CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
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CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG - Local Development build (v2.0.0-cibuild) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: ACH Monthly Event Condition

Official URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/ach-monthly-condition Version: 2.0.0-cibuild
Standards status: Trial-use Maturity Level: 1 Computable Name: AcuteCareHospitalMonthlyReportingCondition

This profile contains Required and Must Support data elements for reporting patient condition information to the NHSN Acute Care Hospital (ACH) Monthly Digital Quality Measure. This profile inherits from the QI Core 6.0.0 Condition Encounter Diagnosis profile, which inherits from US Core 6.1.0 Condition Encounter Diagnosis profile.

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 1.0.0:

  • New Content

    • Formal Views of Profile Content

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

    Name Flags Card. Type Description & Constraints    Filter: Filtersdoco
    .. Condition C 0..* QICoreConditionEncounterDiagnosis Detailed information about conditions, problems or diagnoses
    This profile also complies with the profile US Core Condition Profile (3.1.1)
    Constraints: con-3, con-4, con-5, Condition-coding-from-common-codesystems, dqm-Con-2
    ... id SΣ 1..1 id
    (NHSN-MS)
    Logical id of this artifact
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... Slices for extension S 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:assertedDate S 0..1 dateTime
    (NHSN-MS)
    (USCDI) Date the condition was first asserted
    URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
    ... clinicalStatus ?!SΣC 0..1 CodeableConcept
    (NHSN-MS)
    (USCDI) active | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ... verificationStatus ?!SΣC 0..1 CodeableConcept
    (NHSN-MS)
    (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ... Slices for category S 1..* CodeableConcept
    (NHSN-MS)
    (USCDI) category codes
    Slice: Unordered, Open by pattern:$this
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
    .... category:us-core S 1..1 CodeableConcept
    (NHSN-MS)
    (USCDI) encounter-diagnosis
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.

    Required Pattern: At least the following
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (Complex)
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... version 0..1 string Version of the system - if relevant
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ...... display 0..1 string Representation defined by the system
    ...... userSelected 0..1 boolean If this coding was chosen directly by the user
    ..... text 0..1 string Plain text representation of the concept
    ... code SΣ 1..1 CodeableConcept
    (NHSN-MS)
    (USCDI) Identification of the condition, problem or diagnosis
    Binding: USCoreConditionCodes (6.1.0) (extensible): Valueset to describe the actual problem experienced by the patient
    ... subject SΣ 1..1 Reference(Cross-Measure Patient Profile)
    (NHSN-MS)
    Literal reference, Relative, internal or absolute URL
    .... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
    ... encounter SΣ 0..1 Reference(QICore Encounter)
    (NHSN-MS)
    (QI-Core)(USCDI) Encounter created as part of
    .... reference SΣC 1..1 string
    (NHSN-MS)
    Literal reference, Relative, internal or absolute URL
    ... onset[x] SΣ 0..1
    (NHSN-MS)
    (QI-Core)(USCDI) Estimated or actual date, date-time, or age
    .... onsetDateTime dateTime S
    .... onsetAge Age
    .... onsetPeriod Period
    .... onsetRange Range
    ... abatement[x] SC 0..1
    (NHSN-MS)
    (QI-Core)(USCDI) When in resolution/remission
    .... abatementDateTime dateTime S
    .... abatementAge Age
    .... abatementPeriod Period
    .... abatementRange Range
    ... recordedDate SΣ 0..1 dateTime
    (NHSN-MS)
    (USCDI) Date record was first recorded

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Condition.clinicalStatus Base required Condition Clinical Status Codes 📦4.0.1 FHIR Std.
    Condition.verificationStatus Base required ConditionVerificationStatus 📦4.0.1 FHIR Std.
    Condition.category Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
    Condition.category:us-core Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
    Condition.code Base extensible US Core Condition Codes 📍6.1.0 US Core v6.1

    Constraints

    Id Grade Path(s) Description Expression
    Condition-coding-from-common-codesystems error Condition Condition: code must contains a SNOMED CT, ICD-10-CM, or ICD-9-CM coding code.coding.where(system='http://snomed.info/sct').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-9-cm').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-10-cm').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()
    dqm-Con-2 error Condition At least one Condition.category SHALL be encounter-diagnosis, problem-list-item, or health-concern category.where(coding.where(system = 'http://terminology.hl7.org/CodeSystem/condition-category' and code='encounter-diagnosis').exists()).exists() or category.where(coding.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-problem-or-health-concern')).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 QICoreConditionEncounterDiagnosis

