Australian Digital Health Agency FHIR Implementation Guide 1.1.0

This page is part of the Australian Digital Health Agency FHIR Implementation Guide 1.1.0. It is based on FHIR® version 4.0.1. See the Directory of published versions for a list of available previous 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 2023-08-07 09:41:43+1000 as a active by Australian Digital Health Agency.

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*AUBaseConditionA 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 SC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
... verificationStatus S0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
... category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (extensible)
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
... bodySite SC0..*CodeableConceptAnatomical 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 SC1..1Reference(ADHA Core Patient)Who has the condition?
inv-dh-cond-03: At least reference or a valid identifier shall be present
... encounter S0..1Reference(ADHA Core Encounter)Encounter created as part of
... onset[x] S0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] S0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recorder SC1..1Reference(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 SC0..1Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)Person who asserts this condition
... note S0..*AnnotationAdditional information about the Condition

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*AUBaseConditionA 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 Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!SΣC0..1CodeableConceptunconfirmed | 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 S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (extensible)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
... bodySite SΣC0..*CodeableConceptAnatomical 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 SΣC1..1Reference(ADHA Core Patient)Who has the condition?
inv-dh-cond-03: At least reference or a valid identifier shall be present
... encounter SΣ0..1Reference(ADHA Core Encounter)Encounter created as part of
... onset[x] SΣ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] SC0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder SΣC1..1Reference(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 SΣC0..1Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)Person who asserts this condition
... stage C0..*BackboneElementStage/grade, usually assessed formally
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary C0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C0..*BackboneElementSupporting evidence
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣC0..*CodeableConceptManifestation/symptom
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
.... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
... note S0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*AUBaseConditionA 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 SC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
... verificationStatus S0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
... category S1..*CodeableConceptproblem-list-item | encounter-diagnosis
... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (extensible)
... code S1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
... bodySite SC0..*CodeableConceptAnatomical 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 SC1..1Reference(ADHA Core Patient)Who has the condition?
inv-dh-cond-03: At least reference or a valid identifier shall be present
... encounter S0..1Reference(ADHA Core Encounter)Encounter created as part of
... onset[x] S0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] S0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recorder SC1..1Reference(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 SC0..1Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)Person who asserts this condition
... note S0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*AUBaseConditionA 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 Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.

... verificationStatus ?!SΣC0..1CodeableConceptunconfirmed | 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 S1..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... severity S0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (extensible)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1 (extensible)
... bodySite SΣC0..*CodeableConceptAnatomical 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 SΣC1..1Reference(ADHA Core Patient)Who has the condition?
inv-dh-cond-03: At least reference or a valid identifier shall be present
... encounter SΣ0..1Reference(ADHA Core Encounter)Encounter created as part of
... onset[x] SΣ0..1Estimated or actual date, date-time, or age
.... onsetDateTimedateTime
.... onsetAgeAge
.... onsetPeriodPeriod
.... onsetRangeRange
... abatement[x] SC0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder SΣC1..1Reference(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 SΣC0..1Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)Person who asserts this condition
... stage C0..*BackboneElementStage/grade, usually assessed formally
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary C0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C0..*BackboneElementSupporting evidence
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣC0..*CodeableConceptManifestation/symptom
Binding: https://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1 (preferred)
.... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
... note S0..*AnnotationAdditional information about the Condition

doco Documentation for this format

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

 

Terminology Bindings

PathConformanceValueSet
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severityextensibleCondition/DiagnosisSeverity
Condition.codeextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/clinical-condition-1
Condition.bodySiteextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/clinical-finding-1

Search Parameters

None defined.