Interweave Implementation Guide
0.1.0 - ci-build
Interweave Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the R4 profiles here.
Official URL: https://fhir.yhcr.nhs.uk/StructureDefinition/Interweave-Condition | Version: 0.1.0 | |||
Active as of 2024-07-17 | Computable Name: InterweaveCondition |
Interweave Condition resource profile.
Status: Active: Approved (STU)
This profile sets minimum expectations for the Condition resource.
The following mandatory fields are defined in order to properly describe a Condition:
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.
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
Subject - every Condition must be linked to a Patient (not a Group)
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
In addition the following fields are “Must Support” - ie they must be populated if relevant and known:
Identifier - a Local Id should be provided, such that could be quoted if manually getting in touch to find out more
Body Site - snomed coding for the affected body part. Important to provide if possible and relevant
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
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).
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:
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
Note - Only to be used with caution. Any notes may be shared widely across the region, including being viewed by the patient themselves
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.
Onset and Abatement - these are important to provide if at all possible.
Note: Do not use abatementBoolean, as this is deprecated in FHIR R4
Episodicity (Care Connect Extension) - Discouraged.
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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CareConnect-Condition-1
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | CareConnect-Condition-1 | Detailed information about conditions, problems or diagnoses | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | |
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | |
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - 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 | |
extension:episodisity | 0..* | Extension-CareConnect-ConditionEpisode-1 | DISCOURAGED | |
Slices for identifier | 0..* | Identifier | External Ids for this condition Slice: Unordered, Open by value:system | |
identifier:localIdentifier | S | 0..1 | Identifier | External Ids for this condition |
system | S | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-condition-identifier |
value | S | 1..1 | string | The Local condition Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique |
period | 0..0 | |||
clinicalStatus | S | 1..1 | code | active | recurrence | inactive | remission | resolved |
category | S | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis | presenting-complaint Binding: Care Connect Condition Category (required) |
severity | S | 0..1 | CodeableConcept | Subjective severity of condition |
code | S | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Care Connect Condition Code (preferred) |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
bodySite | S | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMED CT Body Structures (required) |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
subject | S | 1..1 | Reference(CareConnectPatient1) | Who has the condition? (A patient, NOT group) |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
context | S | 0..1 | Reference(CareConnect-Encounter-1) | Encounter or episode when condition first asserted |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
onset[x] | 0..1 | dateTime | Estimated or actual date, date-time, or age | |
assertedDate | S | 1..1 | dateTime | Date record was believed accurate |
asserter | S | 0..1 | Reference(RelatedPerson | CareConnectPatient1 | CareConnect-Practitioner-1) | Person who asserts this condition |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
stage | ||||
summary | S | 1..1 | CodeableConcept | Simple summary (disease specific) Binding: Condition Stage (required) |
assessment | 0..* | Reference(DiagnosticReport | CareConnect-Observation-1) | Formal record of assessment | |
evidence | ||||
code | S | 0..* | CodeableConcept | Manifestation/symptom Binding: Manifestation and Symptom Codes (preferred) |
detail | 0..0 | |||
note | 0..* | Annotation | Additional information about the Condition. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves | |
Documentation for this format |
Path | Conformance | ValueSet |
Condition.category | required | Care Connect Condition Category |
Condition.code | preferred | Care Connect Condition Code |
Condition.bodySite | required | SNOMED CT Body Structures |
Condition.stage.summary | required | Condition Stage |
Condition.evidence.code | preferred | Manifestation and Symptom Codes |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | CareConnect-Condition-1 | Detailed information about conditions, problems or diagnoses | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
security | Σ | 0..* | Coding | DISCOURAGED - 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 | Σ | 0..* | Coding | Tags 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 | SΣ | 0..1 | Coding | MANDATORY 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" | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY 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" | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - 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 | |||||
episodisity | 0..* | code | DISCOURAGED 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..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | Σ | 0..* | Identifier | External Ids for this condition Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | External Ids for this condition | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-condition-identifier | ||||
value | SΣ | 1..1 | string | The Local condition Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
clinicalStatus | ?!SΣC | 1..1 | code | active | recurrence | inactive | remission | resolved Binding: Condition Clinical Status Codes (required): The clinical status of the condition or diagnosis. | ||||
category | S | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis | presenting-complaint Binding: Care Connect Condition Category (required) | ||||
severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/Diagnosis Severity (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: Care Connect Condition Code (preferred) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Condition Code (required): A code from the SNOMED Clinical Terminology UK | ||||
snomedCTDescriptionID | 0..* | (Complex) | Optional Extensions Element URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
bodySite | SΣ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMED CT Body Structures (required) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Body Site (required): A code from SNOMED Clinical Terminology UK | ||||
snomedCTDescriptionID | 0..* | (Complex) | Optional Extensions Element URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
subject | SΣ | 1..1 | Reference(CareConnectPatient1) | Who has the condition? (A patient, NOT group) | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
context | SΣ | 0..1 | Reference(CareConnect-Encounter-1) | Encounter or episode when condition first asserted | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
onset[x] | Σ | 0..1 | dateTime | Estimated or actual date, date-time, or age | ||||
assertedDate | SΣ | 1..1 | dateTime | Date record was believed accurate | ||||
asserter | SΣ | 0..1 | Reference(RelatedPerson | CareConnectPatient1 | CareConnect-Practitioner-1) | Person who asserts this condition | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
stage | C | 0..1 | BackboneElement | Stage/grade, usually assessed formally | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
summary | SC | 1..1 | CodeableConcept | Simple summary (disease specific) Binding: Condition Stage (required) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
assessment | C | 0..* | Reference(DiagnosticReport | CareConnect-Observation-1) | Formal record of assessment | ||||
evidence | C | 0..* | BackboneElement | Supporting evidence | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
code | SΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: Manifestation and Symptom Codes (preferred) | ||||
note | 0..* | Annotation | Additional information about the Condition. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves | |||||
text | 1..1 | string | The annotation - text content | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Condition.meta.security | extensible | All Security Labels | ||||
Condition.meta.tag | example | Common Tags | ||||
Condition.meta.tag:Source | example | Common Tags | ||||
Condition.meta.tag:Provenance | example | Common Tags | ||||
Condition.language | extensible | Common Languages
| ||||
Condition.identifier.use | required | IdentifierUse | ||||
Condition.identifier:localIdentifier.use | required | IdentifierUse | ||||
Condition.clinicalStatus | required | Condition Clinical Status Codes | ||||
Condition.category | required | Care Connect Condition Category | ||||
Condition.severity | preferred | Condition/Diagnosis Severity | ||||
Condition.code | preferred | Care Connect Condition Code | ||||
Condition.code.coding:snomedCT | required | Care Connect Condition Code | ||||
Condition.bodySite | required | SNOMED CT Body Structures | ||||
Condition.bodySite.coding:snomedCT | required | Care Connect Body Site | ||||
Condition.stage.summary | required | Condition Stage | ||||
Condition.evidence.code | preferred | Manifestation and Symptom Codes |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | error | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error : verificationStatus='entered-in-error' or clinicalStatus.exists() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive' | |
dom-1 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource : contained.where(('#'+id in %resource.descendants().reference).not()).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
ele-1 | error | Condition.extension:episodisity, Condition.stage, Condition.evidence | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | error | Condition.extension:episodisity | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | CareConnect-Condition-1 | Detailed information about conditions, problems or diagnoses | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
security | Σ | 0..* | Coding | DISCOURAGED - 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 | Σ | 0..* | Coding | Tags 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 | SΣ | 0..1 | Coding | MANDATORY 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..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY 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..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - 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..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
episodisity | 0..* | code | DISCOURAGED 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..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | Σ | 0..* | Identifier | External Ids for this condition Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (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 | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..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(CareConnect-Organization-1) | Organization that issued id (may be just text) | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | External Ids for this condition | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (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 | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-condition-identifier | ||||
value | SΣ | 1..1 | string | The Local condition Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
assigner | Σ | 0..1 | Reference(CareConnect-Organization-1) | Organization that issued id (may be just text) | ||||
clinicalStatus | ?!SΣC | 1..1 | code | active | recurrence | inactive | remission | resolved Binding: Condition Clinical Status Codes (required): The clinical status of the condition or diagnosis. | ||||
category | S | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis | presenting-complaint Binding: Care Connect Condition Category (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
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 | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/Diagnosis Severity (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: Care Connect Condition Code (preferred) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Condition Code (required): A code from the SNOMED Clinical Terminology UK | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | Optional Extensions Element URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | SΣ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMED CT Body Structures (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Body Site (required): A code from SNOMED Clinical Terminology UK | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | Optional Extensions Element URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
subject | SΣ | 1..1 | Reference(CareConnectPatient1) | Who has the condition? (A patient, NOT group) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
context | SΣ | 0..1 | Reference(CareConnect-Encounter-1) | Encounter or episode when condition first asserted | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
onset[x] | Σ | 0..1 | dateTime | Estimated or actual date, date-time, or age | ||||
abatement[x] | C | 0..1 | If/when in resolution/remission | |||||
abatementDateTime | dateTime | |||||||
abatementAge | Age | |||||||
abatementBoolean | boolean | |||||||
abatementPeriod | Period | |||||||
abatementRange | Range | |||||||
abatementString | string | |||||||
assertedDate | SΣ | 1..1 | dateTime | Date record was believed accurate | ||||
asserter | SΣ | 0..1 | Reference(RelatedPerson | CareConnectPatient1 | CareConnect-Practitioner-1) | Person who asserts this condition | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
stage | C | 0..1 | BackboneElement | Stage/grade, usually assessed formally | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
summary | SC | 1..1 | CodeableConcept | Simple summary (disease specific) Binding: Condition Stage (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
assessment | C | 0..* | Reference(DiagnosticReport | CareConnect-Observation-1) | Formal record of assessment | ||||
evidence | C | 0..* | BackboneElement | Supporting evidence | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
code | SΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: Manifestation and Symptom Codes (preferred) | ||||
note | 0..* | Annotation | Additional information about the Condition. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves | |||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
author[x] | Σ | 0..1 | Individual responsible for the annotation | |||||
authorReference | Reference(RelatedPerson | CareConnect-Practitioner-1 | CareConnectPatient1) | |||||||
authorString | string | |||||||
time | Σ | 0..1 | dateTime | When the annotation was made | ||||
text | 1..1 | string | The annotation - text content | |||||
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | Condition.extension:episodisity | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | error | Condition.extension:episodisity | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from CareConnect-Condition-1
Summary
Mandatory: 5 elements (16 nested mandatory elements)
Must-Support: 24 elements
Fixed Value: 3 elements
Prohibited: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CareConnect-Condition-1
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | CareConnect-Condition-1 | Detailed information about conditions, problems or diagnoses | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | |
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | |
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - 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 | |
extension:episodisity | 0..* | Extension-CareConnect-ConditionEpisode-1 | DISCOURAGED | |
Slices for identifier | 0..* | Identifier | External Ids for this condition Slice: Unordered, Open by value:system | |
identifier:localIdentifier | S | 0..1 | Identifier | External Ids for this condition |
system | S | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-condition-identifier |
value | S | 1..1 | string | The Local condition Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique |
period | 0..0 | |||
clinicalStatus | S | 1..1 | code | active | recurrence | inactive | remission | resolved |
category | S | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis | presenting-complaint Binding: Care Connect Condition Category (required) |
severity | S | 0..1 | CodeableConcept | Subjective severity of condition |
code | S | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Care Connect Condition Code (preferred) |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
bodySite | S | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMED CT Body Structures (required) |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
subject | S | 1..1 | Reference(CareConnectPatient1) | Who has the condition? (A patient, NOT group) |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
context | S | 0..1 | Reference(CareConnect-Encounter-1) | Encounter or episode when condition first asserted |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
onset[x] | 0..1 | dateTime | Estimated or actual date, date-time, or age | |
assertedDate | S | 1..1 | dateTime | Date record was believed accurate |
asserter | S | 0..1 | Reference(RelatedPerson | CareConnectPatient1 | CareConnect-Practitioner-1) | Person who asserts this condition |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
stage | ||||
summary | S | 1..1 | CodeableConcept | Simple summary (disease specific) Binding: Condition Stage (required) |
assessment | 0..* | Reference(DiagnosticReport | CareConnect-Observation-1) | Formal record of assessment | |
evidence | ||||
code | S | 0..* | CodeableConcept | Manifestation/symptom Binding: Manifestation and Symptom Codes (preferred) |
detail | 0..0 | |||
note | 0..* | Annotation | Additional information about the Condition. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves | |
Documentation for this format |
Path | Conformance | ValueSet |
Condition.category | required | Care Connect Condition Category |
Condition.code | preferred | Care Connect Condition Code |
Condition.bodySite | required | SNOMED CT Body Structures |
Condition.stage.summary | required | Condition Stage |
Condition.evidence.code | preferred | Manifestation and Symptom Codes |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | CareConnect-Condition-1 | Detailed information about conditions, problems or diagnoses | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
security | Σ | 0..* | Coding | DISCOURAGED - 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 | Σ | 0..* | Coding | Tags 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 | SΣ | 0..1 | Coding | MANDATORY 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" | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY 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" | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - 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 | |||||
episodisity | 0..* | code | DISCOURAGED 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..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | Σ | 0..* | Identifier | External Ids for this condition Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | External Ids for this condition | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-condition-identifier | ||||
value | SΣ | 1..1 | string | The Local condition Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
clinicalStatus | ?!SΣC | 1..1 | code | active | recurrence | inactive | remission | resolved Binding: Condition Clinical Status Codes (required): The clinical status of the condition or diagnosis. | ||||
category | S | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis | presenting-complaint Binding: Care Connect Condition Category (required) | ||||
severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/Diagnosis Severity (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: Care Connect Condition Code (preferred) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Condition Code (required): A code from the SNOMED Clinical Terminology UK | ||||
snomedCTDescriptionID | 0..* | (Complex) | Optional Extensions Element URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
bodySite | SΣ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMED CT Body Structures (required) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Body Site (required): A code from SNOMED Clinical Terminology UK | ||||
snomedCTDescriptionID | 0..* | (Complex) | Optional Extensions Element URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
subject | SΣ | 1..1 | Reference(CareConnectPatient1) | Who has the condition? (A patient, NOT group) | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
context | SΣ | 0..1 | Reference(CareConnect-Encounter-1) | Encounter or episode when condition first asserted | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
onset[x] | Σ | 0..1 | dateTime | Estimated or actual date, date-time, or age | ||||
assertedDate | SΣ | 1..1 | dateTime | Date record was believed accurate | ||||
asserter | SΣ | 0..1 | Reference(RelatedPerson | CareConnectPatient1 | CareConnect-Practitioner-1) | Person who asserts this condition | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
stage | C | 0..1 | BackboneElement | Stage/grade, usually assessed formally | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
summary | SC | 1..1 | CodeableConcept | Simple summary (disease specific) Binding: Condition Stage (required) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
assessment | C | 0..* | Reference(DiagnosticReport | CareConnect-Observation-1) | Formal record of assessment | ||||
evidence | C | 0..* | BackboneElement | Supporting evidence | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
code | SΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: Manifestation and Symptom Codes (preferred) | ||||
note | 0..* | Annotation | Additional information about the Condition. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves | |||||
text | 1..1 | string | The annotation - text content | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Condition.meta.security | extensible | All Security Labels | ||||
Condition.meta.tag | example | Common Tags | ||||
Condition.meta.tag:Source | example | Common Tags | ||||
Condition.meta.tag:Provenance | example | Common Tags | ||||
Condition.language | extensible | Common Languages
| ||||
Condition.identifier.use | required | IdentifierUse | ||||
Condition.identifier:localIdentifier.use | required | IdentifierUse | ||||
Condition.clinicalStatus | required | Condition Clinical Status Codes | ||||
Condition.category | required | Care Connect Condition Category | ||||
Condition.severity | preferred | Condition/Diagnosis Severity | ||||
Condition.code | preferred | Care Connect Condition Code | ||||
Condition.code.coding:snomedCT | required | Care Connect Condition Code | ||||
Condition.bodySite | required | SNOMED CT Body Structures | ||||
Condition.bodySite.coding:snomedCT | required | Care Connect Body Site | ||||
Condition.stage.summary | required | Condition Stage | ||||
Condition.evidence.code | preferred | Manifestation and Symptom Codes |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | error | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error : verificationStatus='entered-in-error' or clinicalStatus.exists() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive' | |
dom-1 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource : contained.where(('#'+id in %resource.descendants().reference).not()).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
ele-1 | error | Condition.extension:episodisity, Condition.stage, Condition.evidence | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | error | Condition.extension:episodisity | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | CareConnect-Condition-1 | Detailed information about conditions, problems or diagnoses |
id |