    Name Flags Card. Type Description & Constraints    Filter: Filtersdoco
    .. Condition C 0..* QICoreConditionEncounterDiagnosis Detailed information about conditions, problems or diagnoses
    This profile also complies with the profile US Core Condition Profile (3.1.1)
    Constraints: Condition-coding-from-common-codesystems, dqm-Con-2
    ... id S 1..1 id
    (NHSN-MS)
    Logical id of this artifact
    ... meta
    .... Slices for extension Content/Rules for all slices
    ..... extension:link-received-date-extension 0..1 dateTime Received Date
    URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
    ... extension S 0..* Extension Extension
    .... extension:assertedDate 0..1 ConditionAssertedDate(5.2.0) (NHSN-MS)(USCDI) Date the condition was first asserted
    ... clinicalStatus 0..1 CodeableConcept (NHSN-MS)(USCDI) active | recurrence | relapse | inactive | remission | resolved
    ... verificationStatus 0..1 CodeableConcept (NHSN-MS)(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    ... category 1..* CodeableConcept (NHSN-MS)(USCDI) category codes
    ... Slices for category Content/Rules for all slices
    .... category:us-core 1..1 CodeableConcept (NHSN-MS)(USCDI) encounter-diagnosis
    ... code 1..1 CodeableConcept (NHSN-MS)(USCDI) Identification of the condition, problem or diagnosis
    ... subject 1..1 Reference(Cross-Measure Patient Profile) (NHSN-MS) Literal reference, Relative, internal or absolute URL
    .... reference S 1..1 string Literal reference, Relative, internal or absolute URL
    ... encounter 0..1 Reference(QICore Encounter) (NHSN-MS)(QI-Core)(USCDI) Encounter created as part of
    .... reference S 1..1 string
    (NHSN-MS)
    Literal reference, Relative, internal or absolute URL
    ... onset[x] 0..1 dateTime, Age, Period, Range (NHSN-MS)(QI-Core)(USCDI) Estimated or actual date, date-time, or age
    ... abatement[x] 0..1 dateTime, Age, Period, Range (NHSN-MS)(QI-Core)(USCDI) When in resolution/remission
    ... recordedDate 0..1 dateTime (NHSN-MS)(USCDI) Date record was first recorded

    doco Documentation for this format

    Constraints

    Id Grade Path(s) Description Expression
    Condition-coding-from-common-codesystems error Condition Condition: code must contains a SNOMED CT, ICD-10-CM, or ICD-9-CM coding code.coding.where(system='http://snomed.info/sct').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-9-cm').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-10-cm').exists()
    dqm-Con-2 error Condition At least one Condition.category SHALL be encounter-diagnosis, problem-list-item, or health-concern category.where(coding.where(system = 'http://terminology.hl7.org/CodeSystem/condition-category' and code='encounter-diagnosis').exists()).exists() or category.where(coding.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-problem-or-health-concern')).exists()
    Name Flags Card. Type Description & Constraints    Filter: Filtersdoco
    .. Condition C 0..* QICoreConditionEncounterDiagnosis Detailed information about conditions, problems or diagnoses
    This profile also complies with the profile US Core Condition Profile (3.1.1)
    Constraints: con-3, con-4, con-5, Condition-coding-from-common-codesystems, dqm-Con-2
    ... id SΣ 1..1 id
    (NHSN-MS)
    Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    .... id 0..1 string Unique id for inter-element referencing
    .... Slices for extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ..... extension:link-received-date-extension 0..1 dateTime Received Date
    URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
    .... versionId Σ 0..1 id Version specific identifier
    .... lastUpdated Σ 0..1 instant When the resource version last changed
    .... source Σ 0..1 uri Identifies where the resource comes from
    .... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
    .... security Σ 0..* Coding Security Labels applied to this resource
    Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
    .... tag Σ 0..* Coding Tags applied to this resource
    Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension S 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:assertedDate S 0..1 dateTime
    (NHSN-MS)
    (USCDI) 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
    (NHSN-MS)
    (USCDI) active | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ... verificationStatus ?!SΣC 0..1 CodeableConcept
    (NHSN-MS)
    (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ... Slices for category S 1..* CodeableConcept
    (NHSN-MS)
    (USCDI) category codes
    Slice: Unordered, Open by pattern:$this
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
    .... category:us-core S 1..1 CodeableConcept
    (NHSN-MS)
    (USCDI) encounter-diagnosis
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.

