AU Core Implementation Guide
0.1.0-draft - Draft Australia flag

This page is part of the AU Core Implementation Guide 0.1.0 Draft. It is based on AU Base 4.1.0. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Core Condition

Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-condition Version: 0.1.0-draft
Standards status: Draft Maturity Level: 0 Computable Name: AUCoreCondition

Copyright/Legal: HL7 Australia© 2018+; 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.

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.
  • 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
  • Refutation is not expected to be handled except as above - an appropriate negation code in Condition.code and Condition.verificationStatus of “confirmed” or “unconfirmed”

Usage:

Formal Views of Profile Content

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

This structure is derived from AUBaseCondition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*AUBaseConditionA 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 SC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
... verificationStatus S0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
... category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
... bodySite SC0..*CodeableConceptAnatomical location, if relevant
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT
... subject S1..1Reference(AU Core Patient)Who has the condition?
... encounter S0..1Reference(AU Core Encounter)Encounter created as part of
... onset[x] S0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] S0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recorder S0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Who recorded the condition
... asserter S0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Person who asserts this condition
... note S0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Condition.severityextensibleCondition/DiagnosisSeverity
Condition.codeextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-cond-02errorCondition.bodySiteIf 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-05errorConditionClinical 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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*AUBaseConditionA 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
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (extensible)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
... bodySite SΣC0..*CodeableConceptAnatomical location, if relevant
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT
... subject SΣ1..1Reference(AU Core Patient)Who has the condition?
... encounter SΣ0..1Reference(AU Core Encounter)Encounter created as part of
... onset[x] SΣ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] SC0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recorder SΣ0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Who recorded the condition
... asserter SΣ0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Person who asserts this condition
... note S0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severityextensibleCondition/DiagnosisSeverity
Condition.codeextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-cond-02errorCondition.bodySiteIf 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-05errorConditionClinical 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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*AUBaseConditionA 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
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!SΣC0..1CodeableConceptunconfirmed | 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 S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (extensible)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
... bodySite SΣC0..*CodeableConceptAnatomical location, if relevant
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT
... subject SΣ1..1Reference(AU Core Patient)Who has the condition?
... encounter SΣ0..1Reference(AU Core Encounter)Encounter created as part of
... onset[x] SΣ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] SC0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder SΣ0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Who recorded the condition
... asserter SΣ0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Person who asserts this condition
... stage C0..*BackboneElementStage/grade, usually assessed formally
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary C0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C0..*BackboneElementSupporting evidence
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣC0..*CodeableConceptManifestation/symptom
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
.... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
... note S0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severityextensibleCondition/DiagnosisSeverity
Condition.codeextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-cond-02errorCondition.bodySiteIf 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()

Differential View

This structure is derived from AUBaseCondition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*AUBaseConditionA 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 SC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
... verificationStatus S0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
... category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
... bodySite SC0..*CodeableConceptAnatomical location, if relevant
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT
... subject S1..1Reference(AU Core Patient)Who has the condition?
... encounter S0..1Reference(AU Core Encounter)Encounter created as part of
... onset[x] S0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] S0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recorder S0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Who recorded the condition
... asserter S0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Person who asserts this condition
... note S0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Condition.severityextensibleCondition/DiagnosisSeverity
Condition.codeextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-cond-02errorCondition.bodySiteIf 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-05errorConditionClinical 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*AUBaseConditionA 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
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (extensible)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
... bodySite SΣC0..*CodeableConceptAnatomical location, if relevant
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT
... subject SΣ1..1Reference(AU Core Patient)Who has the condition?
... encounter SΣ0..1Reference(AU Core Encounter)Encounter created as part of
... onset[x] SΣ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] SC0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recorder SΣ0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Who recorded the condition
... asserter SΣ0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Person who asserts this condition
... note S0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severityextensibleCondition/DiagnosisSeverity
Condition.codeextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-cond-02errorCondition.bodySiteIf 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-05errorConditionClinical 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()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*AUBaseConditionA 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
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!SΣC0..1CodeableConceptunconfirmed | 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 S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (extensible)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
... bodySite SΣC0..*CodeableConceptAnatomical location, if relevant
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
au-core-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT
... subject SΣ1..1Reference(AU Core Patient)Who has the condition?
... encounter SΣ0..1Reference(AU Core Encounter)Encounter created as part of
... onset[x] SΣ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] SC0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder SΣ0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Who recorded the condition
... asserter SΣ0..1Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson)Person who asserts this condition
... stage C0..*BackboneElementStage/grade, usually assessed formally
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary C0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C0..*BackboneElementSupporting evidence
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣC0..*CodeableConceptManifestation/symptom
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
.... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
... note S0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severityextensibleCondition/DiagnosisSeverity
Condition.codeextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Constraints

IdGradePath(s)DetailsRequirements
au-core-cond-02errorCondition.bodySiteIf 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()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Name Type Conformance Description Path
TBD TBD TBD TBD TBD

Mandatory Search Parameters

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

Optional Search Parameters

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