Condition resource implementation guidance
Important: This site is under active development by NHS Digital and is intended to provide all the technical resources you need to successfully develop applications using the FHIR® CDS API.
Condition: Implementation Guidance
Usage
The Condition resource will be used to carry the chief concern and any secondary concerns which reflect the outcome of triage.
Detailed implementation guidance for a Condition resource in the CDS context is given below:
| Name | Cardinality | Type | FHIR Documentation | CDS Implementation Guidance |
|---|---|---|---|---|
id |
0..1 |
id | Logical id of this artifact | Note that this will always be populated except when the resource is being created (initial creation call) |
meta |
0..1 |
Meta | Metadata about the resource | |
implicitRules |
0..1 |
uri | A set of rules under which this content was created | |
language |
0..1 |
code | Language of the resource content. Common Languages (Extensible but limited to All Languages) |
|
text |
0..1 |
Narrative | Text summary of the resource, for human interpretation | |
contained |
0..* |
Resource | Contained, inline Resources | This SHOULD NOT be populated. |
extension |
0..* |
Extension | Additional Content defined by implementations | |
modifierExtension |
0..* |
Extension | Extensions that cannot be ignored | |
identifier | 0..* | Identifier | External Ids for this condition | |
clinicalStatus | 0..1 | code | active | recurrence | inactive | remission | resolved Condition Clinical Status Codes (Required) | This MUST be populated with 'active'. No other values are valid. |
verificationStatus | 0..1 | code | provisional | differential | confirmed | refuted | entered-in-error | unknown | All values are valid. In practice this is likely to be 'provisional' most of the time. |
category | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis Condition Category Codes (Example) | This MUST be populated with the value 'concern' as per the ValueSet | UEC-ConditionCategory-1 (Required) |
severity | 0..1 | CodeableConcept | Subjective severity of condition Condition/Diagnosis Severity (Preferred) | This SHOULD be populated where available. |
code | 0..1 | CodeableConcept | Identification of the condition, problem or diagnosis | This MUST be populated with a relevant SNOMED code. Common Urgent and Emergency Care conditons can be found in the relevant custom ValueSet UEC Condition Code(Example). |
bodySite | 0..* | CodeableConcept | Anatomical location, if relevant SNOMED CT Body Structures (Example) | This SHOULD be populated where available. |
subject | 1..1 | Reference(Patient | Group) | Who has the condition? | This MUST be the Patient. |
context | 0..1 | Reference(Encounter | EpisodeOfCare) | Encounter or episode when condition first asserted | This MUST be populated with the Encounter. |
onset[x] | 0..1 | Estimated or actual date, date-time, or age | This MUST NOT be populated. | |
abatement[x] | 0..1 | If/when in resolution/remission | This MUST NOT be populated. | |
assertedDate | 0..1 | dateTime | Date record was believed accurate | If populated, SHOULD be the Date of triage result |
asserter | 0..1 | Reference(Practitioner | | Patient | | RelatedPerson) | Person who asserts this condition | This MUST NOT be populated. |
stage | 0..1 | BackboneElement | Stage/grade, usually assessed formally + Stage SHALL have summary or assessment | |
summary | 0..1 | CodeableConcept | Simple summary (disease specific) Condition Stage (Example) | This SHOULD be populated where available. |
assessment | 0..* | Reference(ClinicalImpression | | DiagnosticReport | Observation) | Formal record of assessment | This SHOULD be populated where available. |
evidence | 0..* | BackboneElement | Supporting evidence + evidence SHALL have code or details | |
code | 0..* | CodeableConcept | Manifestation/symptom Manifestation and Symptom Codes (Example) | This MUST NOT be populated. |
detail | 0..* | Reference(Any) | Supporting information found elsewhere | This MUST be populated with reference to the Observations or QuestionnaireResponses where available. |
note | 0..* | Annotation | Additional information about the Condition | This MUST NOT be populated. |