Gives information about the Diagnoses section
Important: Under all circumstances, including any discrepancies, compliance with NHS Digital’s specifications for implementers takes precedence over published PRSB standards.
The latest version of the PRSB documentation should be consulted for further information regarding Section headings and content http://theprsb.org
The latest version of the PRSB documentation should be consulted for further information regarding Section headings and content http://theprsb.org
Diagnoses Section content
The Diagnoses section carries information about Diagnoses. PRSB Elements should be formatted as subheadings in any HTML sent.
| Section | Description | Card. | MRO* | FHIR Target and Guidance |
|---|---|---|---|---|
| Diagnoses | A list of the patient's diagnoses. | 0..1 | R | Carried in the CodeableConcept of Composition.section.code FHIR element. |
| PRSB Element | Description | Card. | MRO* | FHIR Target and Guidance |
| Diagnosis name | Confirmed diagnosis (or symptom); active diagnosis being treated. | 1 only | M | Text and if available a SNOMED CT concept carried in the CodeableConcept of the Condition.code FHIR element. See Constructing Diagnosis Lists (Diagnosis code) for further guidance. |
| Stage | Stage of the disease, where relevant | 0 to 1 | O | Text and if available a SNOMED CT concept carried in the CodeableConcept of the Condition.stage.summary (using the CodeableContext text to hold the stage of disease text) |
| Comment | Supporting text may be given covering diagnosis confirmation, active diagnosis being treated. | 0 to 1 | O | Free text. Supporting text may be given covering diagnosis confirmation, active diagnosis being treated. The section text should be repeated in the text of the Condition.note FHIR element to record Free differential and excluded diagnosis. |
| * M=Mandatory R=Required O=Optional | ||||
Example Diagnoses Section
This section example includes a reference to a coded diagnosis.
Coded Resources
This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.
- Condition
See constructing clinical coded structures - Condition