US Veterans Health Administration FHIR Map Set Implementation Guide
1.4.0 - 250501 United States of America flag

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Resource Profile: Condition: Encounter Diagnosis

Official URL: http://va.gov/fhir/StructureDefinition/ConditionEncounterDiagnosis Version: 1.4.0
Active as of 2025-05-02 Computable Name: ConditionEncounterDiagnosis

This StructureDefinition contains the maps for VistA file V POV (9000010.07) to us-core-condition-encounter-diagnosis.

See also the FHIR Shorthand.

Use Case Overview

Use Case: Condition: Encounter Diagnosis«us-core-condition-encounter-diagnosis»ConditionEncounterDiagnosissubjectrecorderPatientPractitioner

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile Detailed information about conditions, problems or diagnoses
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
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... Slices for extension Content/Rules for all slices
.... extension:assertedDate S 0..1 dateTime Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
.... system SΣ 0..1 uri The namespace for the identifier value
ele-1: All FHIR elements must have a @value or children
Required Pattern: http://va.gov/identifiers/$Sta3n/9000010.07
.... value SΣ 0..1 string The value that is unique
ele-1: All FHIR elements must have a @value or children
Example General: 123456
... clinicalStatus ?!SΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: encounterProblemStatus FHIR (required): see mapping VF_encounterProblemStatus


ele-1: All FHIR elements must have a @value or children
ced-27-350: If (9000010.07-.06) is Null then exclude value
... verificationStatus ?!SΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: encounterProblemVerificationStatus FHIR (required): see mapping VF_encounterProblemVerificationStatus


ele-1: All FHIR elements must have a @value or children
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


ele-1: All FHIR elements must have a @value or children
.... category:us-core S 1..1 CodeableConcept encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


ele-1: All FHIR elements must have a @value or children

Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient


ele-1: All FHIR elements must have a @value or children
.... coding Σ 0..* Coding Code defined by a terminology system
ele-1: All FHIR elements must have a @value or children
..... system SΣ 0..1 uri Identity of the terminology system
ele-1: All FHIR elements must have a @value or children
Required Pattern: urn:see-termmap-in-mapParameter
..... code SΣ 0..1 code Symbol in syntax defined by the system
ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(Patient) Who has the condition?
ele-1: All FHIR elements must have a @value or children
... encounter SΣ 0..1 Reference(US Core Encounter Profile(5.0.1)) Encounter created as part of
ele-1: All FHIR elements must have a @value or children
... Slices for onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
.... onsetDateTime dateTime
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Estimated or actual date, date-time, or age
ele-1: All FHIR elements must have a @value or children
... Slices for abatement[x] SC 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
.... abatementDateTime dateTime
.... abatement[x]:abatementDateTime SC 0..1 dateTime When in resolution/remission
ele-1: All FHIR elements must have a @value or children
... recordedDate SΣ 0..1 dateTime Date record was first recorded
ele-1: All FHIR elements must have a @value or children
... recorder SΣ 0..1 Reference(Practitioner) Who recorded the condition
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Condition.clinicalStatusrequiredEncounterProblemStatus
http://va.gov/fhir/ValueSet/encounterProblemStatus
from this IG
Condition.verificationStatusrequiredEncounterProblemVerificationStatus
http://va.gov/fhir/ValueSet/encounterProblemVerificationStatus
from this IG
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.codeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code

Constraints

IdGradePath(s)DetailsRequirements
ced-27-350warningCondition.clinicalStatusIf (9000010.07-.06) is Null then exclude value
: true
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 USCoreConditionEncounterDiagnosisProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..* USCoreConditionEncounterDiagnosisProfile Detailed information about conditions, problems or diagnoses
... identifier
.... system S 0..1 uri The namespace for the identifier value
Required Pattern: http://va.gov/identifiers/$Sta3n/9000010.07
.... value S 0..1 string The value that is unique
... clinicalStatus C 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: encounterProblemStatus FHIR (required): see mapping VF_encounterProblemStatus


ced-27-350: If (9000010.07-.06) is Null then exclude value
... verificationStatus 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: encounterProblemVerificationStatus FHIR (required): see mapping VF_encounterProblemVerificationStatus

.... category:us-core 1..1 CodeableConcept encounter-diagnosis
... code
.... coding
..... system S 0..1 uri Identity of the terminology system
Required Pattern: urn:see-termmap-in-mapParameter
..... code S 0..1 code Symbol in syntax defined by the system
... subject 1..1 Reference(Patient) Who has the condition?
... encounter 0..1 Reference(US Core Encounter Profile(5.0.1)) Encounter created as part of
... Slices for onset[x] 0..1 dateTime, Age, Period, Range, string Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onset[x]:onsetDateTime S 0..1 dateTime S Estimated or actual date, date-time, or age
... Slices for abatement[x] 0..1 dateTime, Age, Period, Range, string When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatement[x]:abatementDateTime 0..1 dateTime When in resolution/remission
... recordedDate 0..1 dateTime Date record was first recorded
... recorder S 0..1 Reference(Practitioner) Who recorded the condition

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Condition.clinicalStatusrequiredEncounterProblemStatus
http://va.gov/fhir/ValueSet/encounterProblemStatus
from this IG
Condition.verificationStatusrequiredEncounterProblemVerificationStatus
http://va.gov/fhir/ValueSet/encounterProblemVerificationStatus
from this IG

Constraints

IdGradePath(s)DetailsRequirements
ced-27-350warningCondition.clinicalStatusIf (9000010.07-.06) is Null then exclude value
: true
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile Detailed information about conditions, problems or diagnoses
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
... 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
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:assertedDate S 0..1 dateTime Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Ids for this condition
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system SΣ 0..1 uri The namespace for the identifier value
Required Pattern: http://va.gov/identifiers/$Sta3n/9000010.07
.... value SΣ 0..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... clinicalStatus ?!SΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: encounterProblemStatus FHIR (required): see mapping VF_encounterProblemStatus


ced-27-350: If (9000010.07-.06) is Null then exclude value
... verificationStatus ?!SΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: encounterProblemVerificationStatus FHIR (required): see mapping VF_encounterProblemVerificationStatus

... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:us-core S 1..1 CodeableConcept encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... severity 0..1 CodeableConcept Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣ 0..1 uri Identity of the terminology system
Required Pattern: urn:see-termmap-in-mapParameter
..... version Σ 0..1 string Version of the system - if relevant
..... code SΣ 0..1 code Symbol in syntax defined by the system
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ 1..1 Reference(Patient) Who has the condition?
... encounter SΣ 0..1 Reference(US Core Encounter Profile(5.0.1)) Encounter created as part of
... Slices for onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
.... onset[x]:onsetDateTime SΣ 0..1 dateTime S Estimated or actual date, date-time, or age
... Slices for abatement[x] SC 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
.... abatement[x]:abatementDateTime SC 0..1 dateTime S When in resolution/remission
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder SΣ 0..1 Reference(Practitioner) 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: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Condition.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Condition.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Condition.clinicalStatusrequiredEncounterProblemStatus
http://va.gov/fhir/ValueSet/encounterProblemStatus
from this IG
Condition.verificationStatusrequiredEncounterProblemVerificationStatus
http://va.gov/fhir/ValueSet/encounterProblemVerificationStatus
from this IG
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severitypreferredCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
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.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ced-27-350warningCondition.clinicalStatusIf (9000010.07-.06) is Null then exclude value
: true
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 USCoreConditionEncounterDiagnosisProfile

Summary

Must-Support: 6 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Condition.onset[x]
  • The element 1 is sliced based on the value of Condition.abatement[x]

