Condition

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. Refer to the US Core Condition profile and the US Core Condition Encounter profile.

Schema

Elements

Name	Required	Type	Description
identifier		Identifier[]	External Ids for this condition Details 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. This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). 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.
clinicalStatus		CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Details The clinical status of the condition. The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.
verificationStatus		CodeableConcept	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Details The verification status to support the clinical status of the condition. 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. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.
category		CodeableConcept[]	problem-list-item | encounter-diagnosis Details A category assigned to the condition. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.
severity		CodeableConcept	Subjective severity of condition Details A subjective assessment of the severity of the condition as evaluated by the clinician. Coding of the severity with a terminology is preferred, where possible.
code		CodeableConcept	Identification of the condition, problem or diagnosis Details Identification of the condition, problem or diagnosis.
bodySite		CodeableConcept[]	Anatomical location, if relevant Details The anatomical location where this condition manifests itself. 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](extension-bodysite.html). May be a summary code, or a reference to a very precise definition of the location, or both.
subject	✓	Reference<Patient | Group>	Who has the condition? Details Indicates the patient or group who the condition record is associated with.
encounter		Reference<Encounter>	Encounter created as part of Details The Encounter during which this Condition was created or to which the creation of this record is tightly associated. 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".
onset[x]		dateTime, Age, Period, Range, string	Estimated or actual date, date-time, or age Details Estimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
abatement[x]		dateTime, Age, Period, Range, string	When in resolution/remission Details The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate. 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.
recordedDate		dateTime	Date record was first recorded Details The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.
recorder		Reference< Practitioner | PractitionerRole | Patient | RelatedPerson >	Who recorded the condition Details Individual who recorded the record and takes responsibility for its content.
asserter		Reference< Practitioner | PractitionerRole | Patient | RelatedPerson >	Person who asserts this condition Details Individual who is making the condition statement.
stage		ConditionStage[]	Stage/grade, usually assessed formally Details Clinical stage or grade of a condition. May include formal severity assessments.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
summary		CodeableConcept	Simple summary (disease specific) Details A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.
assessment		Reference< ClinicalImpression | DiagnosticReport | Observation >[]	Formal record of assessment Details Reference to a formal record of the evidence on which the staging assessment is based.
type		CodeableConcept	Kind of staging Details The kind of staging, such as pathological or clinical staging.
evidence		ConditionEvidence[]	Supporting evidence Details Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
code		CodeableConcept[]	Manifestation/symptom Details A manifestation or symptom that led to the recording of this condition.
detail		Reference<Resource>[]	Supporting information found elsewhere Details Links to other relevant information, including pathology reports.
note		Annotation[]	Additional information about the Condition Details Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.

Search Parameters

Name	Type	Description	Expression
code	token	Code for the condition	Condition.code
identifier	token	A unique identifier of the condition record	Condition.identifier
patient	reference	Who has the condition?	Condition.subject.where(resolve() is Patient)
abatement-age	quantity	Abatement as age or age range	Condition.abatement.as(Age) | Condition.abatement.as(Range)
abatement-date	date	Date-related abatements (dateTime and period)	Condition.abatement.as(dateTime) | Condition.abatement.as(Period)
abatement-string	string	Abatement as a string	Condition.abatement.as(string)
asserter	reference	Person who asserts this condition	Condition.asserter
body-site	token	Anatomical location, if relevant	Condition.bodySite
category	token	The category of the condition	Condition.category
clinical-status	token	The clinical status of the condition	Condition.clinicalStatus
encounter	reference	Encounter created as part of	Condition.encounter
evidence	token	Manifestation/symptom	Condition.evidence.code
evidence-detail	reference	Supporting information found elsewhere	Condition.evidence.detail
onset-age	quantity	Onsets as age or age range	Condition.onset.as(Age) | Condition.onset.as(Range)
onset-date	date	Date related onsets (dateTime and Period)	Condition.onset.as(dateTime) | Condition.onset.as(Period)
onset-info	string	Onsets as a string	Condition.onset.as(string)
recorded-date	date	Date record was first recorded	Condition.recordedDate
severity	token	The severity of the condition	Condition.severity
stage	token	Simple summary (disease specific)	Condition.stage.summary
subject	reference	Who has the condition?	Condition.subject
verification-status	token	unconfirmed | provisional | differential | confirmed | refuted | entered-in-error	Condition.verificationStatus

