| IB-Problema (Condition) | C | | Condition | There are no (further) constraints on this element Element idCondition Short descriptionDetailed information about conditions, problems or diagnoses DefinitionA clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
Condition Constraints- dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty() - dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative
contained.text.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() - 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() - 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' - con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error
verificationStatus='entered-in-error' or clinicalStatus.exists()
Mappings- rim: Entity. Role, or Act
- sct-concept: < 243796009 |Situation with explicit context|:
246090004 |Associated finding| =
((< 404684003 |Clinical finding| MINUS
<< 420134006 |Propensity to adverse reactions| MINUS
<< 473010000 |Hypersensitivity condition| MINUS
<< 79899007 |Drug interaction| MINUS
<< 69449002 |Drug action| MINUS
<< 441742003 |Evaluation finding| MINUS
<< 307824009 |Administrative status| MINUS
<< 385356007 |Tumor stage finding|) OR
< 272379006 |Event|)
- v2: PPR message
- rim: Observation[classCode=OBS, moodCode=EVN, code=ASSERTION, value<Diagnosis]
- w5: clinical.general
|
| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idCondition.id Short descriptionLogical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
id |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idCondition.meta Short descriptionMetadata about the resource DefinitionThe 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.
Meta |
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idCondition.implicitRules Short descriptionA set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.
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.
uri |
| language | | 0..1 | codeBinding | There are no (further) constraints on this element Element idCondition.language Short descriptionLanguage of the resource content DefinitionThe base language in which the resource is written.
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).
code BindingA human language. Common Languages (extensible) Binding extensions |
| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idCondition.text Short descriptionText summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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.
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.
Narrative ConditionsThe cardinality or value of this element may be affected by these constraints: dom-1 Mappings |
| contained | | 0..* | Resource | There are no (further) constraints on this element Element idCondition.contained Short descriptionContained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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.
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.
Resource Mappings |
| extension | | 0..* | Extension | Element idCondition.extension Short descriptionAdditional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
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.
Extension SlicingUnordered, Open, by url(Value) Mappings |
| jerarquia | C | 1..1 | Extension(Coding)Binding | Element idCondition.extension:jerarquia Short descriptionPrimario | Secundario Alternate namesextensions, user content DefinitionUn problema de salud se considera primario cuando no es consecuencia directa de otro problema de salud o se desconoce esa relación y secundario cuando se conoce esa relación. Ejemplo: Una neumonía podría ser un problema de salud primario, en cuyo contexto la fiebre, la tos y el dolor pleurítico serían problemas de salud secundarios. A su vez una neumonía podría ser un pro-blema secundario a una neoplasia con obstrucción bronquial.
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.
Extension(Coding) Extension URLhttp://example.org/fhir/StructureDefinition/IB-Jerarquia Bindingurn:hn:jerarquia (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- 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()
Mappings |
| atributosComunes | C | 1..1 | Extension(Complex) | Element idCondition.extension:atributosComunes Short descriptionAtributos Comunes Alternate namesextensions, user content DefinitionAtributos Comunes: ID Paciente, Tipo Elemento, Fecha y Hora registro, Sistema que envía, Autor.
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.
Extension(Complex) Extension URLhttp://example.org/fhir/StructureDefinition/IB-AtributosComunes ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- 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()
Mappings |
| modifierExtension | ?! | 0..* | Extension | There are no (further) constraints on this element Element idCondition.modifierExtension Short descriptionExtensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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.
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.
Extension Mappings |
| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idCondition.identifier Short descriptionExternal Ids for this condition DefinitionThis 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).
Need to allow connection to a wider workflow.
Identifier Mappings |
| clinicalStatus | Σ ?! C | 1..1 | codeBinding | Element idCondition.clinicalStatus Short descriptionactive | recurrence | inactive | remission | resolved DefinitionAfirmación sobre la situación actual del problema de salud.
PDTE: confirmar estados remission y recurrence
This element is labeled as a modifier because the status contains codes that mark the condition as not currently valid or of concern.
code BindingThe clinical status of the condition or diagnosis. Condition Clinical Status Codes (required) ConditionsThe cardinality or value of this element may be affected by these constraints: con-3, con-4 Mappings- sct-concept: < 303105007 |Disease phases|
- v2: PRB-14 / DG1-6
- rim: Observation ACT
.inboundRelationship[typeCode=COMP].source[classCode=OBS, code="clinicalStatus", moodCode=EVN].value
- w5: status
|
| verificationStatus | Σ ?! C | 1..1 | codeBinding | Element idCondition.verificationStatus Short descriptionprovisional | differential | confirmed | refuted | entered-in-error | unknown DefinitionEl nivel de certeza de la identificación del problema de salud.
PDTE: mapeos Sospecha y Probable a Provisional y que hacer con: refuted, entered-in-error, unknown, differential
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.
code BindingThe verification status to support or decline the clinical status of the condition or diagnosis. ConditionVerificationStatus (required) ConditionsThe cardinality or value of this element may be affected by these constraints: con-3 Default valueunknown Mappings- sct-concept: < 410514004 |Finding context value|
- v2: PRB-13
- rim: Observation ACT
.inboundRelationship[typeCode=COMP].source[classCode=OBS, code="verificationStatus", moodCode=EVN].value
- sct-attr: 408729009
- w5: status
|
| category | | 1..1 | CodeableConceptBindingAuto Value | Element idCondition.category Short descriptionproblem-list-item DefinitionIdentificador del elemento Problema de Salud
The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.
CodeableConcept BindingA category assigned to the condition. Condition Category Codes (required) Auto value{
"coding": [
{
"system": "http://hl7.org/fhir/ValueSet/condition-category",
"code": "problem-list-item"
}
],
"text": "problem-list-item"
}Default value{
"coding": [
{
"system": "http://hl7.org/fhir/ValueSet/condition-category",
"code": "problem-list-item"
}
],
"text": "problem-list-item"
}Mappings- sct-concept: < 404684003 |Clinical finding|
- v2: 'problem' if from PRB-3. 'diagnosis' if from DG1 segment in PV1 message
- rim: .code
- w5: class
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idCondition.category.id Short descriptionxml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | | 0..* | Extension | There are no (further) constraints on this element Element idCondition.category.extension Short descriptionAdditional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url Mappings |
| coding | Σ | 1..1 | CodingBindingAuto Value | Element idCondition.category.coding Short descriptionCode defined by a terminology system DefinitionA reference to a code defined by a terminology system.
Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.
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.
Coding Bindingproblem-list-item Condition Category Codes (required) Auto value{
"system": "http://hl7.org/fhir/ValueSet/condition-category",
"code": "problem-list-item"
}Default value{
"system": "http://hl7.org/fhir/ValueSet/condition-category",
"code": "problem-list-item"
}Mappings- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idCondition.category.coding.id Short descriptionxml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | | 0..* | Extension | There are no (further) constraints on this element Element idCondition.category.coding.extension Short descriptionAdditional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url Mappings |
| system | Σ | 1..1 | uriBindingAuto Value | Element idCondition.category.coding.system Short descriptionIdentity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code.
Need to be unambiguous about the source of the definition of the symbol.
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.
uri Bindingproblem-list-item Condition Category Codes (required) Auto valueproblem-list-item Default valueproblem-list-item Mappings- v2: C*E.3
- rim: ./codeSystem
- orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.category.coding.version Short descriptionVersion of the system - if relevant DefinitionThe 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.
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.
string Mappings- v2: C*E.7
- rim: ./codeSystemVersion
- orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | Σ | 1..1 | codeAuto Value | Element idCondition.category.coding.code Short descriptionSymbol in syntax defined by the system DefinitionA 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).
Need to refer to a particular code in the system.
code Auto valueproblem-list-item Default valueproblem-list-item Mappings- v2: C*E.1
- rim: ./code
- orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.category.coding.display Short descriptionRepresentation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
string Mappings- v2: C*E.2 - but note this is not well followed
- rim: CV.displayName
- orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idCondition.category.coding.userSelected Short descriptionIf this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).
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.
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.
boolean Mappings- v2: Sometimes implied by being first
- rim: CD.codingRationale
- orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| text | Σ | 1..1 | stringAuto Value | Element idCondition.category.text Short descriptionPlain text representation of the concept DefinitionA 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.
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.
Very often the text is the same as a displayName of one of the codings.
string Auto valueproblem-list-item Default valueproblem-list-item Mappings- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| severity | | 0..1 | CodeableConceptBinding | Element idCondition.severity Short descriptionSubjective severity of condition DefinitionUna evaluación del profesional de la salud sobre la severidad del problema de salud.
PDTE: definir mapeo de campos con el arquetipo
Coding of the severity with a terminology is preferred, where possible.
CodeableConcept BindingA subjective assessment of the severity of the condition as evaluated by the clinician. Condition/Diagnosis Severity (preferred) Mappings- sct-concept: < 272141005 |Severities|
- v2: PRB-26 / ABS-3
- rim: Can be pre/post-coordinated into value. Or ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="severity"].value
- sct-attr: 246112005
- w5: grade
|
| code | Σ | 1..1 | CodeableConceptBinding | Element idCondition.code Short descriptionIdentification of the condition, problem or diagnosis Alternate namestype DefinitionIdentification of the condition, problem or diagnosis.
RefSet de snomed
0..1 to account for primarily narrative only resources.
CodeableConcept BindingIdentification of the condition or diagnosis. Condition/Problem/Diagnosis Codes (required) Mappings- sct-concept: code 246090004 |Associated finding| (< 404684003 |Clinical finding| MINUS
<< 420134006 |Propensity to adverse reactions| MINUS
<< 473010000 |Hypersensitivity condition| MINUS
<< 79899007 |Drug interaction| MINUS
<< 69449002 |Drug action| MINUS
<< 441742003 |Evaluation finding| MINUS
<< 307824009 |Administrative status| MINUS
<< 385356007 |Tumor stage finding|)
OR < 413350009 |Finding with explicit context|
OR < 272379006 |Event|
- v2: PRB-3
- rim: .value
- sct-attr: 246090004
- w5: what
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.id Short descriptionxml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | | 0..* | Extension | There are no (further) constraints on this element Element idCondition.code.extension Short descriptionAdditional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url Mappings |
| coding | Σ | 1..1 | Coding | There are no (further) constraints on this element Element idCondition.code.coding Short descriptionCode defined by a terminology system DefinitionA reference to a code defined by a terminology system.
Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.
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.
Coding Mappings- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| text | Σ | 1..1 | string | There are no (further) constraints on this element Element idCondition.code.text Short descriptionPlain text representation of the concept DefinitionA 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.
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.
Very often the text is the same as a displayName of one of the codings.
string Mappings- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| bodySite | Σ | 0..* | CodeableConcept | Element idCondition.bodySite Short descriptionAnatomical location, if relevant DefinitionLocalización anatómica estructurada para el problema de salud.
PDTE: confirmar datos del mapeo o listado de snomed
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.
CodeableConcept BindingCodes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example) Examples
Izquierdo{
"text": "Izquierdo"
}Derecho{
"text": "Derecho"
}Bilateral{
"text": "Bilateral"
}Mappings- sct-concept: < 442083009 |Anatomical or acquired body structure|
- rim: .targetBodySiteCode
- sct-attr: 363698007
|
| subject | Σ | 1..1 | Reference(Patient) | Element idCondition.subject Short descriptionWho has the condition? Alternate namespatient DefinitionIndicates the patient or group who the condition record is associated with.
Identificador único de paciente de IB-Salut. Debe cumplir con la codificación específica de este tipo de identificador.
Group is typically used for veterinary or public health use cases.
Reference(Patient) Mappings- v2: PID-3
- rim: .participation[typeCode=SBJ].role[classCode=PAT]
- w5: who.focus
|
| context | Σ | 0..1 | Reference(Encounter | EpisodeOfCare) | There are no (further) constraints on this element Element idCondition.context Short descriptionEncounter or episode when condition first asserted Alternate namesencounter DefinitionEncounter during which the condition was first asserted.
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".
Reference(Encounter | EpisodeOfCare) Mappings- v2: PV1-19 (+PV1-54)
- rim: .inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
- w5: context
|
| onsetDateTime | Σ | 1..1 | dateTimePattern | Element idCondition.onset[x]:onsetDateTime Short descriptionEstimated or actual date, date-time, or age DefinitionFecha y hora en las cuales el problema de salud fue reconocido por un profesional de la salud. Es la fecha de mecanización en el sistema de información de la historia clínica.
Age is generally used when the patient reports an age at which the Condition began to occur.
dateTime Pattern2020-02-28 Mappings- v2: PRB-16
- rim: .effectiveTime.low or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at onset"].value
- w5: when.init
|
| abatementDateTime | C | 0..1 | dateTime | Element idCondition.abatement[x]:abatementDateTime Short descriptionIf/when in resolution/remission DefinitionFecha y hora estimadas o confirmadas en las cuales este problema de salud remitió o se resolvió, determinadas por un profesional de la salud.
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.
dateTime ConditionsThe cardinality or value of this element may be affected by these constraints: con-4 Mappings- rim: .effectiveTime.high or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at remission"].value or .inboundRelationship[typeCode=SUBJ]source[classCode=CONC, moodCode=EVN].status=completed
- w5: when.done
|
| assertedDate | Σ | 0..1 | dateTime | Element idCondition.assertedDate Short descriptionDate record was believed accurate DefinitionFecha y hora estimada o confirmadas en las cuales los signos o sintomas del problema fueron observados por primera vez.
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.
dateTime Mappings- v2: REL-11
- rim: .participation[typeCode=AUT].time
- w5: when.recorded
|
| asserter | Σ | 0..1 | Reference(Practitioner | Patient | RelatedPerson) | There are no (further) constraints on this element Element idCondition.asserter Short descriptionPerson who asserts this condition DefinitionIndividual who is making the condition statement.
Reference(Practitioner | Patient | RelatedPerson) Mappings- v2: REL-7.1 identifier + REL-7.12 type code
- rim: .participation[typeCode=AUT].role
- w5: who.author
|
| stage | C | 0..1 | BackboneElement | Element idCondition.stage Short descriptionStage/grade, usually assessed formally DefinitionUn problema de salud se considera primario cuando no es consecuencia directa de otro problema de salud o se desconoce esa relación y secundario cuando se conoce esa relación.
Ejemplo: Una neumonía podría ser un problema de salud primaria, en cuyo contexto la fiebre, la tos y el dolor pleurítico serían problemas de salud secundarios. A su vez una neumonía podría ser un problema secundario a una neoplasia con obstrucción bronquial.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - con-1: Stage SHALL have summary or assessment
summary.exists() or assessment.exists()
Mappings- rim: ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage/grade"]
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| id | | 0..1 | string | There are no (further) constraints on this element Element idCondition.stage.id Short descriptionxml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.extension Short descriptionAdditional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
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.
Extension Mappings |
| modifierExtension | Σ ?! | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.modifierExtension Short descriptionExtensions that cannot be ignored Alternate namesextensions, user content, modifiers DefinitionMay 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.
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.
Extension Mappings |
| summary | C | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCondition.stage.summary Short descriptionSimple summary (disease specific) DefinitionA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.
CodeableConcept BindingCodes describing condition stages (e.g. Cancer stages). Condition Stage (example) ConditionsThe cardinality or value of this element may be affected by these constraints: con-1 Mappings- sct-concept: < 254291000 |Staging and scales|
- v2: PRB-14
- rim: .value
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| assessment | C | 1..1 | Reference(ValueSet) | Element idCondition.stage.assessment Short descriptionFormal record of assessment DefinitionReference to a formal record of the evidence on which the staging assessment is based.
Reference(ValueSet) ConditionsThe cardinality or value of this element may be affected by these constraints: con-1 Examples
Primario{
"reference": "Primario",
"display": "Primario"
}Secundario{
"reference": "Secundario",
"display": "Secundario"
}Mappings |
| evidence | C | 0..* | BackboneElement | There are no (further) constraints on this element Element idCondition.evidence Short descriptionSupporting evidence DefinitionSupporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed.
The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - con-2: evidence SHALL have code or details
code.exists() or detail.exists()
Mappings- rim: .outboundRelationship[typeCode=SPRT].target[classCode=OBS, moodCode=EVN]
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| id | | 0..1 | string | There are no (further) constraints on this element Element idCondition.evidence.id Short descriptionxml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.extension Short descriptionAdditional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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.
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.
Extension Mappings |
| modifierExtension | Σ ?! | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.modifierExtension Short descriptionExtensions that cannot be ignored Alternate namesextensions, user content, modifiers DefinitionMay 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.
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.
Extension Mappings |
| code | Σ C | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCondition.evidence.code Short descriptionManifestation/symptom DefinitionA manifestation or symptom that led to the recording of this condition.
CodeableConcept BindingCodes that describe the manifestation or symptoms of a condition. Manifestation and Symptom Codes (example) ConditionsThe cardinality or value of this element may be affected by these constraints: con-2 Mappings- sct-concept: < 404684003 |Clinical finding|
- rim: [code="diagnosis"].value
- w5: why
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| detail | Σ C | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idCondition.evidence.detail Short descriptionSupporting information found elsewhere DefinitionLinks to other relevant information, including pathology reports.
Reference(Resource) ConditionsThe cardinality or value of this element may be affected by these constraints: con-2 Mappings |
| note | | 0..* | Annotation | Element idCondition.note Short descriptionAdditional information about the Condition DefinitionData typeAnnotation Mappings- v2: NTE child of PRB
- rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
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