Interweave Implementation Guide
0.1.0 - ci-build

Interweave Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions

Resource Profile: InterweaveCondition

Official URL: https://fhir.yhcr.nhs.uk/StructureDefinition/Interweave-Condition Version: 0.1.0
Draft as of 2022-08-19 Computable Name: InterweaveCondition

Interweave Condition resource profile - DRAFT

  Status: Draft - Work In Progress

Introduction

This profile sets minimum expectations for the Condition resource.

Mandatory fields

The following mandatory fields are defined in order to properly describe a Condition:

  1. Clinical Status - Essential to explain the status of the condition – eg is it currently active.

    This implies a need to keep this status up-to-date – and ideally this will be done, but in reality might not always be possible. For example in the case of historical records where the patient has moved on. At a minimum however this status must be valid as-at the “assertedDate”. This allows a viewer to make an informed judgement about the likelihood that it is still relevant now.

  2. Code - Essential to describe what the condition actually is. Based on SNOMED codes eg “Sprain of shoulder”. We pre-adopt the UK Core code list, which extends the default FHIR list with additional codes covering Social Care and Urgent Care

  3. Subject - every Condition must be linked to a Patient (not a Group)

  4. Asserted Date - vital information about when the condition was noted. Provides essential guidance for a viewer about the recency and thus likely relevance / accuracy of historical records

Must Support fields

In addition the following fields are “Must Support” - ie they must be populated if relevant and known:

  1. Identifier - a Local Id should be provided, such that could be quoted if manually getting in touch to find out more

  2. Body Site - snomed coding for the affected body part. Important to provide if possible and relevant

  3. Context - a link to the Encounter when the condition was first asserted. Will not be relevant to all Conditions (eg historical lists), but should be populated if applicable. Should link to the lowest level possible in any hierarchy, thus providing maximum detail about where the condition was noted.

    Note: Do not link to an Episode of Care, as this is deprecated in FHIR R4

  4. Onset and Abatement - these are important to provide if at all possible.
    • Onset might be omitted if genuinely not known (eg a long-standing historical condition), but should normally be populated
    • Abatement is obviously only relevant if the condition has actually abated – in which case useful and important to populate
    • Note that in both cases there are a variety of options for how to express this (eg datetime, age, period, etc). These do seem relevant for accurately conveying what is known - with the implication that Data Consumers will need corresponding flexibility in displaying this information.

    Note: Do not use abatementBoolean, as this is deprecated in FHIR R4

  5. Asserter - Required to populate if known. The main purpose would be to provide details of a Practitioner who can give more information about the condition. Therefore it should not be populated with details of purely admin staff who may have keyed in the data. If the asserter is not populated then an unknown Practitioner should be assumed.

    A further consideration is the possibility of a Condition being asserted by a non-care-professional, for example the Patient themselves or a relative. FHIR caters for this possibiity by allowing the asserter to be a Patient or RelatedPerson, and this option is left open here. However if you have a use-case of this type then please get in touch so that the implications can be more fully considered.

Optional fields

Other fields are optional and may be populated if known - on the understanding that not all data consumers will necessarily make use of them. Points of note include:

  • Episodicity (Care Connect Extension) - Optional additional information if available

  • Stage - Additional information that may be useful for relevant conditions eg cancer

  • Evidence - To some extent duplicates the “code”, but may optionally provide further information about what led to this code being assigned

    NB: The option to provide a “detail” link to any other resource must NOT be used – as it is difficult for a Data Consumer to interpret and display

  • Note - Only to be used with caution. Any notes may be shared widely across the region, including being viewed by the patient themselves

  • Category - There are a few codes here to classify a Condition eg “Encounter Diagnosis” or “Problem List Item”. (The original FHIR spec only has these two, but Care Connect adds a few more which perhaps makes it a bit more useful)

Discouraged or Removed fields

  • Verification Status - This appears to be a significant modifier of the Condition, however it has been removed by Care Connect. Note that an implication of this decision by Care Connect is that this becomes a set of Conditions which DO apply to the subject. Ie there is no mechanism to capture a “refuted” Condition.

Usage:

Formal Views of Profile Content

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

This structure is derived from CareConnect-Condition-1

Summary

Mandatory: 5 elements (17 nested mandatory elements)
Must-Support: 23 elements
Fixed Value: 3 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Condition.meta.tag is sliced based on the value of value:system
  • The element Condition.identifier is sliced based on the value of value:system

This structure is derived from CareConnect-Condition-1

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*CareConnect-Condition-1Detailed information about conditions, problems or diagnoses
... id S0..1idLogical id of this artifact
... meta
.... versionId S0..1idVersion specific identifier
.... lastUpdated S0..1instantMANDATORY except in Contained Resources. When the resource version last changed.
.... profile S0..*uriProfiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
.... security 0..*CodingDISCOURAGED - may not be honoured by Data Consumers
.... Slices for tag 0..*CodingTags applied to this resource
Slice: Unordered, Open by value:system
..... tag:Source S0..1CodingMANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data
...... system 1..1uriIdentity of the terminology system
Fixed Value: https://yhcr.nhs.uk/Source
...... code S1..1codeThe Data Provider Id of the system supplying the data
...... display S1..1stringName of the system supplying the data
..... tag:Provenance S0..1CodingMANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data
...... system 1..1uriIdentity of the terminology system
Fixed Value: https://yhcr.nhs.uk/Provenance
...... code S1..1codeThe ODS Code of the organisation responsible for the data
...... display S1..1stringName of the organisation supplying the data
... implicitRules 0..1uriDISCOURAGED - may not be honoured by Data Consumers
... text 0..1NarrativeDISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users
... Slices for identifier 0..*IdentifierExternal Ids for this condition
Slice: Unordered, Open by value:system
.... identifier:localIdentifier S0..1IdentifierExternal Ids for this condition
..... system S1..1uriThe namespace for the identifier value
Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-condition-identifier
..... value S1..1stringThe Local condition Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique
..... period 0..0
... clinicalStatus S1..1codeactive | recurrence | inactive | remission | resolved
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Interweave UkCore Condition Code (required)
.... coding 0..*CodingCode defined by a terminology system
..... system 1..1uriIdentity of the terminology system
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
... bodySite S0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (required)
.... coding 1..*CodingCode defined by a terminology system
..... system 1..1uriIdentity of the terminology system
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
.... coding:snomedCT S1..1CodingCode defined by a terminology system
Binding: SNOMED CT Body Structures (required)
... subject S1..1Reference(CareConnect-Patient-1)Who has the condition? (A patient, NOT group)
.... reference 1..1stringReference to a resource (could be Contained)
.... identifier 0..1IdentifierIf relevant could include an id
.... display 1..1stringDescription of the referenced resource
... context S0..1Reference(CareConnect-Encounter-1)Encounter or episode when condition first asserted
.... reference 1..1stringReference to a resource (could be Contained)
.... identifier 0..1IdentifierIf relevant could include an id
.... display 0..1stringIf relevant, description of the referenced resource
... onset[x] S0..1dateTime, Age, Period, Range, stringEstimated or actual date, date-time, or age
... abatement[x] S0..1dateTime, Age, boolean, Period, Range, stringIf/when in resolution/remission
... assertedDate S1..1dateTimeDate record was believed accurate
... asserter S0..1Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1)Person who asserts this condition
.... reference 1..1stringReference to a resource (could be Contained)
.... identifier 0..1IdentifierIf relevant could include an id
.... display 1..1stringDescription of the referenced resource
... evidence
.... detail 0..0
... note 0..*AnnotationAdditional information about the Condition. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*CareConnect-Condition-1Detailed information about conditions, problems or diagnoses
... id SΣ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... versionId SΣ0..1idVersion specific identifier
.... lastUpdated SΣ0..1instantMANDATORY except in Contained Resources. When the resource version last changed.
.... profile SΣ0..*uriProfiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
.... security Σ0..*CodingDISCOURAGED - may not be honoured by Data Consumers
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... Slices for tag Σ0..*CodingTags applied to this resource
Slice: Unordered, Open by value:system
Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"


..... tag:Source SΣ0..1CodingMANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data
Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"


...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: https://yhcr.nhs.uk/Source
...... version Σ0..1stringVersion of the system - if relevant
...... code SΣ1..1codeThe Data Provider Id of the system supplying the data
...... display SΣ1..1stringName of the system supplying the data
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... tag:Provenance SΣ0..1CodingMANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data
Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"


...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: https://yhcr.nhs.uk/Provenance
...... version Σ0..1stringVersion of the system - if relevant
...... code SΣ1..1codeThe ODS Code of the organisation responsible for the data
...... display SΣ1..1stringName of the organisation supplying the data
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
... implicitRules ?!Σ0..1uriDISCOURAGED - may not be honoured by Data Consumers
... text 0..1NarrativeDISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... Extension-CareConnect-ConditionEpisode-1 0..*codeEpisodicity of condition
URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-ConditionEpisode-1
Binding: Care Connect Condition Episodicity (required): Specifies the episodicity of a condition.