    Required Pattern: At least the following
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (Complex)
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... version 0..1 string Version of the system - if relevant
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ...... display 0..1 string Representation defined by the system
    ...... userSelected 0..1 boolean If this coding was chosen directly by the user
    ..... text 0..1 string Plain text representation of the concept
    ... 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
    (NHSN-MS)
    (USCDI) Identification of the condition, problem or diagnosis
    Binding: USCoreConditionCodes (6.1.0) (extensible): Valueset to describe the actual problem experienced by the patient
    ... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
    Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
    ... subject SΣ 1..1 Reference(Cross-Measure Patient Profile)
    (NHSN-MS)
    Literal reference, Relative, internal or absolute URL
    .... 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 SΣC 1..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
    .... display Σ 0..1 string Text alternative for the resource
    ... encounter SΣ 0..1 Reference(QICore Encounter)
    (NHSN-MS)
    (QI-Core)(USCDI) 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 SΣC 1..1 string
    (NHSN-MS)
    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
    .... display Σ 0..1 string Text alternative for the resource
    ... onset[x] SΣ 0..1
    (NHSN-MS)
    (QI-Core)(USCDI) Estimated or actual date, date-time, or age
    .... onsetDateTime dateTime S
    .... onsetAge Age
    .... onsetPeriod Period
    .... onsetRange Range
    ... abatement[x] SC 0..1
    (NHSN-MS)
    (QI-Core)(USCDI) When in resolution/remission
    .... abatementDateTime dateTime S
    .... abatementAge Age
    .... abatementPeriod Period
    .... abatementRange Range
    ... recordedDate SΣ 0..1 dateTime
    (NHSN-MS)
    (USCDI) 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
    Constraints: con-1
    .... 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
    Constraints: con-2
    .... 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

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Condition.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
    Condition.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
    Condition.language Base preferred Common Languages 📦4.0.1 FHIR Std.
    Condition.clinicalStatus Base required Condition Clinical Status Codes 📦4.0.1 FHIR Std.
    Condition.verificationStatus Base required ConditionVerificationStatus 📦4.0.1 FHIR Std.
    Condition.category Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
    Condition.category:us-core Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
    Condition.severity Base preferred Condition/Diagnosis Severity 📦4.0.1 FHIR Std.
    Condition.code Base extensible US Core Condition Codes 📍6.1.0 US Core v6.1
    Condition.bodySite Base example SNOMED CT Body Structures 📦4.0.1 FHIR Std.
    Condition.subject.type Base extensible ResourceType 📍4.0.1 FHIR Std.
    Condition.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
    Condition.stage.summary Base example Condition Stage 📦4.0.1 FHIR Std.
    Condition.stage.type Base example Condition Stage Type 📦4.0.1 FHIR Std.
    Condition.evidence.code Base example Manifestation and Symptom Codes 📦4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    Condition-coding-from-common-codesystems error Condition Condition: code must contains a SNOMED CT, ICD-10-CM, or ICD-9-CM coding code.coding.where(system='http://snomed.info/sct').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-9-cm').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-10-cm').exists()
    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()
    dqm-Con-2 error Condition At least one Condition.category SHALL be encounter-diagnosis, problem-list-item, or health-concern category.where(coding.where(system = 'http://terminology.hl7.org/CodeSystem/condition-category' and code='encounter-diagnosis').exists()).exists() or category.where(coding.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-problem-or-health-concern')).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 QICoreConditionEncounterDiagnosis

    Summary

    Mandatory: 2 elements(1 nested mandatory element)
    Must-Support: 4 elements

    Structures

    This structure refers to these other structures:

    Extensions

    This structure refers to these extensions:

