HL7 FHIR Profile: Skin and Wound Assessment, Release 1 (For Comment)

FindingSiteConditionPresenceStatementModel

 

The official URL for this logical model is: 

http://hl7.org/fhir/us/sw/StructureDefinition/cimi-statement-FindingSiteConditionPresenceStatement-model

Presence of a distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. Body structures are continuants that allow observations of the same body structure to be related to be tracked over time.

This logical model was published on Fri Aug 17 00:00:00 EDT 2018 as a draft by HL7 Patient Care and Clinical Information Modeling Initiative Work Groups.

View the corresponding FindingSiteConditionPresenceStatementProfile profile.

NameFlagsCard.TypeDescription & Constraintsdoco
.. cimi-statement-FindingSiteConditionPresenceStatement-model 0..*
... personOfRecord 1..1Reference(SW Person Logical Model)The person this entry belongs to.
... recorded 0..1AttributionModelThe person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
... signed 0..1AttributionModelProvenance information specific to the signing of the clinical statement.
... additionalText 0..1stringA text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
... contextCode 0..1CodingCode representing the sense in which the statement is interpreted, for example, the degree of presence in a PresenceStatement.
Binding: SW PresenceContextVS ValueSet (required)
... statementTopic 0..1StatementTopicModelCompositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement.
... encounter 0..1EncounterModelA description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.
... interpretation 0..1CodingA clinical interpretation of a finding (applies to both assertions and observation).
Binding: Observation Interpretation Codes (extensible)
... relevantTime 0..1dateTime, TimePeriodModelThe time or time period that the finding addresses.
... findingMethod 0..1CodingThe technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Binding: SW FindingMethodVS ValueSet (preferred)
... media 0..*MediaModelA file that contains audio, video, image, or similar content.
... verificationStatus 1..1CodingWhether an assessment has been confirmed by testing or observation.
... onset 0..1dateTime, AgeModel, TimePeriodModel, RangeModel, stringThe beginning or first appearance of a mental or physical disorder.
... abatement 0..1dateTime, AgeModel, boolean, TimePeriodModel, RangeModel, stringThe end, remission or resolution.
... certainty 0..1CodingThe degree of confidence in a conclusion or assertion.
... topicCode 1..1CodingThe concept representing the finding or action that is the topic of the statement.
Binding: (extensible)
... category 1..*CodingThe type, kind, or class of this item.
Binding: SW ConditionCategoryVS ValueSet (required)
... anatomicalLocation 1..*AnatomicalLocationModelA location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.
... conditionCause 0..*Coding, Reference(SW Entity Logical Model | SW ClinicalStatement Logical Model)The cause of the condition. This includes such causes as disease vectors and endogenous states (e.g., macular degeneration due to diabetes), substances, medications, micro-organisms, and forces associated with the occurrence of a Condition from temporal or causative perspectives
... conditionIdentifier 0..1stringA human-readable identifier for the condition at the finding site, for example, a wound number or tumor identifier.
... clinicalStatus 1..1codeA flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).
Binding: Condition Clinical Status Codes (required)
... whenClinicallyRecognized 0..1dateThe time at which a condition or condition was first identified in a healthcare context.
... presentOnAdmission 0..1CodingIf the problem or condition existed before the current episode of care.
Binding: SW YesNoUnknownVS ValueSet (required)
... severity 0..1CodingDegree of harshness or extent of a symptom, disorder, or condition.
Binding: Condition/Diagnosis Severity (required)
... criticality 0..1codeThe potential clinical harm associated with a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.
Binding: AllergyIntoleranceCriticality (required)
... stage 0..1StageModelThe relative advancement in the course of a disease. The value is the summary stage or stage group. StageDetail optionally contains the full staging information.

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, TTL)

 

Terminology Bindings

PathNameConformanceValueSet
cimi-statement-FindingSiteConditionPresenceStatement-model.contextCodeSW PresenceContextVS ValueSetrequiredPresenceContextVS
cimi-statement-FindingSiteConditionPresenceStatement-model.interpretationObservation Interpretation CodesextensibleObservation Interpretation Codes
cimi-statement-FindingSiteConditionPresenceStatement-model.findingMethodSW FindingMethodVS ValueSetpreferredFindingMethodVS
cimi-statement-FindingSiteConditionPresenceStatement-model.topicCodeProblem Value SetextensibleProblem Value Set
cimi-statement-FindingSiteConditionPresenceStatement-model.categorySW ConditionCategoryVS ValueSetrequiredConditionCategoryVS
cimi-statement-FindingSiteConditionPresenceStatement-model.clinicalStatusCondition Clinical Status CodesrequiredCondition Clinical Status Codes
cimi-statement-FindingSiteConditionPresenceStatement-model.presentOnAdmissionSW YesNoUnknownVS ValueSetrequiredYesNoUnknownVS
cimi-statement-FindingSiteConditionPresenceStatement-model.severityCondition/Diagnosis SeverityrequiredCondition/Diagnosis Severity
cimi-statement-FindingSiteConditionPresenceStatement-model.criticalityAllergyIntoleranceCriticalityrequiredAllergyIntoleranceCriticality