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier Σ0..*IdentifierExternal Ids for this condition
Slice: Unordered, Open by value:system
.... identifier:All Slices Content/Rules for all slices
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription 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 Σ1..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ1..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(CareConnect-Organization-1)Organization that issued id (may be just text)
.... identifier:localIdentifier SΣ0..1IdentifierExternal Ids for this condition
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription 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 SΣ1..1uriThe namespace for the identifier value
Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-condition-identifier
..... value SΣ1..1stringThe Local condition Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique
Example General: 123456
..... assigner Σ0..1Reference(CareConnect-Organization-1)Organization that issued id (may be just text)
... clinicalStatus ?!SΣI1..1codeactive | recurrence | inactive | remission | resolved
Binding: Condition Clinical Status Codes (required): The clinical status of the condition or diagnosis.

... category 0..*CodeableConceptproblem-list-item | encounter-diagnosis | presenting-complaint
Binding: Care Connect Condition Category (extensible)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ1..1uriIdentity of the terminology system
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Interweave UkCore Condition Code (required)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:All Slices Content/Rules for all slices
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... coding:snomedCT Σ0..1CodingCode defined by a terminology system
Binding: Care Connect Condition Code (required): A code from the SNOMED Clinical Terminology UK


...... id 0..1stringxml:id (or equivalent in JSON)
...... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
...... Extension-coding-sctdescid 0..*(Complex)Optional Extensions Element
URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... bodySite SΣ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (required)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ1..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:All Slices Content/Rules for all slices
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... coding:snomedCT SΣ1..1CodingCode defined by a terminology system
Binding: SNOMED CT Body Structures (required)
...... id 0..1stringxml:id (or equivalent in JSON)
...... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
...... Extension-coding-sctdescid 0..*(Complex)Optional Extensions Element
URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(CareConnect-Patient-1)Who has the condition? (A patient, NOT group)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringReference to a resource (could be Contained)
.... identifier Σ0..1IdentifierIf relevant could include an id
.... display Σ1..1stringDescription of the referenced resource
... context SΣ0..1Reference(CareConnect-Encounter-1)Encounter or episode when condition first asserted
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringReference to a resource (could be Contained)
.... identifier Σ0..1IdentifierIf relevant could include an id
.... display Σ0..1stringIf relevant, description of the referenced resource
... onset[x] SΣ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] SI0..1If/when in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementBooleanboolean
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... assertedDate SΣ1..1dateTimeDate record was believed accurate
... asserter SΣ0..1Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1)Person who asserts this condition
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringReference to a resource (could be Contained)
.... identifier Σ0..1IdentifierIf relevant could include an id
.... display Σ1..1stringDescription of the referenced resource
... stage I0..1BackboneElementStage/grade, usually assessed formally
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example): Codes describing condition stages (e.g. Cancer stages).

..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
...... coding:snomedCT Σ0..1CodingCode defined by a terminology system
....... id 0..1stringxml:id (or equivalent in JSON)
....... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
....... Extension-coding-sctdescid 0..*(Complex)The SNOMED CT Description ID for the display
URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid
....... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
....... display Σ1..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | CareConnect-Observation-1)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example): Codes that describe the manifestation or symptoms of a condition.


... note 0..*AnnotationAdditional information about the Condition. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... author[x] Σ0..1Individual responsible for the annotation
..... authorReferenceReference(RelatedPerson | CareConnect-Practitioner-1 | CareConnect-Patient-1)
..... authorStringstring
.... time Σ0..1dateTimeWhen the annotation was made
.... text 1..1stringThe annotation - text content

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*CareConnect-Condition-1Detailed information about conditions, problems or diagnoses
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantMANDATORY except in Contained Resources. When the resource version last changed.
.... profile Σ0..*uriProfiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
.... tag:Source Σ0..1CodingMANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data
Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"


..... code Σ1..1codeThe Data Provider Id of the system supplying the data
..... display Σ1..1stringName of the system supplying the data
.... tag:Provenance Σ0..1CodingMANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data
Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"