    Maturity: 1

    Key Elements View

    Name Flags Card. Type Description & Constraints    Filter: Filtersdoco
    .. Condition C 0..* QICoreConditionEncounterDiagnosis Detailed information about conditions, problems or diagnoses
    This profile also complies with the profile US Core Condition Profile (3.1.1)
    Constraints: con-3, con-4, con-5, Condition-coding-from-common-codesystems, dqm-Con-2
    ... id SΣ 1..1 id
    (NHSN-MS)
    Logical id of this artifact
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... Slices for extension S 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:assertedDate S 0..1 dateTime
    (NHSN-MS)
    (USCDI) Date the condition was first asserted
    URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
    ... clinicalStatus ?!SΣC 0..1 CodeableConcept
    (NHSN-MS)
    (USCDI) active | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ... verificationStatus ?!SΣC 0..1 CodeableConcept
    (NHSN-MS)
    (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ... Slices for category S 1..* CodeableConcept
    (NHSN-MS)
    (USCDI) category codes
    Slice: Unordered, Open by pattern:$this
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
    .... category:us-core S 1..1 CodeableConcept
    (NHSN-MS)
    (USCDI) encounter-diagnosis
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.

    Required Pattern: At least the following
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (Complex)
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... version 0..1 string Version of the system - if relevant
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ...... display 0..1 string Representation defined by the system
    ...... userSelected 0..1 boolean If this coding was chosen directly by the user
    ..... text 0..1 string Plain text representation of the concept
    ... code SΣ 1..1 CodeableConcept
    (NHSN-MS)
    (USCDI) Identification of the condition, problem or diagnosis
    Binding: USCoreConditionCodes (6.1.0) (extensible): Valueset to describe the actual problem experienced by the patient
    ... subject SΣ 1..1 Reference(Cross-Measure Patient Profile)
    (NHSN-MS)
    Literal reference, Relative, internal or absolute URL
    .... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
    ... encounter SΣ 0..1 Reference(QICore Encounter)
    (NHSN-MS)
    (QI-Core)(USCDI) Encounter created as part of
    .... reference SΣC 1..1 string
    (NHSN-MS)
    Literal reference, Relative, internal or absolute URL
    ... onset[x] SΣ 0..1
    (NHSN-MS)
    (QI-Core)(USCDI) Estimated or actual date, date-time, or age
    .... onsetDateTime dateTime S
    .... onsetAge Age
    .... onsetPeriod Period
    .... onsetRange Range
    ... abatement[x] SC 0..1
    (NHSN-MS)
    (QI-Core)(USCDI) When in resolution/remission
    .... abatementDateTime dateTime S
    .... abatementAge Age
    .... abatementPeriod Period
    .... abatementRange Range
    ... recordedDate SΣ 0..1 dateTime
    (NHSN-MS)
    (USCDI) Date record was first recorded

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Condition.clinicalStatus Base required Condition Clinical Status Codes 📦4.0.1 FHIR Std.
    Condition.verificationStatus Base required ConditionVerificationStatus 📦4.0.1 FHIR Std.
    Condition.category Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
    Condition.category:us-core Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
    Condition.code Base extensible US Core Condition Codes 📍6.1.0 US Core v6.1

    Constraints

    Id Grade Path(s) Description Expression
    Condition-coding-from-common-codesystems error Condition Condition: code must contains a SNOMED CT, ICD-10-CM, or ICD-9-CM coding code.coding.where(system='http://snomed.info/sct').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-9-cm').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-10-cm').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()
    dqm-Con-2 error Condition At least one Condition.category SHALL be encounter-diagnosis, problem-list-item, or health-concern category.where(coding.where(system = 'http://terminology.hl7.org/CodeSystem/condition-category' and code='encounter-diagnosis').exists()).exists() or category.where(coding.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-problem-or-health-concern')).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()