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile Detailed information about conditions, problems or diagnoses
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
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... Slices for extension Content/Rules for all slices
.... extension:assertedDate S 0..1 dateTime Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
.... system SΣ 0..1 uri The namespace for the identifier value
ele-1: All FHIR elements must have a @value or children
Required Pattern: http://va.gov/identifiers/$Sta3n/9000010.07
.... value SΣ 0..1 string The value that is unique
ele-1: All FHIR elements must have a @value or children
Example General: 123456
... clinicalStatus ?!SΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: encounterProblemStatus FHIR (required): see mapping VF_encounterProblemStatus


ele-1: All FHIR elements must have a @value or children
ced-27-350: If (9000010.07-.06) is Null then exclude value
... verificationStatus ?!SΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: encounterProblemVerificationStatus FHIR (required): see mapping VF_encounterProblemVerificationStatus


ele-1: All FHIR elements must have a @value or children
... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


ele-1: All FHIR elements must have a @value or children
.... category:us-core S 1..1 CodeableConcept encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


ele-1: All FHIR elements must have a @value or children

Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient


ele-1: All FHIR elements must have a @value or children
.... coding Σ 0..* Coding Code defined by a terminology system
ele-1: All FHIR elements must have a @value or children
..... system SΣ 0..1 uri Identity of the terminology system
ele-1: All FHIR elements must have a @value or children
Required Pattern: urn:see-termmap-in-mapParameter
..... code SΣ 0..1 code Symbol in syntax defined by the system
ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(Patient) Who has the condition?
ele-1: All FHIR elements must have a @value or children
... encounter SΣ 0..1 Reference(US Core Encounter Profile(5.0.1)) Encounter created as part of
ele-1: All FHIR elements must have a @value or children
... Slices for onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
.... onsetDateTime dateTime
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Estimated or actual date, date-time, or age
ele-1: All FHIR elements must have a @value or children
... Slices for abatement[x] SC 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
ele-1: All FHIR elements must have a @value or children
.... abatementDateTime dateTime
.... abatement[x]:abatementDateTime SC 0..1 dateTime When in resolution/remission
ele-1: All FHIR elements must have a @value or children
... recordedDate SΣ 0..1 dateTime Date record was first recorded
ele-1: All FHIR elements must have a @value or children
... recorder SΣ 0..1 Reference(Practitioner) Who recorded the condition
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Condition.clinicalStatusrequiredEncounterProblemStatus
http://va.gov/fhir/ValueSet/encounterProblemStatus
from this IG
Condition.verificationStatusrequiredEncounterProblemVerificationStatus
http://va.gov/fhir/ValueSet/encounterProblemVerificationStatus
from this IG
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.codeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code

Constraints

IdGradePath(s)DetailsRequirements
ced-27-350warningCondition.clinicalStatusIf (9000010.07-.06) is Null then exclude value
: true
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()

Differential View

This structure is derived from USCoreConditionEncounterDiagnosisProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..* USCoreConditionEncounterDiagnosisProfile Detailed information about conditions, problems or diagnoses
... identifier
.... system S 0..1 uri The namespace for the identifier value
Required Pattern: http://va.gov/identifiers/$Sta3n/9000010.07
.... value S 0..1 string The value that is unique
... clinicalStatus C 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: encounterProblemStatus FHIR (required): see mapping VF_encounterProblemStatus


ced-27-350: If (9000010.07-.06) is Null then exclude value
... verificationStatus 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: encounterProblemVerificationStatus FHIR (required): see mapping VF_encounterProblemVerificationStatus

.... category:us-core 1..1 CodeableConcept encounter-diagnosis
... code
.... coding
..... system S 0..1 uri Identity of the terminology system
Required Pattern: urn:see-termmap-in-mapParameter
..... code S 0..1 code Symbol in syntax defined by the system
... subject 1..1 Reference(Patient) Who has the condition?
... encounter 0..1 Reference(US Core Encounter Profile(5.0.1)) Encounter created as part of
... Slices for onset[x] 0..1 dateTime, Age, Period, Range, string Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onset[x]:onsetDateTime S 0..1 dateTime S Estimated or actual date, date-time, or age
... Slices for abatement[x] 0..1 dateTime, Age, Period, Range, string When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatement[x]:abatementDateTime 0..1 dateTime When in resolution/remission
... recordedDate 0..1 dateTime Date record was first recorded
... recorder S 0..1 Reference(Practitioner) Who recorded the condition

