HRSA 2023 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG
1.0.1 - STU1 Release 1 - Standard for Trial-Use
This page is part of the HRSA Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+ or uds-plus) FHIR IG (v1.0.1: STU1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Official URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-diagnosis | Version: 1.0.1 | |||
Standards status: Trial-use | Maturity Level: 2 | Computable Name: UDSPlusDiagnosis |
The UDS+ profile is based on the Condition resource and establishes the core elements, extensions, vocabularies and value sets for representing Diagnosis for UDS+ program.
This profile is used to represent de-identified diagnosis information. The de-identification process has to remove all data elements not explicitly identified as “SUPPORTED” in the profile.
The HHS De-identification Guidance is to be followed to ensure appropriate level of de-identification is performed.
According to the HHS guidance, dates should not have a precision of more than the year. This means month and day cannot be included. This includes diagnosis dates, visit dates, onset dates etc.
In FHIR Resources, text elements and reference.display elements which provide human readable information to the providers may be generated using programs and tools from the data present within the resource. For e.g a Condition resource text element may contain information such as the visit date, onset date. This type of information will enable identification of the individuals. In order to avoid inadvertent revealing of PII/PHI, text elements cannot be included in the De-identified FHIR resource and the submission will be rejected when text elements are present by the validation process.
Ids and References
The original Condition resource id should not be included in the De-identified condition instance. Instead a new id should be created and provided as part of the FHIR resource. This Data Submitter should be capable of using the generated id to relink the data to the original Condition. All resource references to the Condition submitted as part of the UDS+ report should refer to newly generated id.
Resource references cannot contain text element as it may contain PHI/PII. The text element for following references are not allowed
Date Truncation
The Data Submitter has to truncate the following dates to only have a precision of year
Examples
Examples of identifiable data and its corresponding de-identifiable data is present in Reporting Guidance.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Condition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | Condition | De-Identified UDS Plus Diagnosis | |
id | S | 0..1 | id | The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver |
text | 0..0 | |||
contained | 0..0 | |||
assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate |
clinicalStatus | S | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved |
text | 0..0 | |||
verificationStatus | S | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error |
text | 0..0 | |||
category | S | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis |
text | 0..0 | |||
code | S | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis |
text | 0..0 | |||
subject | S | 1..1 | Reference(De-Identified UDS Plus Patient) | Who has the condition? |
display | 0..0 | |||
encounter | S | 0..1 | Reference(De-Identified UDS Plus Encounter) | Encounter created as part of |
display | 0..0 | |||
onsetDateTime | S | 0..1 | dateTime | Estimated or actual date, date-time, or age |
abatementDateTime | S | 0..1 | dateTime | When in resolution/remission |
recordedDate | S | 0..1 | dateTime | Date record was first recorded |
Documentation for this format |
Path | Conformance | ValueSet |
Condition.code | extensible | USCoreConditionCodes |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | Condition | De-Identified UDS Plus Diagnosis |
id | SΣ | 0..1 | id | The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. |
verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. |
category | S | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. |
code | SΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis |
subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who has the condition? |
encounter | SΣ | 0..1 | Reference(De-Identified UDS Plus Encounter) | Encounter created as part of |
Slices for onset[x] | Σ | 0..1 | dateTime | Estimated or actual date, date-time, or age Slice: Unordered, Closed by type:$this |
onset[x]:onsetDateTime | SΣ | 0..1 | dateTime | Estimated or actual date, date-time, or age |
Slices for abatement[x] | C | 0..1 | dateTime | When in resolution/remission Slice: Unordered, Closed by type:$this |
abatement[x]:abatementDateTime | SC | 0..1 | dateTime | When in resolution/remission |
recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded |
Documentation for this format |
Path | Conformance | ValueSet |
Condition.clinicalStatus | required | ConditionClinicalStatusCodes |
Condition.verificationStatus | required | ConditionVerificationStatus |
Condition.category | extensible | ConditionCategoryCodes |
Condition.code | extensible | USCoreConditionCodes |
Id | Grade | Path(s) | Details | Requirements |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | Condition | De-Identified UDS Plus Diagnosis | ||||
id | SΣ | 0..1 | id | The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
category | S | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | |||||
code | SΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who has the condition? | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
encounter | SΣ | 0..1 | Reference(De-Identified UDS Plus Encounter) | Encounter created as part of | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
Slices for onset[x] | Σ | 0..1 | dateTime | Estimated or actual date, date-time, or age Slice: Unordered, Closed by type:$this | ||||
onset[x]:onsetDateTime | SΣ | 0..1 | dateTime | Estimated or actual date, date-time, or age | ||||
Slices for abatement[x] | C | 0..1 | dateTime | When in resolution/remission Slice: Unordered, Closed by type:$this | ||||
abatement[x]:abatementDateTime | SC | 0..1 | dateTime | When in resolution/remission | ||||
recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | ||||
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | ||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||
evidence | C | 0..* | BackboneElement | Supporting evidence | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||
detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||
note | 0..* | Annotation | Additional information about the Condition | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Condition.language | preferred | CommonLanguages