..... code Σ1..1codeThe ODS Code of the organisation responsible for the data
..... display Σ1..1stringName of the organisation supplying the data
... identifier:localIdentifier Σ0..1IdentifierExternal Ids for this condition
.... system Σ1..1uriThe namespace for the identifier value
Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-condition-identifier
.... value Σ1..1stringThe Local condition Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique
... code Σ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Interweave UkCore Condition Code (required)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (required)
.... coding:snomedCT Σ1..1CodingCode defined by a terminology system
Binding: SNOMED CT Body Structures (required)
... subject Σ1..1Reference(CareConnect-Patient-1)Who has the condition? (A patient, NOT group)
... context Σ0..1Reference(CareConnect-Encounter-1)Encounter or episode when condition first asserted
... onset[x] Σ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] I0..1If/when in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementBooleanboolean
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... assertedDate Σ1..1dateTimeDate record was believed accurate
... asserter Σ0..1Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1)Person who asserts this condition

doco Documentation for this format

This structure is derived from CareConnect-Condition-1

Summary

Mandatory: 5 elements (17 nested mandatory elements)
Must-Support: 23 elements
Fixed Value: 3 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Condition.meta.tag is sliced based on the value of value:system
  • The element Condition.identifier is sliced based on the value of value:system

Differential View

This structure is derived from CareConnect-Condition-1

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*CareConnect-Condition-1Detailed information about conditions, problems or diagnoses
... id S0..1idLogical id of this artifact
... meta
.... versionId S0..1idVersion specific identifier
.... lastUpdated S0..1instantMANDATORY except in Contained Resources. When the resource version last changed.
.... profile S0..*uriProfiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
.... security 0..*CodingDISCOURAGED - may not be honoured by Data Consumers
.... Slices for tag 0..*CodingTags applied to this resource
Slice: Unordered, Open by value:system
..... tag:Source S0..1CodingMANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data
...... system 1..1uriIdentity of the terminology system
Fixed Value: https://yhcr.nhs.uk/Source
...... code S1..1codeThe Data Provider Id of the system supplying the data
...... display S1..1stringName of the system supplying the data
..... tag:Provenance S0..1CodingMANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data
...... system 1..1uriIdentity of the terminology system
Fixed Value: https://yhcr.nhs.uk/Provenance
...... code S1..1codeThe ODS Code of the organisation responsible for the data
...... display S1..1stringName of the organisation supplying the data
... implicitRules 0..1uriDISCOURAGED - may not be honoured by Data Consumers
... text 0..1NarrativeDISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users
... Slices for identifier 0..*IdentifierExternal Ids for this condition
Slice: Unordered, Open by value:system
.... identifier:localIdentifier S0..1IdentifierExternal Ids for this condition
..... system S1..1uriThe namespace for the identifier value
Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-condition-identifier
..... value S1..1stringThe Local condition Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique
..... period 0..0
... clinicalStatus S1..1codeactive | recurrence | inactive | remission | resolved
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Interweave UkCore Condition Code (required)
.... coding 0..*CodingCode defined by a terminology system
..... system 1..1uriIdentity of the terminology system
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
... bodySite S0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (required)
.... coding 1..*CodingCode defined by a terminology system
..... system 1..1uriIdentity of the terminology system
..... code 1..1codeSymbol in syntax defined by the system
..... display 1..1stringRepresentation defined by the system
.... coding:snomedCT S1..1CodingCode defined by a terminology system
Binding: SNOMED CT Body Structures (required)
... subject S1..1Reference(CareConnect-Patient-1)Who has the condition? (A patient, NOT group)
.... reference 1..1stringReference to a resource (could be Contained)
.... identifier 0..1IdentifierIf relevant could include an id
.... display 1..1stringDescription of the referenced resource
... context S0..1Reference(CareConnect-Encounter-1)Encounter or episode when condition first asserted
.... reference 1..1stringReference to a resource (could be Contained)
.... identifier 0..1IdentifierIf relevant could include an id
.... display 0..1stringIf relevant, description of the referenced resource
... onset[x] S0..1dateTime, Age, Period, Range, stringEstimated or actual date, date-time, or age
... abatement[x] S0..1dateTime, Age, boolean, Period, Range, stringIf/when in resolution/remission
... assertedDate S1..1dateTimeDate record was believed accurate
... asserter S0..1Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1)Person who asserts this condition
.... reference 1..1stringReference to a resource (could be Contained)
.... identifier 0..1IdentifierIf relevant could include an id
.... display 1..1stringDescription of the referenced resource
... evidence
.... detail 0..0
... note 0..*AnnotationAdditional information about the Condition. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*CareConnect-Condition-1Detailed information about conditions, problems or diagnoses
... id SΣ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... versionId SΣ0..1idVersion specific identifier
.... lastUpdated SΣ0..1instantMANDATORY except in Contained Resources. When the resource version last changed.
.... profile SΣ0..*uriProfiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
.... security Σ0..*CodingDISCOURAGED - may not be honoured by Data Consumers
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... Slices for tag Σ0..*CodingTags applied to this resource
Slice: Unordered, Open by value:system
Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"


