con-2
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 | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: Clinical Finding (preferred)
detail | Σ C | 0..* | Reference(Resource) | Supporting information found elsewhere
note | SO | 0..* | Annotation | Additional information about the Condition
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std.
Condition.severity | Base | extensible | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | extensible | Clinical Condition | ⏿1.0.2 | tx.ontoserver.csiro.au
Condition.bodySite | Base | extensible | Body Site | ⏿1.0.2 | tx.ontoserver.csiro.au
Condition.stage.summary | Base | example | Condition Stage | 📍4.0.1 | FHIR Std.
Condition.stage.type | Base | example | Condition Stage Type | 📍4.0.1 | FHIR Std.
Condition.evidence.code | Base | preferred | Clinical Finding | ⏿1.0.2 | tx.ontoserver.csiro.au

#### Constraints

Id | Grade | Path(s) | Description | Expression
au-core-cond-01 | error | Condition.bodySite | If a coded body site is provided, at least one coding shall be from SNOMED CT | `coding.exists() implies coding.where(system='http://snomed.info/sct').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:

- AU Core Patient (http://hl7.org.au/fhir/core/StructureDefinition/au-core-patient)

Maturity: 2

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context Constraints: con-3, con-4, con-5
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
clinicalStatus | ?!SO Σ C | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
verificationStatus | ?!SO Σ C | 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.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
bodySite | Σ C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) Constraints: au-core-cond-01
subject | SO Σ | 1..1 | Reference(AU Core Patient) | Who has the condition?
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
onset[x] | SO Σ | 0..1 |  | Estimated or actual date, date-time, or age
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
onsetDateTime |  |  | dateTime S |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | SO C | 0..1 |  | When in resolution/remission
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
note | SO | 0..* | Annotation | Additional information about the Condition
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std.
Condition.severity | Base | extensible | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | extensible | Clinical Condition | ⏿1.0.2 | tx.ontoserver.csiro.au
Condition.bodySite | Base | extensible | Body Site | ⏿1.0.2 | tx.ontoserver.csiro.au

#### Constraints

Id | Grade | Path(s) | Description | Expression
au-core-cond-01 | error | Condition.bodySite | If a coded body site is provided, at least one coding shall be from SNOMED CT | `coding.exists() implies coding.where(system='http://snomed.info/sct').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()`

Differential View

This structure is derived from AUBaseCondition

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition |  | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context
clinicalStatus | SO | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
verificationStatus | SO | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
bodySite | C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) Constraints: au-core-cond-01
subject | SO | 1..1 | Reference(AU Core Patient) | Who has the condition?
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
onset[x] | SO | 0..1 |  | Estimated or actual date, date-time, or age
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
onsetDateTime |  |  | dateTime S |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | SO | 0..1 |  | When in resolution/remission
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
note | SO | 0..* | Annotation | Additional information about the Condition
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Condition.severity | Base | extensible | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | extensible | Clinical Condition | ⏿1.0.2 | tx.ontoserver.csiro.au
Condition.bodySite | Base | extensible | Body Site | ⏿1.0.2 | tx.ontoserver.csiro.au

#### Constraints

Id | Grade | Path(s) | Description | Expression
au-core-cond-01 | error | Condition.bodySite | If a coded body site is provided, at least one coding shall be from SNOMED CT | `coding.exists() implies coding.where(system='http://snomed.info/sct').exists()`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context Constraints: con-3, con-4, con-5
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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 | ?!SO Σ C | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
verificationStatus | ?!SO Σ C | 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.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
category | SO | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
severity | SO | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
code | SO Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Clinical Condition (extensible)
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
bodySite | Σ C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body Site (extensible) Constraints: au-core-cond-01
subject | SO Σ | 1..1 | Reference(AU Core Patient) | Who has the condition?
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of
onset[x] | SO Σ | 0..1 |  | Estimated or actual date, date-time, or age
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
onsetDateTime |  |  | dateTime S |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | SO C | 0..1 |  | When in resolution/remission
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
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 Constraints: con-1
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 Constraints: con-2
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 | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: Clinical Finding (preferred)
detail | Σ C | 0..* | Reference(Resource) | Supporting information found elsewhere
note | SO | 0..* | Annotation | Additional information about the Condition
Obligations | Actor
SHALL:populate-if-known | AU Core Responder
SHALL:no-error | AU Core Requester
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Condition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Condition.clinicalStatus | Base | required | Condition Clinical Status Codes | 📍4.0.1 | FHIR Std.
Condition.verificationStatus | Base | required | ConditionVerificationStatus | 📍4.0.1 | FHIR Std.
Condition.category | Base | extensible | Condition Category Codes | 📍4.0.1 | FHIR Std.
Condition.severity | Base | extensible | Condition/Diagnosis Severity | 📦4.0.1 | FHIR Std.
Condition.code | Base | extensible | Clinical Condition | ⏿1.0.2 | tx.ontoserver.csiro.au
Condition.bodySite | Base | extensible | Body Site | ⏿1.0.2 | tx.ontoserver.csiro.au
Condition.stage.summary | Base | example | Condition Stage | 📍4.0.1 | FHIR Std.
Condition.stage.type | Base | example | Condition Stage Type | 📍4.0.1 | FHIR Std.
Condition.evidence.code | Base | preferred | Clinical Finding | ⏿1.0.2 | tx.ontoserver.csiro.au