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodes | ||||
Condition.verificationStatus | required | ConditionVerificationStatus | ||||
Condition.category | extensible | ConditionCategoryCodes | ||||
Condition.severity | preferred | Condition/DiagnosisSeverity | ||||
Condition.code | extensible | USCoreConditionCodes | ||||
Condition.bodySite | example | SNOMEDCTBodyStructures | ||||
Condition.subject.type | extensible | ResourceType | ||||
Condition.encounter.type | extensible | ResourceType | ||||
Condition.stage.summary | example | ConditionStage | ||||
Condition.stage.type | example | ConditionStageType | ||||
Condition.evidence.code | example | ManifestationAndSymptomCodes |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Condition
Summary
Mandatory: 3 elements
Must-Support: 11 elements
Prohibited: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Differential View
This structure is derived from Condition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | Condition | De-Identified UDS Plus Diagnosis | |
id | S | 0..1 | id | The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver |
text | 0..0 | |||
contained | 0..0 | |||
assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate |
clinicalStatus | S | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved |
text | 0..0 | |||
verificationStatus | S | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error |
text | 0..0 | |||
category | S | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis |
text | 0..0 | |||
code | S | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis |
text | 0..0 | |||
subject | S | 1..1 | Reference(De-Identified UDS Plus Patient) | Who has the condition? |
display | 0..0 | |||
encounter | S | 0..1 | Reference(De-Identified UDS Plus Encounter) | Encounter created as part of |
display | 0..0 | |||
onsetDateTime | S | 0..1 | dateTime | Estimated or actual date, date-time, or age |
abatementDateTime | S | 0..1 | dateTime | When in resolution/remission |
recordedDate | S | 0..1 | dateTime | Date record was first recorded |
Documentation for this format |
Path | Conformance | ValueSet |
Condition.code | extensible | USCoreConditionCodes |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | Condition | De-Identified UDS Plus Diagnosis |
id | SΣ | 0..1 | id | The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. |
verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. |
category | S | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. |
code | SΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis |
subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who has the condition? |
encounter | SΣ | 0..1 | Reference(De-Identified UDS Plus Encounter) | Encounter created as part of |
Slices for onset[x] | Σ | 0..1 | dateTime | Estimated or actual date, date-time, or age Slice: Unordered, Closed by type:$this |
onset[x]:onsetDateTime | SΣ | 0..1 | dateTime | Estimated or actual date, date-time, or age |
Slices for abatement[x] | C | 0..1 | dateTime | When in resolution/remission Slice: Unordered, Closed by type:$this |
abatement[x]:abatementDateTime | SC | 0..1 | dateTime | When in resolution/remission |
recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded |
Documentation for this format |
Path | Conformance | ValueSet |
Condition.clinicalStatus | required | ConditionClinicalStatusCodes |
Condition.verificationStatus | required | ConditionVerificationStatus |
Condition.category | extensible | ConditionCategoryCodes |
Condition.code | extensible | USCoreConditionCodes |
Id | Grade | Path(s) | Details | Requirements |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | Condition | De-Identified UDS Plus Diagnosis | ||||
id | SΣ | 0..1 | id | The de-identified Condition identifier created by the health center to send data to UDS+ Data Receiver | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
assertedDate | S | 0..1 | dateTime | Date the condition was first asserted URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||
clinicalStatus | ?!SΣC | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
verificationStatus | ?!SΣC | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
category | S | 1..1 | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician. | |||||
code | SΣ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: US Core Condition Codes (extensible): The set of codes indicating the diagnosis | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who has the condition? | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
encounter | SΣ | 0..1 | Reference(De-Identified UDS Plus Encounter) | Encounter created as part of | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
Slices for onset[x] | Σ | 0..1 | dateTime | Estimated or actual date, date-time, or age Slice: Unordered, Closed by type:$this | ||||
onset[x]:onsetDateTime | SΣ | 0..1 | dateTime | Estimated or actual date, date-time, or age | ||||
Slices for abatement[x] | C | 0..1 | dateTime | When in resolution/remission Slice: Unordered, Closed by type:$this | ||||
abatement[x]:abatementDateTime | SC | 0..1 | dateTime | When in resolution/remission | ||||
recordedDate | SΣ | 0..1 | dateTime | Date record was first recorded | ||||
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||
asserter | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Person who asserts this condition | ||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||
evidence | C | 0..* | BackboneElement | Supporting evidence | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||
detail | ΣC | 0..* | Reference(Resource) | Supporting information found elsewhere | ||||
note | 0..* | Annotation | Additional information about the Condition | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Condition.language | preferred | CommonLanguages
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodes | ||||
Condition.verificationStatus | required | ConditionVerificationStatus | ||||
Condition.category | extensible | ConditionCategoryCodes | ||||
Condition.severity | preferred | Condition/DiagnosisSeverity | ||||
Condition.code | extensible | USCoreConditionCodes | ||||
Condition.bodySite | example | SNOMEDCTBodyStructures | ||||
Condition.subject.type | extensible | ResourceType | ||||
Condition.encounter.type | extensible | ResourceType | ||||
Condition.stage.summary | example | ConditionStage | ||||
Condition.stage.type | example | ConditionStageType | ||||
Condition.evidence.code | example | ManifestationAndSymptomCodes |
Id | Grade | Path(s) | Details | Requirements |
con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
con-3 | best practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Condition
Summary
Mandatory: 3 elements
Must-Support: 11 elements
Prohibited: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron