| Australian Digital Health Agency FHIR Implementation Guide 1.0.0

Australian Digital Health Agency FHIR Implementation Guide. This is the current published version. It is based on FHIR® version 4.0.1. See the Directory of published versions for a list of available versions.

### StructureDefinition: ADHA Core Condition [Active]

The purpose of this profile is to provide a core representation of a condition for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia. This profile supports a statement of a condition, problem, or diagnosis including asserting negation for specific conditions or problems.

This profile identifies the additional constraints, extensions, and value sets that build on and extend Condition that are supported.

This profile is designed to set a core Condition standard for:

- Query for a patient’s conditions
- Record or update a condition belonging to a patient

#### Profile specific guidance

- `Condition.category` provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
- An active condition is represented using “active” in `Condition.clinicalStatus`.
- To represent that a patient does not have a condition or history of condition, an appropriate negation code is used in `Condition.code`.
- Refutation is not expected to be handled except as above - an appropriate negation code in `Condition.code` and `Condition.verificationStatus` of “confirmed” or “unconfirmed”.

#### Boundaries and relationships

This profile is referenced by ADHA Core Encounter and ADHA Core Procedure.

#### Formal Views of Profile Content

The official URL for this profile is:

    http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-condition-core-1

The purpose of this profile is to provide a core representation of a condition for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia. This profile supports a statement of a condition, problem, or diagnosis including asserting negation for specific conditions or problems.

This profile builds on AUBaseCondition.

This profile was published on 2023-04-14 04:02:01+0000 as a active by Australian Digital Health Agency.

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

- Differential Table
- Snapshot Table
- All

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context inv-dh-cond-01: If present, an asserter shall at least have a reference, an identifier or a display inv-dh-cond-05: Clinical status shall be present if verification status is not entered-in-error
clinicalStatus | S C | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved
verificationStatus | S | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
category | S | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis
severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
code | S | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
bodySite | S C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible) inv-dh-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT
subject | S C | 1..1 | Reference(ADHA Core Patient) | Who has the condition? inv-dh-cond-03: At least reference or a valid identifier shall be present
encounter | S | 0..1 | Reference(ADHA Core Encounter) | Encounter created as part of
onset[x] | S | 0..1 |  | Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | S | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recorder | S C | 1..1 | Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson) | Who recorded the condition inv-dh-cond-04: At least reference or display or a valid identifier shall be present
asserter | S C | 0..1 | Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson) | Person who asserts this condition
note | S | 0..* | Annotation | Additional information about the Condition
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context inv-dh-cond-01: If present, an asserter shall at least have a reference, an identifier or a display inv-dh-cond-05: Clinical status shall be present if verification status is not entered-in-error
id | Σ | 0..1 | id | Logical id of this artifact
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | External Ids for this condition
clinicalStatus | ?!S Σ C | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!S Σ C | 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..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
code | S Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
bodySite | S Σ C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible) inv-dh-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT
subject | S Σ C | 1..1 | Reference(ADHA Core Patient) | Who has the condition? inv-dh-cond-03: At least reference or a valid identifier shall be present
encounter | S Σ | 0..1 | Reference(ADHA Core Encounter) | Encounter created as part of
onset[x] | S Σ | 0..1 |  | Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | S C | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate | Σ | 0..1 | dateTime | Date record was first recorded
recorder | S Σ C | 1..1 | Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson) | Who recorded the condition inv-dh-cond-04: At least reference or display or a valid identifier shall be present
asserter | S Σ C | 0..1 | Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core 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 | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
detail | Σ C | 0..* | Reference(Resource) | Supporting information found elsewhere
note | S | 0..* | Annotation | Additional information about the Condition
Documentation for this format

Differential View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context inv-dh-cond-01: If present, an asserter shall at least have a reference, an identifier or a display inv-dh-cond-05: Clinical status shall be present if verification status is not entered-in-error
clinicalStatus | S C | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved
verificationStatus | S | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
category | S | 1..* | CodeableConcept | problem-list-item | encounter-diagnosis
severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
code | S | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
bodySite | S C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible) inv-dh-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT
subject | S C | 1..1 | Reference(ADHA Core Patient) | Who has the condition? inv-dh-cond-03: At least reference or a valid identifier shall be present
encounter | S | 0..1 | Reference(ADHA Core Encounter) | Encounter created as part of
onset[x] | S | 0..1 |  | Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | S | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recorder | S C | 1..1 | Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson) | Who recorded the condition inv-dh-cond-04: At least reference or display or a valid identifier shall be present
asserter | S C | 0..1 | Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson) | Person who asserts this condition
note | S | 0..* | Annotation | Additional information about the Condition
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Condition | C | 0..* | AUBaseCondition | A condition, problem or diagnosis statement in an Australian healthcare context inv-dh-cond-01: If present, an asserter shall at least have a reference, an identifier or a display inv-dh-cond-05: Clinical status shall be present if verification status is not entered-in-error
id | Σ | 0..1 | id | Logical id of this artifact
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | External Ids for this condition
clinicalStatus | ?!S Σ C | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus | ?!S Σ C | 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..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
severity | S | 0..1 | CodeableConcept | Subjective severity of condition Binding: Condition/DiagnosisSeverity (extensible)
code | S Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
bodySite | S Σ C | 0..* | CodeableConcept | Anatomical location, if relevant Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible) inv-dh-cond-02: If a coded body site is provided, at least one code shall be from SNOMED CT
subject | S Σ C | 1..1 | Reference(ADHA Core Patient) | Who has the condition? inv-dh-cond-03: At least reference or a valid identifier shall be present
encounter | S Σ | 0..1 | Reference(ADHA Core Encounter) | Encounter created as part of
onset[x] | S Σ | 0..1 |  | Estimated or actual date, date-time, or age
onsetDateTime |  |  | dateTime |
onsetAge |  |  | Age |
onsetPeriod |  |  | Period |
onsetRange |  |  | Range |
abatement[x] | S C | 0..1 |  | When in resolution/remission
abatementDateTime |  |  | dateTime |
abatementAge |  |  | Age |
abatementPeriod |  |  | Period |
abatementRange |  |  | Range |
recordedDate | Σ | 0..1 | dateTime | Date record was first recorded
recorder | S Σ C | 1..1 | Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson) | Who recorded the condition inv-dh-cond-04: At least reference or display or a valid identifier shall be present
asserter | S Σ C | 0..1 | Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core 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 | Σ C | 0..* | CodeableConcept | Manifestation/symptom Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
detail | Σ C | 0..* | Reference(Resource) | Supporting information found elsewhere
note | S | 0..* | Annotation | Additional information about the Condition
Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

#### Terminology Bindings

Path | Conformance | ValueSet
Condition.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
Condition.clinicalStatus | required | ConditionClinicalStatusCodes
Condition.verificationStatus | required | ConditionVerificationStatus
Condition.category | extensible | ConditionCategoryCodes
Condition.severity | extensible | Condition/DiagnosisSeverity
Condition.code | extensible | https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySite | extensible | https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Condition.stage.summary | example | ConditionStage
Condition.stage.type | example | ConditionStageType
Condition.evidence.code | preferred | https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

#### Search Parameters

None defined.