Smart Bear Implementation Guide - Local Development build (v1.0.0). See the Directory of published versions
Resource Profile: Medical History Condition
| Defining URL: | https://140.164.14.210/fhir/StructureDefinition/MedicalHistoryCondition |
| Version: | 1.0.0 |
| Name: | MedicalHistoryCondition |
| Title: | Medical History Condition |
| Status: | Active as of 2021-06-09T14:27:31+02:00 |
| Definition: | Conditions on medical history |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
https://140.164.14.210/fhir/StructureDefinition/MedicalHistoryCondition
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Condition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Condition | 0..* | Condition | Detailed information about conditions, problems or diagnoses | |
  code | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Medical History Value Set (required) | |
 onset[x] | 1..1 | (Slice Definition) | Estimated or actual date, date-time, or age Slice: Unordered, Open by type:$this | |
 onsetDateTime | 1..1 | dateTime | Estimated or actual date, date-time, or age | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Condition | I | 0..* | Condition | Detailed information about conditions, problems or diagnoses |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Additional content defined by implementations | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External Ids for this condition |
| clinicalStatus | ?!ΣI | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. |
| verificationStatus | ?!ΣI | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. |
| category | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. | |
| severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | |
| code | Σ | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Medical History Value Set (required) |
| bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
 subject | Σ | 1..1 | Reference(Patient | Group) | Who has the condition? |
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of |
 onset[x] | Σ | 1..1 | (Slice Definition) | Estimated or actual date, date-time, or age Slice: Unordered, Closed by type:$this |
   onset[x]:onsetDateTime | Σ | 1..1 | dateTime | Estimated or actual date, date-time, or age |
 abatement[x] | I | 0..1 | When in resolution/remission | |
| abatementDateTime | dateTime | |||
| abatementAge | Age | |||
| abatementPeriod | Period | |||
| abatementRange | Range | |||
| abatementString | string | |||
| recordedDate | Σ | 0..1 | dateTime | Date record was first recorded |
| recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition |
| asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition |
| stage | I | 0..* | BackboneElement | Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| summary | I | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). |
| assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment |
| type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |
| evidence | I | 0..* | BackboneElement | Supporting evidence con-2: evidence SHALL have code or details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | ΣI | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. |
| detail | ΣI | 0..* | Reference(Resource) | Supporting information found elsewhere |
| note | 0..* | Annotation | Additional information about the Condition | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Condition | I | 0..* | Condition | Detailed information about conditions, problems or diagnoses |
| Documentation for this format | ||||
This structure is derived from Condition
Summary
Mandatory: 2 elements
Slices
This structure defines the following Slices:
- The element Condition.onset[x] is sliced based on the value of type:$this
Differential View
This structure is derived from Condition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Condition | 0..* | Condition | Detailed information about conditions, problems or diagnoses | |
| code | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Medical History Value Set (required) | |
| onset[x] | 1..1 | (Slice Definition) | Estimated or actual date, date-time, or age Slice: Unordered, Open by type:$this | |
| onsetDateTime | 1..1 | dateTime | Estimated or actual date, date-time, or age | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Condition | I | 0..* | Condition | Detailed information about conditions, problems or diagnoses |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External Ids for this condition |
| clinicalStatus | ?!ΣI | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. |
| verificationStatus | ?!ΣI | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. |
| category | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. | |
| severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | |
| code | Σ | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Medical History Value Set (required) |
| bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| subject | Σ | 1..1 | Reference(Patient | Group) | Who has the condition? |
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of |
| onset[x] | Σ | 1..1 | (Slice Definition) | Estimated or actual date, date-time, or age Slice: Unordered, Closed by type:$this |
| onset[x]:onsetDateTime | Σ | 1..1 | dateTime | Estimated or actual date, date-time, or age |
| abatement[x] | I | 0..1 | When in resolution/remission | |
| abatementDateTime | dateTime | |||
| abatementAge | Age | |||
| abatementPeriod | Period | |||
| abatementRange | Range | |||
| abatementString | string | |||
| recordedDate | Σ | 0..1 | dateTime | Date record was first recorded |
| recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition |
| asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition |
| stage | I | 0..* | BackboneElement | Stage/grade, usually assessed formally con-1: Stage SHALL have summary or assessment |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| summary | I | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). |
| assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment |
| type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |
| evidence | I | 0..* | BackboneElement | Supporting evidence con-2: evidence SHALL have code or details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | ΣI | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. |
| detail | ΣI | 0..* | Reference(Resource) | Supporting information found elsewhere |
| note | 0..* | Annotation | Additional information about the Condition | |
| Documentation for this format | ||||
Other representations of profile: CSV, Excel, Schematron
Terminology Bindings
| Path | Conformance | ValueSet |
| Condition.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Condition.clinicalStatus | required | ConditionClinicalStatusCodes |
| Condition.verificationStatus | required | ConditionVerificationStatus |
| Condition.category | extensible | ConditionCategoryCodes |
| Condition.severity | preferred | Condition/DiagnosisSeverity |
| Condition.code | required | MedicalHistoryConditionsVS |
| Condition.bodySite | example | SNOMEDCTBodyStructures |
| Condition.stage.summary | example | ConditionStage |
| Condition.stage.type | example | ConditionStageType |
| Condition.evidence.code | example | ManifestationAndSymptomCodes |
Constraints
| Id | Path | Details | Requirements |
| con-1 | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
| con-2 | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() |