..... tag:Source SΣ0..1CodingMANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data
Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"


...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: https://yhcr.nhs.uk/Source
...... version Σ0..1stringVersion of the system - if relevant
...... code SΣ1..1codeThe Data Provider Id of the system supplying the data
...... display SΣ1..1stringName of the system supplying the data
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... tag:Provenance SΣ0..1CodingMANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data
Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"


...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: https://yhcr.nhs.uk/Provenance
...... version Σ0..1stringVersion of the system - if relevant
...... code SΣ1..1codeThe ODS Code of the organisation responsible for the data
...... display SΣ1..1stringName of the organisation supplying the data
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
... implicitRules ?!Σ0..1uriDISCOURAGED - may not be honoured by Data Consumers
... text 0..1NarrativeDISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... Extension-CareConnect-ConditionEpisode-1 0..*codeEpisodicity of condition
URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-ConditionEpisode-1
Binding: Care Connect Condition Episodicity (required): Specifies the episodicity of a condition.


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier Σ0..*IdentifierExternal Ids for this condition
Slice: Unordered, Open by value:system
.... identifier:All Slices Content/Rules for all slices
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription 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 Σ1..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ1..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(CareConnect-Organization-1)Organization that issued id (may be just text)
.... identifier:localIdentifier SΣ0..1IdentifierExternal Ids for this condition
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription 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 SΣ1..1uriThe namespace for the identifier value
Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-condition-identifier
..... value SΣ1..1stringThe Local condition Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique
Example General: 123456
..... assigner Σ0..1Reference(CareConnect-Organization-1)Organization that issued id (may be just text)
... clinicalStatus ?!SΣI1..1codeactive | recurrence | inactive | remission | resolved
Binding: Condition Clinical Status Codes (required): The clinical status of the condition or diagnosis.

... category 0..*CodeableConceptproblem-list-item | encounter-diagnosis | presenting-complaint
Binding: Care Connect Condition Category (extensible)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ1..1uriIdentity of the terminology system
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ1..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/Diagnosis Severity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: Interweave UkCore Condition Code (required)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:All Slices Content/Rules for all slices
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... coding:snomedCT Σ0..1CodingCode defined by a terminology system
Binding: Care Connect Condition Code (required): A code from the SNOMED Clinical Terminology UK


...... id 0..1stringxml:id (or equivalent in JSON)
...... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
...... Extension-coding-sctdescid 0..*(Complex)Optional Extensions Element
URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... bodySite SΣ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMED CT Body Structures (required)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ1..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
..... coding:All Slices Content/Rules for all slices
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... coding:snomedCT SΣ1..1CodingCode defined by a terminology system
Binding: SNOMED CT Body Structures (required)
...... id 0..1stringxml:id (or equivalent in JSON)
...... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
...... Extension-coding-sctdescid 0..*(Complex)Optional Extensions Element
URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ1..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(CareConnect-Patient-1)Who has the condition? (A patient, NOT group)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringReference to a resource (could be Contained)
.... identifier Σ0..1IdentifierIf relevant could include an id
.... display Σ1..1stringDescription of the referenced resource
... context SΣ0..1Reference(CareConnect-Encounter-1)Encounter or episode when condition first asserted
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringReference to a resource (could be Contained)
.... identifier Σ0..1IdentifierIf relevant could include an id
.... display Σ0..1stringIf relevant, description of the referenced resource
... onset[x] SΣ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
.... onsetStringstring
... abatement[x] SI0..1If/when in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementBooleanboolean
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... assertedDate SΣ1..1dateTimeDate record was believed accurate
... asserter SΣ0..1Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1)Person who asserts this condition
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringReference to a resource (could be Contained)
.... identifier Σ0..1IdentifierIf relevant could include an id
.... display Σ1..1stringDescription of the referenced resource
... stage I0..1BackboneElementStage/grade, usually assessed formally
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: Condition Stage (example): Codes describing condition stages (e.g. Cancer stages).

..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... Slices for coding Σ0..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:system
...... coding:snomedCT Σ0..1CodingCode defined by a terminology system
....... id 0..1stringxml:id (or equivalent in JSON)
....... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
....... Extension-coding-sctdescid 0..*(Complex)The SNOMED CT Description ID for the display
URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid
....... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
....... display Σ1..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... assessment I0..*Reference(ClinicalImpression | DiagnosticReport | CareConnect-Observation-1)Formal record of assessment
... evidence I0..*BackboneElementSupporting evidence
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: Manifestation and Symptom Codes (example): Codes that describe the manifestation or symptoms of a condition.


... note 0..*