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Condition.clinicalStatusrequiredEncounterProblemStatus
http://va.gov/fhir/ValueSet/encounterProblemStatus
from this IG
Condition.verificationStatusrequiredEncounterProblemVerificationStatus
http://va.gov/fhir/ValueSet/encounterProblemVerificationStatus
from this IG

Constraints

IdGradePath(s)DetailsRequirements
ced-27-350warningCondition.clinicalStatusIf (9000010.07-.06) is Null then exclude value
: true

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C 0..* USCoreConditionEncounterDiagnosisProfile Detailed information about conditions, problems or diagnoses
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
... 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
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:assertedDate S 0..1 dateTime Date the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Ids for this condition
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system SΣ 0..1 uri The namespace for the identifier value
Required Pattern: http://va.gov/identifiers/$Sta3n/9000010.07
.... value SΣ 0..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... clinicalStatus ?!SΣC 0..1 CodeableConcept active | recurrence | relapse | inactive | remission | resolved
Binding: encounterProblemStatus FHIR (required): see mapping VF_encounterProblemStatus


ced-27-350: If (9000010.07-.06) is Null then exclude value
... verificationStatus ?!SΣC 0..1 CodeableConcept unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: encounterProblemVerificationStatus FHIR (required): see mapping VF_encounterProblemVerificationStatus

... Slices for category S 1..* CodeableConcept category codes
Slice: Unordered, Open by pattern:$this
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


.... category:us-core S 1..1 CodeableConcept encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: encounter-diagnosis
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... severity 0..1 CodeableConcept Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ 1..1 CodeableConcept Identification of the condition, problem or diagnosis
Binding: US Core Condition Codes (extensible): Valueset to describe the actual problem experienced by the patient

.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣ 0..1 uri Identity of the terminology system
Required Pattern: urn:see-termmap-in-mapParameter
..... version Σ 0..1 string Version of the system - if relevant
..... code SΣ 0..1 code Symbol in syntax defined by the system
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ 1..1 Reference(Patient) Who has the condition?
... encounter SΣ 0..1 Reference(US Core Encounter Profile(5.0.1)) Encounter created as part of
... Slices for onset[x] SΣ 0..1 Estimated or actual date, date-time, or age
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime S
.... onsetAge Age
.... onsetPeriod Period
.... onsetRange Range
.... onsetString string
.... onset[x]:onsetDateTime SΣ 0..1 dateTime S Estimated or actual date, date-time, or age
... Slices for abatement[x] SC 0..1 When in resolution/remission
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime S
.... abatementAge Age
.... abatementPeriod Period
.... abatementRange Range
.... abatementString string
.... abatement[x]:abatementDateTime SC 0..1 dateTime S When in resolution/remission
... recordedDate SΣ 0..1 dateTime Date record was first recorded
... recorder SΣ 0..1 Reference(Practitioner) 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: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note 0..* Annotation Additional information about the Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Condition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Condition.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Condition.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Condition.clinicalStatusrequiredEncounterProblemStatus
http://va.gov/fhir/ValueSet/encounterProblemStatus
from this IG
Condition.verificationStatusrequiredEncounterProblemVerificationStatus
http://va.gov/fhir/ValueSet/encounterProblemVerificationStatus
from this IG
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.category:us-coreextensiblePattern: encounter-diagnosis
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severitypreferredCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
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.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ced-27-350warningCondition.clinicalStatusIf (9000010.07-.06) is Null then exclude value
: true
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 USCoreConditionEncounterDiagnosisProfile

Summary

Must-Support: 6 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Condition.onset[x]
  • The element 1 is sliced based on the value of Condition.abatement[x]

 

Other representations of profile: CSV, Excel, Schematron