#### Constraints

Id | Grade | Path(s) | Description | Expression
au-core-cond-01 | error | Condition.bodySite | If a coded body site is provided, at least one coding shall be from SNOMED CT | `coding.exists() implies coding.where(system='http://snomed.info/sct').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:

- AU Core Patient (http://hl7.org.au/fhir/core/StructureDefinition/au-core-patient)

Maturity: 2

Other representations of profile: CSV, Excel, Schematron

### Notes:

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. The requester SHOULD support chained search patient.identifier using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. The responder SHOULD support chained search patient.identifier using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile.
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+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. The requester SHOULD support `multipleOr`. The responder SHOULD support `multipleOr`.
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 requester SHALL support these search comparators `gt`, `lt`, `ge`, `le`. The responder SHALL support these search comparators `gt`, `lt`, `ge`, `le`. The requester SHOULD support `multipleAnd`, and if `multipleAnd` is supported, SHALL support the search comparators `gt`, `lt`, `ge`, `le`. The responder SHOULD support `multipleAnd`, and if `multipleAnd` is supported, SHALL support the search comparators `gt`, `lt`, `ge`, `le`.

#### Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

1. SHALL support searching using the `patient` search parameter:
   - SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`)

   `GET [base]/Condition?patient={Type/}[id]` or optionally `GET [base]/Condition?patient.identifier=[system|][code]`

   Example:

   1. GET [base]/Condition?patient=5678
   2. GET [base]/Condition?patient.identifier=http://ns.electronichealth.net.au/id/medicare-number|32788511952
   3. GET [base]/Condition?patient.identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608833357361

   Implementation Notes: Fetches a bundle of all Condition resources for the specified patient (how to search by reference and how to search by token)

2. SHALL support searching using the combination of the `patient` and `category` search parameters:
   - SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`)

   `GET [base]/Condition?patient={Type/}[id]&category={system|}[code]`

   Example:

   1. GET [base]/Condition?patient=5678&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis

   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)

3. SHALL support searching using the combination of the `patient` and `clinical-status` search parameters:
   - SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`)

   `GET [base]/Condition?patient={Type/}[id]&clinical-status={system|}[code]`

   Example:

   1. GET [base]/Condition?patient=5678&clinical-status=http://terminology.hl7.org/CodeSystem/condition-clinical|active

   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)

#### Optional Search Parameters

The following search parameters and search parameter combinations SHOULD be supported:

1. SHOULD support searching using the combination of the `patient` and `category` and `clinical-status` search parameters:
   - SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`)

   `GET [base]/Condition?patient={Type/}[id]&category={system|}[code]&clinical-status={system|}[code]`

   Example:

   1. 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)

2. SHOULD support searching using the combination of the `patient` and `code` search parameters:
   - SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`)
   - SHOULD support multipleOr search on `code` (e.g.`code={system|}[code],{system|}[code],...`)

   `GET [base]/Condition?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}`

   Example:

   1. GET [base]/Condition?patient=5678&code=http://snomed.info/sct|68566005,http://snomed.info/sct|394659003

   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)

3. SHOULD support searching using the combination of the `patient` and `onset-date` search parameters:
   - SHOULD support chained searching of patient canonical identifier `patient.identifier` (e.g. `patient.identifier=[system|][code]`)
   - SHALL support these `onset-date` comparators: `gt,lt,ge,le`
   - SHOULD support multipleAnd search on `onset-date` (e.g.`onset-date=[date]&date=[date]]&...`), and if multipleAnd is supported, SHALL support the search comparators `gt,lt,ge,le`

   `GET [base]/Condition?patient={Type/}[id]&onset-date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}`

   Example:

   1. GET [base]/Condition?patient=5678&onset-date=ge2020-01-01T00:00:00Z
   2. GET [base]/Condition?patient.identifier=http://example.org/fhir/mrn|12345&onset-date=ge2020-01-01T00:00:00Z

   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)