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Patient Care Work GroupMaturity Level: 3 Trial Use Compartments: Encounter, Patient, Practitioner, RelatedPerson

Подробное описание элементов ресурса Condition.

Condition
Element IdCondition
Definition

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

Control0..*
TypeDomainResource
Invariants
Defined on this element
con-3Guideline Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-itemclinicalStatus.exists() or verificationStatus='entered-in-error' or category.select($this='problem-list-item').empty()
This is (only) a best practice guideline because:

Most systems will expect a clinicalStatus to be valued for problem-list-items that are managed over time, but might not need a clinicalStatus for point in time encounter-diagnosis.

con-4Rule If condition is abated, then clinicalStatus must be either inactive, resolved, or remissionabatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5Rule Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-errorverificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
Condition.identifier
Element IdCondition.identifier
Definition

Business identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers.

Summarytrue
Comments

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

Condition.clinicalStatus
Element IdCondition.clinicalStatus
Definition

Клинический статус состояния.

Control0..1
Terminology BindingCondition Clinical Status Codes (Required)
TypeCodeableConcept
Is Modifiertrue (Reason: This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.)
Summarytrue
Comments

It is possible that the well-controlled or poorly-controlled clinical status could alternatively be conveyed via a pre-coordinated Condition.code.

Invariants
Affect this element
con-3Guideline Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-itemclinicalStatus.exists() or verificationStatus='entered-in-error' or category.select($this='problem-list-item').empty()
This is (only) a best practice guideline because:

Most systems will expect a clinicalStatus to be valued for problem-list-items that are managed over time, but might not need a clinicalStatus for point in time encounter-diagnosis.

con-4Rule If condition is abated, then clinicalStatus must be either inactive, resolved, or remissionabatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5Rule Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-errorverificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
Condition.verificationStatus
Element IdCondition.verificationStatus
Definition

Статус подтверждения клинического состояния.

Control0..1
Terminology BindingConditionVerificationStatus (Required)
TypeCodeableConcept
Is Modifiertrue (Reason: This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.)
Summarytrue
Comments

verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status.

Invariants
Affect this element
con-3Guideline Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-itemclinicalStatus.exists() or verificationStatus='entered-in-error' or category.select($this='problem-list-item').empty()
This is (only) a best practice guideline because:

Most systems will expect a clinicalStatus to be valued for problem-list-items that are managed over time, but might not need a clinicalStatus for point in time encounter-diagnosis.

con-5Rule Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-errorverificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
Condition.category
Element IdCondition.category
Definition

Категория данного клинического состояния.

Control0..*
Terminology BindingCondition Category Codes (Extensible)
TypeCodeableConcept
Comments

Эта классификация часто очень зависит от контекста и может оказаться слабо дифференцированной или не слишком полезной в других контекстах.

Condition.severity
Element IdCondition.severity
Definition

Субъективная оценка тяжести состояния, оценённая клиницистом.

Control0..1
Terminology BindingCondition/Diagnosis Severity (Preferred)
TypeCodeableConcept
Comments

Coding of the severity with a terminology is preferred, where possible.

Condition.code
Element IdCondition.code
Definition

Идентификация состояния, проблемы или диагноза.

Control0..1
Terminology BindingCondition/Problem/Diagnosis Codes (Example)
TypeCodeableConcept
Requirements

0..1 to account for primarily narrative only resources.

Alternate Namestype
Summarytrue
Condition.bodySite
Element IdCondition.bodySite
Definition

Анатомическое местоположение, в котором данное состояние проявляет себя.

Control0..*
Terminology BindingSNOMED CT Body Structures (Example)
TypeCodeableConcept
Summarytrue
Comments

Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension bodySite. May be a summary code, or a reference to a very precise definition of the location, or both.

Condition.subject
Element IdCondition.subject
Definition

Указывает пациента, с которым связана эта запись состояния.

Control1..1
TypeReference(Patient | Group)
Requirements

Group is typically used for veterinary or public health use cases.

Alternate Namespatient
Summarytrue
Condition.encounter
Element IdCondition.encounter
Definition

The Encounter during which this Condition was created or to which the creation of this record is tightly associated.

