condition.yaml

---
name: Condition
field_name_base_url: https://hl7.org/fhir/r4/condition-definitions.html#Condition
fields:
- name: resourceType
  required: 'Yes'
  type: string
  description: The type of the FHIR resource.
  example: |
    {
      "resourceType": "Condition"
    }
  note: resourceType must be Condition.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition

- name: id
  required: 'Yes'
  type: id
  description: The logical id of the resource to update.
  action: update
  example: |
    {
      "id": "p123412"
    }
  note: The id value must match the Condition/<id> value.
  url: https://hl7.org/fhir/resource-definitions.html#Resource.id

- name: clinicalStatus
  type: CodeableConcept
  description: active | recurrence | relapse | inactive | remission | resolved
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.clinicalStatus
  action: terminology
  binding:
    description: The clinical status of the condition.
    terminology:
      - display: Condition Clinical Status Codes
        system: http://terminology.hl7.org/CodeSystem/condition-clinical
        info_link: https://hl7.org/fhir/r4/valueset-condition-clinical.html

- name: clinicalStatus
  required: 'Yes'
  type: CodeableConcept
  description: The clinical status of the condition.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.clinicalStatus
  action: create
  note: |
    <ul>
      <li> A clinicalStatus must always be provided while creating a Condition. </li>
      <li> Only the <code>active</code> code is supported when the category is <code>encounter-diagnosis</code>. </li>
    </ul>
  example: |
    {
      "clinicalStatus": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "resolved",
            "display": "Resolved"
          }
        ],
        "text": "Resolved"
      }
    }

- name: clinicalStatus
  required: 'No'
  type: CodeableConcept
  description: The clinical status of the condition.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.clinicalStatus
  action: update
  note: |
    <ul>
      <li> A clinicalStatus must always be provided when updating a Condition, unless verificationStatus is <code>entered-in-error</code>. </li>
      <li> Only the <code>active</code> code is supported when the category is <code>encounter-diagnosis</code>. </li>
    </ul>
  example: |
    {
      "clinicalStatus": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "resolved",
            "display": "Resolved"
          }
        ],
        "text": "Resolved"
      }
    }

- name: verificationStatus
  type: CodeableConcept
  action: terminology
  description: unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.verificationStatus
  binding:
    description: The verification status to support or decline the clinical status of the condition or diagnosis.
    terminology:
      - display: Condition Verification Status Codes
        system: http://terminology.hl7.org/CodeSystem/condition-ver-status
        info_link: https://hl7.org/fhir/r4/valueset-condition-ver-status.html

- name: verificationStatus
  required: 'No'
  type: CodeableConcept
  description: The verification status to support or decline the clinical status of the condition or diagnosis.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.verificationStatus
  action: create
  note: verificationStatus codes of <code>entered-in-error</code> and <code>refuted</code> are not supported during Condition creates.
  example: |
    {
      "verificationStatus": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
            "code": "confirmed",
            "display": "Confirmed"
          }
        ],
        "text": "Confirmed"
      }
    }

- name: verificationStatus
  required: 'No'
  type: CodeableConcept
  description: The verification status to support or decline the clinical status of the condition or diagnosis.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.verificationStatus
  action: update
  example: |
    {
      "verificationStatus": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
            "code": "confirmed",
            "display": "Confirmed"
          }
        ],
        "text": "Confirmed"
      }
    }

- name: category
  required: 'Yes'
  type: List of CodeableConcept
  description: A category assigned to the condition.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.category
  note: |
    <ul>
      <li> Only a single category may be provided. </li>
      <li> Category codes <code>problem-list-item</code> and <code>encounter-diagnosis</code> are supported. </li>
    </ul>
  example: |
    {
      "category": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/condition-category",
              "code": "problem-list-item",
              "display": "Problem List Item"
            }
          ],
          "text": "Problem List Item"
        }
      ]
    }
  binding:
    description: A category assigned to the condition.
    terminology:
      - display: Condition Category Codes
        system: http://terminology.hl7.org/CodeSystem/condition-category
        info_link: https://hl7.org/fhir/r4/valueset-condition-category.html