Inherited Elements

Name	Required	Type	Description
id		string	Logical id of this artifact Details The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
meta		Meta	Metadata about the resource Details The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules		uri	A set of rules under which this content was created Details A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
language		code	Language of the resource content Details The base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
text		Narrative	Text summary of the resource, for human interpretation Details A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
contained		Resource[]	Contained, inline Resources Details These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored Details May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Usage

Condition is one of the event resources in the FHIR workflow specification.

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 condition could be a point in time diagnosis in context of an encounter, it could be an item on the practitioner’s Problem List, or it could be a concern that doesn’t exist on the practitioner’s Problem List. Often times, a condition is about a clinician's assessment and assertion of a particular aspect of a patient's state of health. It can be used to record information about a disease/illness identified from application of clinical reasoning over the pathologic and pathophysiologic findings (diagnosis), or identification of health issues/situations that a practitioner considers harmful, potentially harmful and may be investigated and managed (problem), or other health issue/situation that may require ongoing monitoring and/or management (health issue/concern).

The condition resource may be used to record a certain health state of a patient which does not normally present a negative outcome, e.g. pregnancy. The condition resource may be used to record a condition following a procedure, such as the condition of Amputee-BKA following an amputation procedure.

While conditions are frequently a result of a clinician's assessment and assertion of a particular aspect of a patient's state of health, conditions can also be expressed by the patient, related person, or any care team member. A clinician may have a concern about a patient condition (e.g. anorexia) that the patient is not concerned about. Likewise, the patient may have a condition (e.g. hair loss) that does not rise to the level of importance such that it belongs on a practitioner’s Problem List.

For example, each of the following conditions could rise to the level of importance such that it belongs on a problem or concern list due to its direct or indirect impact on the patient’s health. These examples may also be represented using other resources, such as FamilyMemberHistory, Observation, or Procedure.

• Unemployed
• Without transportation (or other barriers)
• Susceptibility to falls
• Exposure to communicable disease
• Family History of cardiovascular disease
• Fear of cancer
• Cardiac pacemaker
• Amputee-BKA
• Risk of Zika virus following travel to a country
• Former smoker
• Travel to a country planned (that warrants immunizations)
• Motor Vehicle Accident
• Patient has had coronary bypass graft

Relationships

The condition resource may be referenced by other resources as "reasons" for an action (e.g. MedicationRequest, Procedure, ServiceRequest, etc.)

This resource is not typically used to record information about subjective and objective information that might lead to the recording of a Condition resource. Such signs and symptoms are typically captured using the Observation resource; although in some cases a persistent symptom, e.g. fever, headache may be captured as a condition before a definitive diagnosis can be discerned by a clinician. By contrast, headache may be captured as an Observation when it contributes to the establishment of a meningitis Condition.

Use the Observation resource when a symptom is resolved without long term management, tracking, or when a symptom contributes to the establishment of a condition.

Use Condition when a symptom requires long term management, tracking, or is used as a proxy for a diagnosis or problem that is not yet determined.

When the diagnosis is related to an allergy or intolerance, the Condition and AllergyIntolerance resources can both be used. However, to be actionable for decision support, using Condition alone is not sufficient as the allergy or intolerance condition needs to be represented as an AllergyIntolerance.

Referenced By

• AdverseEvent
• Appointment
• CarePlan
• CareTeam
• Claim
• ClinicalImpression
• Communication
• CommunicationRequest
• Contract
• CoverageEligibilityRequest
• DeviceRequest
• DeviceUseStatement
• Encounter
• EpisodeOfCare
• ExplanationOfBenefit
• FamilyMemberHistory
• Goal
• GuidanceResponse
• ImagingStudy
• Immunization
• MedicationAdministration
• MedicationRequest
• MedicationStatement
• Procedure
• RequestGroup
• RiskAssessment
• ServiceRequest
• SupplyRequest