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

WoundPresenceAssertionProfile

Definitions for sw-WoundPresenceAssertion.

Condition
Definition

A determination that a wound that exists at a particular body site. The WoundIdentifier serves as a link between this assertion and assessments of the wound that might occur at later times. Multiple wound assessments can be associated with a single wound.

Control0..*
InvariantsDefined on this element
con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error (: verificationStatus='entered-in-error' or clinicalStatus.exists())
con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission (: abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive')
dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative (: contained.text.empty())
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource (: contained.where(('#'+id in %resource.descendants().reference).not()).empty())
dom-4: 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())
us-core-1: A code in Condition.category SHOULD be from US Core Condition Category Codes value set. (: where(category in 'http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category').exists())
Condition.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Condition.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
Condition.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

Condition.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language.
The codes SHALL be taken from Common Languages; other codes may be used where these codes are not suitable
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Condition.text
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.

Condition.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

Condition.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control3..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.extension ([CanonicalType[http://hl7.org/fhir/StructureDefinition/condition-targetBodySite]])
Definition

An Extension

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(BodySite))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-core-PersonOfRecord-extension]])
Definition

The person this entry belongs to.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Reference(US Core Patient Profile))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-core-Recorded-extension]])
Definition

The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-core-Signed-extension]])
Definition

Provenance information specific to the signing of the clinical statement.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference, SampledData, Signature, Timing, Meta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-core-AdditionalText-extension]])
Definition

A text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: string)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-statement-ContextCode-extension]])
Definition

Code representing the sense in which the statement is interpreted, for example, the degree of presence in a PresenceStatement.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Condition.extension.extension(extension)
Definition

An Extension

Control0..0
TypeExtension
Condition.extension.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Fixed Valuehttp://hl7.org/fhir/us/sw/StructureDefinition/cimi-statement-ContextCode-extension
Condition.extension.valueCodeableConcept
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control1..1
BindingThe codes SHALL be taken from PresenceContextVS
TypeCodeableConcept
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-statement-Interpretation-extension]])
Definition

A clinical interpretation of a finding (applies to both assertions and observation).

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-statement-RelevantTime-extension]])
Definition

The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Choice of: dateTime, Period)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-statement-FindingMethod-extension]])
Definition

The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-datatypes-Media-extension]])
Definition

A file that contains audio, video, image, or similar content.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: Attachment)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/sw-WoundTypeEtiology-extension]])
Definition

A specialization of condition cause, specific to the causes of injuries (or not having injury in the wound absent context).

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/sw-WoundIdentifier-extension]])
Definition

A human-readable identifier for the lesion; e.g., a letter or integer.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: string)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-statement-WhenClinicallyRecognized-extension]])
Definition

The time at which a condition or condition was first identified in a healthcare context.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: date)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/cimi-statement-PresentOnAdmission-extension]])
Definition

If the problem or condition existed before the current episode of care.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.extension ([CanonicalType[http://hl7.org/fhir/us/sw/StructureDefinition/sw-WoundType-extension]])
Definition

A type code describing the wound or skin injury. Differentiating pressure ulcers and other types of wounds is important for an accurate count of their number and for identifying appropriate wound treatment. The values will be used for documenting and retrieving data regarding the number and types of wounds present.

Control0..* This element is affected by the following invariants: ele-1
Type (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: children().count() > id.count())
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Condition.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.identifier
Definition

This records identifiers associated with this condition that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Need to allow connection to a wider workflow.

Condition.clinicalStatus
Definition

The clinical status of the condition.

Control1..1 This element is affected by the following invariants: con-3, con-4
BindingThe codes SHALL be taken from Condition Clinical Status Codes
Typecode
Is Modifiertrue
Must Supporttrue
Comments

This element is labeled as a modifier because the status contains codes that mark the condition as not currently valid or of concern.

Condition.verificationStatus
Definition

The verification status to support the clinical status of the condition.

Control1..1 This element is affected by the following invariants: con-3
BindingThe codes SHALL be taken from ConditionVerificationStatus
Typecode
Is Modifiertrue
Must Supporttrue
Comments

verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status.

This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.

Default Valueunknown
Condition.category
Definition

A category assigned to the condition.

Control1..1
BindingThe codes SHOULD be taken from US Core Condition Category Codes
TypeCodeableConcept
Must Supporttrue
Comments

The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.

Condition.category.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Condition.category.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.category.coding
Definition

A reference to a code defined by a terminology system.

Control1..*
TypeCoding
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Condition.category.coding(Fixed_exam)
Definition

A reference to a code defined by a terminology system.

Control1..1
TypeCoding
Condition.category.coding.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Condition.category.coding.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.category.coding.system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Control0..1
Typeuri
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

Fixed Valuehttp://hl7.org/fhir/observation-category
Condition.category.coding.version
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

NoteThis is a business versionId, not a resource version id (see discussion)
Control0..1
Typestring
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

Condition.category.coding.code
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Control0..1
Typecode
Requirements

Need to refer to a particular code in the system.