    Differential View

    This structure is derived from QICoreConditionEncounterDiagnosis

    Name Flags Card. Type Description & Constraints    Filter: Filtersdoco
    .. Condition C 0..* QICoreConditionEncounterDiagnosis Detailed information about conditions, problems or diagnoses
    This profile also complies with the profile US Core Condition Profile (3.1.1)
    Constraints: Condition-coding-from-common-codesystems, dqm-Con-2
    ... id S 1..1 id
    (NHSN-MS)
    Logical id of this artifact
    ... meta
    .... Slices for extension Content/Rules for all slices
    ..... extension:link-received-date-extension 0..1 dateTime Received Date
    URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
    ... extension S 0..* Extension Extension
    .... extension:assertedDate 0..1 ConditionAssertedDate(5.2.0) (NHSN-MS)(USCDI) Date the condition was first asserted
    ... clinicalStatus 0..1 CodeableConcept (NHSN-MS)(USCDI) active | recurrence | relapse | inactive | remission | resolved
    ... verificationStatus 0..1 CodeableConcept (NHSN-MS)(USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    ... category 1..* CodeableConcept (NHSN-MS)(USCDI) category codes
    ... Slices for category Content/Rules for all slices
    .... category:us-core 1..1 CodeableConcept (NHSN-MS)(USCDI) encounter-diagnosis
    ... code 1..1 CodeableConcept (NHSN-MS)(USCDI) Identification of the condition, problem or diagnosis
    ... subject 1..1 Reference(Cross-Measure Patient Profile) (NHSN-MS) Literal reference, Relative, internal or absolute URL
    .... reference S 1..1 string Literal reference, Relative, internal or absolute URL
    ... encounter 0..1 Reference(QICore Encounter) (NHSN-MS)(QI-Core)(USCDI) Encounter created as part of
    .... reference S 1..1 string
    (NHSN-MS)
    Literal reference, Relative, internal or absolute URL
    ... onset[x] 0..1 dateTime, Age, Period, Range (NHSN-MS)(QI-Core)(USCDI) Estimated or actual date, date-time, or age
    ... abatement[x] 0..1 dateTime, Age, Period, Range (NHSN-MS)(QI-Core)(USCDI) When in resolution/remission
    ... recordedDate 0..1 dateTime (NHSN-MS)(USCDI) Date record was first recorded

    doco Documentation for this format

    Constraints

    Id Grade Path(s) Description Expression
    Condition-coding-from-common-codesystems error Condition Condition: code must contains a SNOMED CT, ICD-10-CM, or ICD-9-CM coding code.coding.where(system='http://snomed.info/sct').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-9-cm').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-10-cm').exists()
    dqm-Con-2 error Condition At least one Condition.category SHALL be encounter-diagnosis, problem-list-item, or health-concern category.where(coding.where(system = 'http://terminology.hl7.org/CodeSystem/condition-category' and code='encounter-diagnosis').exists()).exists() or category.where(coding.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-problem-or-health-concern')).exists()

    Snapshot View

    Name Flags Card. Type Description & Constraints    Filter: Filtersdoco
    .. Condition C 0..* QICoreConditionEncounterDiagnosis Detailed information about conditions, problems or diagnoses
    This profile also complies with the profile US Core Condition Profile (3.1.1)
    Constraints: con-3, con-4, con-5, Condition-coding-from-common-codesystems, dqm-Con-2
    ... id SΣ 1..1 id
    (NHSN-MS)
    Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    .... id 0..1 string Unique id for inter-element referencing
    .... Slices for extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ..... extension:link-received-date-extension 0..1 dateTime Received Date
    URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
    .... versionId Σ 0..1 id Version specific identifier
    .... lastUpdated Σ 0..1 instant When the resource version last changed
    .... source Σ 0..1 uri Identifies where the resource comes from
    .... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
    .... security Σ 0..* Coding Security Labels applied to this resource
    Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
    .... tag Σ 0..* Coding Tags applied to this resource
    Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension S 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:assertedDate S 0..1 dateTime
    (NHSN-MS)
    (USCDI) 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
    (NHSN-MS)
    (USCDI) active | recurrence | relapse | inactive | remission | resolved
    Binding: ConditionClinicalStatusCodes (required)
    ... verificationStatus ?!SΣC 0..1 CodeableConcept
    (NHSN-MS)
    (USCDI) unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
    Binding: ConditionVerificationStatus (required)
    ... Slices for category S 1..* CodeableConcept
    (NHSN-MS)
    (USCDI) category codes
    Slice: Unordered, Open by pattern:$this
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
    .... category:us-core S 1..1 CodeableConcept
    (NHSN-MS)
    (USCDI) encounter-diagnosis
    Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.

