Constructing a condition list

Overview

This section details the design approach using FHIR Resources to support the PRSB heading model for a condition list. The condition Resource is referenced via the List Resource. Implementation guidance on diagnoses from the discharge summary PRSB standard: The discharge summary should inform the GP of the main diagnosis / diagnoses that were important during the admission (or symptom(s) if no diagnosis), including any new diagnosis that came to light during the admission. When a diagnosis has not yet been made, the most granular clinical concept with the highest level of certainty should be recorded. This may be a problem, symptom, sign, or test result, and may evolve over time, as a conventional diagnosis is reached. For example, ‘dyspepsia’ may be the diagnosis when a patient first presents with indigestion, upgraded to ‘gastric ulcer’ when this is found at endoscopy, and ‘gastric cancer’ when biopsies reveal this. ‘Co-morbidities’ should be recorded as separate diagnoses. For example, dementia may be recorded as a primary diagnosis by a psycho-geriatrician, but as a co-morbidity where a patient is admitted for a hip replacement. Unconfirmed or excluded diagnoses should not be recorded in structured code.

Resources Used for Profile Design

The following FHIR Resources are profiled to create the condition list.

  • CareConnect-ITK-Condition-List-1 - A CareConnect derived NHS Digital Profile for recording a snapshot of the list of Conditions for the patient.
  • CareConnect-ITK-Condition-1 - A CareConnect derived NHS Digital Profile for conditions. The Condition Resource records detailed information about conditions (diagnoses) recognised by a clinician.

List

This Resource acts as a container for the conditions. The following is an example of the main elements used:

  • identifier - uniquely identifies this list of conditions (UUIDs)
  • code - the type of list (for example SNOMED CT concept for “Primary Diagnosis”)
  • status - should always be “current”
  • mode - should always be “snapshot”
  • subject - a reference to the patient whose condition list this is
  • Encounter - a reference to the context in which the list was created (the inpatient stay for example)
  • date - when the list was prepared
  • source - who or what defined the list
  • entry - a reference to the condition Resource entry

Condition

This Resource is used to record detailed information about a condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. The following is an example of the elements that can be used:

  • identifier - uniquely identifies this condition (UUIDs)
  • clinicalStatus - active, recurrence, inactive, remission, resolved etc
  • category - for Mental Health eDischarge this will normally be encounter-diagnosis
  • code - identification of the condition, problem or diagnosis
  • subject - the patient
  • onset - estimated or actual date, date-time, or age
  • abatement - if/when in resolution/remission
  • stage - stage/grade, usually assessed formally
  • evidence - supporting evidence

Diagnosis Code

Handles information entered for each individual diagnosis. Confirmed diagnosis (or symptom); active diagnosis (or symptom) being treated. Should include the stage of the disease where relevant. The SNOMED CT concept should be from the following ref set:

< 404684003 |Clinical finding|
OR < 413350009 |Finding with explicit context|
OR < 272379006 |Event|

For Inpatient Discharge Summary this is used in conjunction with condition.category with encounter-diagnosis as the ValueSet.

Condition.severity

MUST NOT be used for Transfer of Care Documents.

Condition.bodysite

MUST NOT be used for Transfer of Care Documents.

Condition.subject

A reference to the Patient Resource.

Condition.context

A reference to the Encounter Resource.

Condition.onset

The estimated or actual date, date-time, or age of onset which MUST be populated if available using one of the following sub-elements:

  • onsetDateTime
  • onsetAge
  • onsetPeriod
  • onsetRange
  • onsetString

Condition.abatement

The estimated or actual date, date-time, or age of abatement which MUST be populated if available using one of the following sub-elements:

  • abatementDateTime
  • abatementAge
  • abatementBoolean
  • abatementPeriod
  • abatementRange
  • abatementString

How the Condition List is Constructed

The condition list is constructed as a list, there may be one or more list types. The diagram below shows the Resources used and relationships between the Resources.

Condition List Item Example

Example to show a condition list.

Condition List

Condition

Tags: design