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input/examples/condition-encounter-diagnosis-example1.json
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|---|---|---|
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| { | ||
| "resourceType": "Condition", | ||
| "id": "encounter-diagnosis-example1", | ||
| "meta": { | ||
| "extension": [ | ||
| { | ||
| "url": "http://hl7.org/fhir/StructureDefinition/instance-name", | ||
| "valueString": "Encounter Diagnosis Example 1" | ||
| }, | ||
| { | ||
| "url": "http://hl7.org/fhir/StructureDefinition/instance-description", | ||
| "valueMarkdown": "This example of a US Core Condition Encounter Diagnosis Profile illustrates its use to capture information about a patient's encounter diagnosis." | ||
| } | ||
| ], | ||
| "profile": [ | ||
| "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis" | ||
| ] | ||
| }, | ||
| "extension": [ | ||
| "resourceType": "Condition", | ||
| "id": "encounter-diagnosis-example1", | ||
| "meta": { | ||
| "profile": [ | ||
| "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis" | ||
| ] | ||
| }, | ||
| "extension": [ | ||
| { | ||
| "url": "http://hl7.org/fhir/StructureDefinition/condition-assertedDate", | ||
| "valueDateTime": "2015-10-31" | ||
| } | ||
| ], | ||
| "clinicalStatus": { | ||
| "coding": [ | ||
| { | ||
| "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", | ||
| "code": "resolved" | ||
| } | ||
| ] | ||
| }, | ||
| "verificationStatus": { | ||
| "coding": [ | ||
| { | ||
| "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", | ||
| "code": "confirmed" | ||
| } | ||
| ] | ||
| }, | ||
| "category": [ | ||
| { | ||
| "coding": [ | ||
| { | ||
| "url": "http://hl7.org/fhir/StructureDefinition/condition-assertedDate", | ||
| "valueDateTime": "2015-10-31" | ||
| "system": "http://terminology.hl7.org/CodeSystem/condition-category", | ||
| "code": "encounter-diagnosis", | ||
| "display": "Encounter Diagnosis" | ||
| } | ||
| ] | ||
| } | ||
| ], | ||
| "code": { | ||
| "coding": [ | ||
| { | ||
| "system": "http://snomed.info/sct", | ||
| "code": "39065001", | ||
| "display": "Burn of ear", | ||
| "version": "http://snomed.info/sct/731000124108" | ||
| } | ||
| ], | ||
| "clinicalStatus": { | ||
| "coding": [ | ||
| { | ||
| "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", | ||
| "code": "resolved" | ||
| } | ||
| ] | ||
| }, | ||
| "verificationStatus": { | ||
| "coding": [ | ||
| { | ||
| "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", | ||
| "code": "confirmed" | ||
| } | ||
| ] | ||
| }, | ||
| "category": [ | ||
| { | ||
| "coding": [ | ||
| { | ||
| "system": "http://terminology.hl7.org/CodeSystem/condition-category", | ||
| "code": "encounter-diagnosis", | ||
| "display": "Encounter Diagnosis" | ||
| } | ||
| ] | ||
| } | ||
| ], | ||
| "code": { | ||
| "coding": [ | ||
| { | ||
| "system": "http://snomed.info/sct", | ||
| "code": "39065001", | ||
| "display": "Burn of ear", | ||
| "version": "http://snomed.info/sct/731000124108" | ||
| } | ||
| ], | ||
| "text": "Burnt Ear" | ||
| }, | ||
| "subject": { | ||
| "reference": "Patient/example", | ||
| "display": "Amy Shaw" | ||
| }, | ||
| "encounter": { | ||
| "reference": "Encounter/example-1" | ||
| }, | ||
| "onsetDateTime": "2015-10-31", | ||
| "abatementDateTime": "2015-12-01", | ||
| "recordedDate": "2015-11-01" | ||
| } | ||
| "text": "Burnt Ear" | ||
| }, | ||
| "subject": { | ||
| "reference": "Patient/example", | ||
| "display": "Amy Shaw" | ||
| }, | ||
| "encounter": { | ||
| "reference": "Encounter/example-1" | ||
| }, | ||
| "onsetDateTime": "2015-10-31", | ||
| "abatementDateTime": "2015-12-01", | ||
| "recordedDate": "2015-11-01" | ||
| } |
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input/intro-notes/StructureDefinition-us-core-average-blood-pressure-notes.md
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.../intro-notes/StructureDefinition-us-core-condition-encounter-diagnosis-intro.md
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| **Example Usage Scenarios:** | ||
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| The following are example usage scenarios for this profile: | ||
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| - Query for a Patient's current or historical encounter diagnosis | ||
| - [Record or update] a Patient's encounter diagnosis | ||
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| ### Mandatory and Must Support Data Elements | ||
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| The following data-elements must always be present ([Mandatory] definition) or must be supported if the data is present in the sending system ([Must Support] definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The [Formal Views] below provides the formal summary, definitions, and terminology requirements. | ||
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| **Each Condition Must Have:** | ||
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| <!-- 1. a status of the condition* --> | ||
| 1. a category code of ‘encounter-diagnosis' | ||
| 1. a code that identifies the condition* | ||
| 1. a patient | ||
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| **Each Condition Must Support:** | ||
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| 1. a clinical status of the condition (e.g., active or resolved) | ||
| 1. a verification status | ||
| 1. an encounter | ||
| 1. a date of diagnosis* | ||
| 1. abatement date (in other words, date of resolution or remission) | ||
| 1. a date when recorded* | ||
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| *see guidance below | ||
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| **Profile Specific Implementation Guidance:** | ||
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| * For Problems and Health Concerns use the [US Core Condition Problems and Health Concerns Profile]. | ||
| * <span class="bg-success" markdown="1">\*The `Condition.code` has an *additional binding* of "current" and a base [preferred] binding.</span><!-- new-content --> | ||
| - <span class="bg-success" markdown="1">For the conformance rules on current binding for coded data, review [this section](general-requirements.html#current-binding-for-coded-elements) in the General Requirements page.</span><!-- new-content --> | ||
| - USCDI's applicable vocabulary standards for Encounter Diagnosis are SNOMED CT and ICD-10-CM. | ||
| - The [US Core Condition Codes] supports ICD-9-CM for historical purposes only. ICD-10-CM is available and **SHOULD** be used as the primary code for current encounter diagnoses. | ||
| * The encounter **SHOULD** always be referenced in `Condition.encounter`. | ||
| * To search for an encounter diagnosis, query for Conditions that reference the Encounter of interest and have a category of `encounter-diagnosis`. An example search is shown in the [Quick Start](#search) section below. | ||
| * \*There is no single element in Condition that represents the date of diagnosis. It may be the [assertedDate Extension], `Condition.onsetDateTime`, or `Condition.recordedDate`. | ||
| * Although all three are marked as Must Support, the server is not required to support all. | ||
| * A server **SHALL** support `Condition.recordedDate`. | ||
| * A server **SHALL** support at least one of [assertedDate Extension] and `Condition.onsetDateTime`. A server may support both, which means they support all 3 dates. | ||
| * The client application **SHALL** support all three elements. | ||
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| {% include link-list.md %} |
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