    Required Pattern: At least the following
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (Complex)
    ...... id 0..1 string Unique id for inter-element referencing
    ...... extension 0..* Extension Additional content defined by implementations
    ...... system 1..1 uri Identity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/condition-category
    ...... version 0..1 string Version of the system - if relevant
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: encounter-diagnosis
    ...... display 0..1 string Representation defined by the system
    ...... userSelected 0..1 boolean If this coding was chosen directly by the user
    ..... text 0..1 string Plain text representation of the concept
    ... 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
    (NHSN-MS)
    (USCDI) Identification of the condition, problem or diagnosis
    Binding: USCoreConditionCodes (6.1.0) (extensible): Valueset to describe the actual problem experienced by the patient
    ... bodySite Σ 0..* CodeableConcept Anatomical location, if relevant
    Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
    ... subject SΣ 1..1 Reference(Cross-Measure Patient Profile)
    (NHSN-MS)
    Literal reference, Relative, internal or absolute URL
    .... 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 SΣC 1..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
    .... display Σ 0..1 string Text alternative for the resource
    ... encounter SΣ 0..1 Reference(QICore Encounter)
    (NHSN-MS)
    (QI-Core)(USCDI) 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 SΣC 1..1 string
    (NHSN-MS)
    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
    .... display Σ 0..1 string Text alternative for the resource
    ... onset[x] SΣ 0..1
    (NHSN-MS)
    (QI-Core)(USCDI) Estimated or actual date, date-time, or age
    .... onsetDateTime dateTime S
    .... onsetAge Age
    .... onsetPeriod Period
    .... onsetRange Range
    ... abatement[x] SC 0..1
    (NHSN-MS)
    (QI-Core)(USCDI) When in resolution/remission
    .... abatementDateTime dateTime S
    .... abatementAge Age
    .... abatementPeriod Period
    .... abatementRange Range
    ... recordedDate SΣ 0..1 dateTime
    (NHSN-MS)
    (USCDI) 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
    Constraints: con-1
    .... 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
    Constraints: con-2
    .... 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

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Condition.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
    Condition.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
    Condition.language Base preferred Common Languages 📦4.0.1 FHIR Std.
    Condition.clinicalStatus Base required Condition Clinical Status Codes 📦4.0.1 FHIR Std.
    Condition.verificationStatus Base required ConditionVerificationStatus 📦4.0.1 FHIR Std.
    Condition.category Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
    Condition.category:us-core Base extensible Condition Category Codes 📦4.0.1 FHIR Std.
    Condition.severity Base preferred Condition/Diagnosis Severity 📦4.0.1 FHIR Std.
    Condition.code Base extensible US Core Condition Codes 📍6.1.0 US Core v6.1
    Condition.bodySite Base example SNOMED CT Body Structures 📦4.0.1 FHIR Std.
    Condition.subject.type Base extensible ResourceType 📍4.0.1 FHIR Std.
    Condition.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
    Condition.stage.summary Base example Condition Stage 📦4.0.1 FHIR Std.
    Condition.stage.type Base example Condition Stage Type 📦4.0.1 FHIR Std.
    Condition.evidence.code Base example Manifestation and Symptom Codes 📦4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    Condition-coding-from-common-codesystems error Condition Condition: code must contains a SNOMED CT, ICD-10-CM, or ICD-9-CM coding code.coding.where(system='http://snomed.info/sct').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-9-cm').exists() or code.coding.where(system='http://hl7.org/fhir/sid/icd-10-cm').exists()
    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()
    dqm-Con-2 error Condition At least one Condition.category SHALL be encounter-diagnosis, problem-list-item, or health-concern category.where(coding.where(system = 'http://terminology.hl7.org/CodeSystem/condition-category' and code='encounter-diagnosis').exists()).exists() or category.where(coding.memberOf('http://hl7.org/fhir/us/core/ValueSet/us-core-problem-or-health-concern')).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 QICoreConditionEncounterDiagnosis

    Summary

    Mandatory: 2 elements(1 nested mandatory element)
    Must-Support: 4 elements

    Structures

    This structure refers to these other structures:

    Extensions

    This structure refers to these extensions:

    Maturity: 1

     

    Other representations of profile: CSV, Excel, Schematron