- name: severity
  required: 'No'
  type: CodeableConcept
  description: A subjective assessment of the severity of the condition as evaluated by the clinician.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.severity
  example: |
    {
      "severity": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "255604002",
            "display": "Mild"
          }
        ]
      }
    }
  example2: |
    {
      "severity": {
        "coding": [
          {
            "system": "https://fhir.cerner.com/0b8a0111-e8e6-4c26-a91c-5069cbc6b1ca/codeSet/12022",
            "code": "3293",
            "display": "Mild"
          }
        ]
      }
    }
  binding:
    description: A subjective assessment of the severity of the condition as evaluated by the clinician.
    terminology:
      - display: SNOMED CT
        system: http://snomed.info/sct
        info_link: https://hl7.org/fhir/r4/snomedct.html
      - display: Millennium Condition Severity
        system: https://fhir.cerner.com/&lt;EHR source id&gt;/codeSet/12022
        info_link: https://fhir.cerner.com/millennium/r4/proprietary-codes-and-systems/#code-set-12022-severity

- name: code
  required: 'Yes'
  type: CodeableConcept
  description: Identification of the condition, problem or diagnosis.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.code
  note: A code must be provided.
  example: |
    {
      "code": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "209832007",
            "display": "Concussion NOS (disorder)",
            "userSelected": true
          }
        ],
        "text": "Concussion with loss of consciousness"
      }
    }
  binding:
    description: Identification of the condition, problem or diagnosis.
    terminology:
      - display: SNOMED CT
        system: http://snomed.info/sct
        info_link: https://hl7.org/fhir/r4/snomedct.html
      - display: ICD-9-CM
        system: http://hl7.org/fhir/sid/icd-9-cm
        info_link: https://hl7.org/fhir/icd.html
      - display: ICD-10-CM
        system: http://hl7.org/fhir/sid/icd-10-cm
        info_link: https://hl7.org/fhir/icd.html

- name: subject
  required: 'Yes'
  type: Reference
  description: Indicates the patient who the condition record is associated with.
  example: |
    {
      "subject": {
        "reference": "Patient/631923",
        "display": "Nilsson, Christine"
      }
    }
  note: subject must be a reference to a Patient.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.subject

- name: encounter
  required: 'No'
  type: Reference
  description: Encounter during which the condition was first asserted.
  example: |
    {
      "encounter": {
        "reference": "Encounter/631923"
      }
    }
  note: |
    <ul>
      <li> encounter must be a reference to an Encounter. </li>
      <li> encounter is required when the condition category code is <code>encounter-diagnosis</code>. </li>
    </ul>
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.encounter
  action: create

- name: encounter
  required: 'No'
  type: Reference
  description: Encounter during which the condition was first asserted.
  example: |
    {
      "encounter": {
        "reference": "Encounter/631923"
      }
    }
  note: |
    <ul>
      <li> encounter must be a reference to an Encounter. </li>
      <li> encounter is only supported for Conditions with a category of <code>encounter-diagnosis</code>. </li>
    </ul>
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.encounter
  action: update

- name: onset[x]
  required: 'No'
  type: dateTime
  description: Estimated or actual date or date-time the condition began, in the opinion of the clinician.
  note: |
    <ul>
      <li> Only a type of dateTime is supported. </li>
      <li> The dateTime is converted to a GMT date. </li>
    </ul>
  example: |
    {
      "onsetDateTime": "2015-10-14T13:13:20-06:00"
    }
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.onset_x_

- name: abatement[x]
  required: 'No'
  type: dateTime
  description: The date or estimated date that the condition resolved or went into remission.
  note: |
    <ul>
      <li> Only a type of dateTime is supported. </li>
      <li> The dateTime is converted to a GMT date. </li>
      <li> <code>abatementDateTime</code> is not supported for Conditions with a category of <code>encounter-diagnosis</code>. </li>
    </ul>
  example: |
    {
      "abatementDateTime": "2015-10-14T13:13:20-06:00"
    }
  note: <code>abatementDateTime</code> is not supported for Conditions with a category of <code>encounter-diagnosis</code>.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.abatement_x_

- name: note
  required: 'No'
  type: List of Annotation
  description: Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.
  action: create
  example: |
    {
      "note": [
        {
          "authorReference": {
            "reference": "Practitioner/4594011",
            "display": "Leroux, Erik"
          },
          "text": "Test Comment 2"
        }
      ]
    }
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.note

- name: note
  required: 'No'
  type: List of Annotation
  description: Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.
  action: update
  example: |
    {
      "note": [
        {
          "authorReference": {
            "reference": "Practitioner/4594011",
            "display": "Leroux, Erik"
          },
          "text": "Test Comment 2"
        }
      ]
    }
  note: note cannot be added if note already exists. An existing note field cannot be modified.
  url: https://hl7.org/fhir/r4/condition-definitions.html#Condition.note