Fixed Valueexam
Condition.category.coding.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Control0..1
Typestring
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Condition.category.coding.userSelected
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Control0..1
Typeboolean
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

Condition.category.text
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Control0..1
Typestring
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

Condition.severity
Definition

A subjective assessment of the severity of the condition as evaluated by the clinician.

Control0..0
BindingA subjective assessment of the severity of the condition as evaluated by the clinician.
The codes SHALL be taken from Condition/Diagnosis Severity
TypeCodeableConcept
Comments

Coding of the severity with a terminology is preferred, where possible.

Condition.code
Definition

Identification of the condition, problem or diagnosis.

Control1..1
BindingValueset to describe the actual problem experienced by the patient
The codes SHALL be taken from Problem Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Requirements

0..1 to account for primarily narrative only resources.

Alternate Namestype
Condition.code.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Condition.code.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.code.coding
Definition

A reference to a code defined by a terminology system.

Control1..*
TypeCoding
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Condition.code.coding(Fixed_416462003)
Definition

Wound (disorder)

Control1..1
TypeCoding
Condition.code.coding.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Condition.code.coding.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.code.coding.system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Control0..1
Typeuri
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

Fixed Valuehttp://snomed.info/sct
Condition.code.coding.version
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

NoteThis is a business versionId, not a resource version id (see discussion)
Control0..1
Typestring
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

Condition.code.coding.code
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Control0..1
Typecode
Requirements

Need to refer to a particular code in the system.

Fixed Value416462003
Condition.code.coding.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Control0..1
Typestring
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Condition.code.coding.userSelected
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Control0..1
Typeboolean
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

Condition.code.text
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Control0..1
Typestring
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

Condition.bodySite
Definition

The anatomical location where this condition manifests itself.

Control0..0
BindingCodes describing anatomical locations. May include laterality.
For example codes, see SNOMED CT Body Structures
TypeCodeableConcept
Comments

Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension body-site-instance. May be a summary code, or a reference to a very precise definition of the location, or both.

Condition.subject
Definition

Indicates the patient or group who the condition record is associated with.

Control1..1
TypeReference(US Core Patient Profile)
Must Supporttrue
Requirements

Group is typically used for veterinary or public health use cases.

Alternate Namespatient
Condition.context
Definition

Encounter during which the condition was first asserted.

Control0..1
TypeReference(EncounterProfile)
Alternate Namesencounter
Comments

This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".

Condition.onsetDateTime
Definition

Estimated or actual date or date-time the condition began, in the opinion of the clinician.

Control0..1
TypedateTime
Comments

Age is generally used when the patient reports an age at which the Condition began to occur.

Condition.abatementDateTime
Definition

The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate.

Control0..1 This element is affected by the following invariants: con-4
TypedateTime
Comments

There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.

Condition.assertedDate
Definition

The date on which the existance of the Condition was first asserted or acknowledged.

Control0..1
TypedateTime
Comments

The assertedDate represents the date when this particular Condition record was created in the EHR, not the date of the most recent update in terms of when severity, abatement, etc. were specified.  The date of the last record modification can be retrieved from the resource metadata.

Condition.asserter
Definition

Individual who is making the condition statement.

Control0..1
TypeReference(Practitioner | Patient | RelatedPerson)
Condition.stage
Definition

Clinical stage or grade of a condition. May include formal severity assessments.

Control0..1
TypeBackboneElement
InvariantsDefined on this element
con-1: Stage SHALL have summary or assessment (: summary.exists() or assessment.exists())
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Condition.stage.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Condition.stage.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.stage.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.stage.summary
Definition

A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.

Control0..1 This element is affected by the following invariants: con-1
BindingCodes describing condition stages (e.g. Cancer stages).
For example codes, see Condition Stage
TypeCodeableConcept
Condition.stage.assessment
Definition

Reference to a formal record of the evidence on which the staging assessment is based.

Control0..1 This element is affected by the following invariants: con-1
TypeReference(ObservationProfile)
Condition.evidence
Definition

Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed.

Control0..*
TypeBackboneElement
Comments

The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.

InvariantsDefined on this element
con-2: evidence SHALL have code or details (: code.exists() or detail.exists())
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
Condition.evidence.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Condition.evidence.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.evidence.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Condition.evidence.code
Definition

A manifestation or symptom that led to the recording of this condition.

Control0..* This element is affected by the following invariants: con-2
BindingCodes that describe the manifestation or symptoms of a condition.
For example codes, see Manifestation and Symptom Codes
TypeCodeableConcept
Condition.evidence.detail
Definition

Links to other relevant information, including pathology reports.

Control0..* This element is affected by the following invariants: con-2
TypeReference(Resource)
Condition.note
Definition

Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.

Control0..*
TypeAnnotation