Control0..1
TypeReference(Encounter)
Summarytrue
Comments

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".

Condition.onset[x]
Element IdCondition.onset[x]
Definition

Предполагаемая или фактическая дата или дата/время начала состояния по мнению клинициста.

Control0..1
TypedateTime|Age|Period|Range|string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Comments

Возраст, как правило, используют, когда пациент сообщает возраст, в котором стало проявляться состояние.

Condition.abatement[x]
Element IdCondition.abatement[x]
Definition

Дата или предполагаемая дата разрешения состояния или перехода в ремиссию. Это названо "abatement" (уменьшение боли или выраженности симптома, ослабление боли или выраженности симптома, смягчение боли или выраженности симптома) из-за перегруженности терминов "remission" или "resolution" - состояния никогда по-настоящему не проходят, но могут быть улучшения.

Control0..1
TypedateTime|Age|Period|Range|string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Comments

There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.

Invariants
Affect this element
con-4Rule If condition is abated, then clinicalStatus must be either inactive, resolved, or remissionabatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
Condition.recordedDate
Element IdCondition.recordedDate
Definition

The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.

Control0..1
TypedateTime
Summarytrue
Condition.recorder
Element IdCondition.recorder
Definition

Individual who recorded the record and takes responsibility for its content.

Control0..1
TypeReference(Practitioner | Patient | RelatedPerson)
Summarytrue
Condition.asserter
Element IdCondition.asserter
Definition

Человек, который установил это клиническое состояние.

Control0..1
TypeReference(Practitioner | PractitionerRole | Patient | RelatedPerson)
Summarytrue
Condition.stage
Element IdCondition.stage
Definition

Клиническая стадия или степень состояния. Может включать формальные оценки тяжести.

Control0..*
Invariants
Defined on this element
con-1Rule Стадия должна иметь краткое изложение или оценкуsummary.exists() or assessment.exists()
Condition.stage.summary
Element IdCondition.stage.summary
Definition

Простое заключение о стадии, например "Stage 3". Установление стадии зависит от болезни.

Control0..1
Terminology BindingCondition Stage (Example)
TypeCodeableConcept
Invariants
Affect this element
con-1Rule Стадия должна иметь краткое изложение или оценкуsummary.exists() or assessment.exists()
Condition.stage.assessment
Element IdCondition.stage.assessment
Definition

Ссылка на официальную запись основания, на котором основывается оценка стадии.

Control0..*
TypeReference(ClinicalImpression | DiagnosticReport | Observation)
Invariants
Affect this element
con-1Rule Стадия должна иметь краткое изложение или оценкуsummary.exists() or assessment.exists()
Condition.stage.type
Element IdCondition.stage.type
Definition

The kind of staging, such as pathological or clinical staging.

Control0..1
Terminology BindingCondition Stage Type (Example)
TypeCodeableConcept
Condition.evidence
Element IdCondition.evidence
Definition

Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition.

Control0..*
Comments

Основания могут быть простым перечислением кодированных симптомов/проявлений или ссылками на наблюдения или официальные оценки, или и на то, и другое одновременно.

Invariants
Defined on this element
con-2Rule Элемент evidence должен иметь code или detailcode.exists() or detail.exists()
Condition.evidence.code
Element IdCondition.evidence.code
Definition

Проявление или симптом, который привел к записи об этом состоянии.

Control0..*
Terminology BindingManifestation and Symptom Codes (Example)
TypeCodeableConcept
Summarytrue
Invariants
Affect this element
con-2Rule Элемент evidence должен иметь code или detailcode.exists() or detail.exists()
Condition.evidence.detail
Element IdCondition.evidence.detail
Definition

Ссылки на другую существенную информацию, в том числе патологические отчеты.

Control0..*
TypeReference(Any)
Summarytrue
Invariants
Affect this element
con-2Rule Элемент evidence должен иметь code или detailcode.exists() or detail.exists()
Condition.note
Element IdCondition.note
Definition

Дополнительная информация о состоянии. Это общая запись текстовых заметок/комментариев к описанию состояния, его диагноз и прогноз.

Control0..*
TypeAnnotation