AU Core Implementation Guide
0.4.0-preview - Preview Australia flag

This page is part of the AU Core (v0.4.0-preview: QA Preview) based on FHIR (HL7® FHIR® Standard) R4. . 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: 0.4.0-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.

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

Comparison with other national and international IGs

A resource conforming to this profile is conformant to:

Conformance 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.

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.
  • 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
  • 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”

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:

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 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
ObligationsActor
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
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... category SO 1..* CodeableConcept problem-list-item | encounter-diagnosis
ObligationsActor
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)
ObligationsActor
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)
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?
ObligationsActor
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
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] SO 0..1 When in resolution/remission
ObligationsActor
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
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeextensibleClinicalCondition .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensibleBodySite .
https://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 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.

ObligationsActor
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.


ObligationsActor
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)
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... code SOΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: Clinical Condition . (extensible)
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... 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?
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... onset[x] SOΣ 0..1 Estimated or actual date, date-time, or age
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] SOC 0..1 When in resolution/remission
ObligationsActor
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
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeextensibleClinicalCondition .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensibleBodySite .
https://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()
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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.

ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... 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.

ObligationsActor
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.


ObligationsActor
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)
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... code SOΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: Clinical Condition . (extensible)
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... 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?
ObligationsActor
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] SOΣ 0..1 Estimated or actual date, date-time, or age
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] SOC 0..1 When in resolution/remission
ObligationsActor
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
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
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeextensibleClinicalCondition .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensibleBodySite .
https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Condition.stage.summaryexampleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codepreferredClinicalFinding .
https://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()
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()
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
ObligationsActor
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
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... category SO 1..* CodeableConcept problem-list-item | encounter-diagnosis
ObligationsActor
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)
ObligationsActor
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)
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?
ObligationsActor
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
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] SO 0..1 When in resolution/remission
ObligationsActor
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
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeextensibleClinicalCondition .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensibleBodySite .
https://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 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.

ObligationsActor
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.


ObligationsActor
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)
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... code SOΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: Clinical Condition . (extensible)
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... 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?
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... onset[x] SOΣ 0..1 Estimated or actual date, date-time, or age
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] SOC 0..1 When in resolution/remission
ObligationsActor
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
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeextensibleClinicalCondition .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensibleBodySite .
https://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()
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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.

ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... 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.

ObligationsActor
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.


ObligationsActor
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)
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... code SOΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: Clinical Condition . (extensible)
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
... 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?
ObligationsActor
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] SOΣ 0..1 Estimated or actual date, date-time, or age
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester
.... onsetDateTime dateTime
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
... abatement[x] SOC 0..1 When in resolution/remission
ObligationsActor
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
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
ObligationsActor
SHALL:populate-if-known AU Core Responder
SHALL:no-error AU Core Requester

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severityextensibleCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeextensibleClinicalCondition .
https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensibleBodySite .
https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Condition.stage.summaryexampleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codepreferredClinicalFinding .
https://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()
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()
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
con-3best practiceConditionCondition.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-4errorConditionIf 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-5errorConditionCondition.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-2errorConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorConditionIf 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-4errorConditionIf 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-5errorConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceConditionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust 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

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.
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.

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)

    1. 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]]&...)

    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)