MHNSushi - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: Condition (MY Core)

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

Usage:

• This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
audit		0..1	(Complex)	Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
clinicalStatus	?!ΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. ele-1: All FHIR elements must have a @value or children
verificationStatus	?!ΣC	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. ele-1: All FHIR elements must have a @value or children
category		1..1	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required) ele-1: All FHIR elements must have a @value or children
subject	Σ	1..1	Reference(Patient | Group)	Who has the condition? ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard
Condition.category	required	ValueSetConditionCategoryMyCore http://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core from this IG

Constraints

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()

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
audit		0..1	(Complex)	Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core
category		1..1	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required)
code
coding
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text		1..1	string	Plain text representation of the concept
note
author[x]		0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization | Practitioner (MY Core))
authorString			string
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Condition.category	required	ValueSetConditionCategoryMyCore http://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core from this IG

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is 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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
audit		0..1	(Complex)	Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!ΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!ΣC	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		1..1	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required)
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	Σ	0..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification 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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	1..1	string	Plain text representation of the concept
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	Σ	1..1	Reference(Patient | Group)	Who has the condition?
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
onset[x]	Σ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	C	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	Σ	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 con-1: Stage SHALL have summary or assessment
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 con-2: evidence SHALL have code or details
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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization | Practitioner (MY Core))
authorString			string
time	Σ	0..1	dateTime	When the annotation was made
text	Σ	1..1	markdown	The annotation - text content (as markdown)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard
Condition.category	required	ValueSetConditionCategoryMyCore http://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core from this IG
Condition.severity	preferred	Condition/DiagnosisSeverity http://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard
Condition.code	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Condition.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Condition.stage.summary	example	ConditionStage http://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard
Condition.stage.type	example	ConditionStageType http://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard
Condition.evidence.code	example	ManifestationAndSymptomCodes http://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard

Constraints

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: 1 element(3 nested mandatory elements)

Structures

This structure refers to these other structures:

• Practitioner (MY Core) (https://veinscdr.mhnexus.com/baseR4/StructureDefinition/Practitioner-my-core)

Extensions

This structure refers to these extensions:

• http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
audit		0..1	(Complex)	Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
clinicalStatus	?!ΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. ele-1: All FHIR elements must have a @value or children
verificationStatus	?!ΣC	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. ele-1: All FHIR elements must have a @value or children
category		1..1	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required) ele-1: All FHIR elements must have a @value or children
subject	Σ	1..1	Reference(Patient | Group)	Who has the condition? ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard
Condition.category	required	ValueSetConditionCategoryMyCore http://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core from this IG

Constraints

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()

Differential View

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
audit		0..1	(Complex)	Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core
category		1..1	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required)
code
coding
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text		1..1	string	Plain text representation of the concept
note
author[x]		0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization | Practitioner (MY Core))
authorString			string
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Condition.category	required	ValueSetConditionCategoryMyCore http://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is 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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
audit		0..1	(Complex)	Extension of the individual who recorded and updated the date URL: http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!ΣC	0..1	CodeableConcept	active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
verificationStatus	?!ΣC	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		1..1	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ValueSetConditionCategory (MY Core) (required)
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	Σ	0..1	CodeableConcept	Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification 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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	1..1	string	Plain text representation of the concept
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	Σ	1..1	Reference(Patient | Group)	Who has the condition?
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
onset[x]	Σ	0..1		Estimated or actual date, date-time, or age
onsetDateTime			dateTime
onsetAge			Age
onsetPeriod			Period
onsetRange			Range
onsetString			string
abatement[x]	C	0..1		When in resolution/remission
abatementDateTime			dateTime
abatementAge			Age
abatementPeriod			Period
abatementRange			Range
abatementString			string
recordedDate	Σ	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 con-1: Stage SHALL have summary or assessment
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 con-2: evidence SHALL have code or details
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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization | Practitioner (MY Core))
authorString			string
time	Σ	0..1	dateTime	When the annotation was made
text	Σ	1..1	markdown	The annotation - text content (as markdown)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Condition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Condition.clinicalStatus	required	ConditionClinicalStatusCodes http://hl7.org/fhir/ValueSet/condition-clinical|4.0.1 from the FHIR Standard
Condition.verificationStatus	required	ConditionVerificationStatus http://hl7.org/fhir/ValueSet/condition-ver-status|4.0.1 from the FHIR Standard
Condition.category	required	ValueSetConditionCategoryMyCore http://fhir.hie.moh.gov.my/ValueSet/condition-category-my-core from this IG
Condition.severity	preferred	Condition/DiagnosisSeverity http://hl7.org/fhir/ValueSet/condition-severity from the FHIR Standard
Condition.code	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Condition.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Condition.stage.summary	example	ConditionStage http://hl7.org/fhir/ValueSet/condition-stage from the FHIR Standard
Condition.stage.type	example	ConditionStageType http://hl7.org/fhir/ValueSet/condition-stage-type from the FHIR Standard
Condition.evidence.code	example	ManifestationAndSymptomCodes http://hl7.org/fhir/ValueSet/manifestation-or-symptom from the FHIR Standard

Constraints

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: 1 element(3 nested mandatory elements)

Structures

This structure refers to these other structures:

• Practitioner (MY Core) (https://veinscdr.mhnexus.com/baseR4/StructureDefinition/Practitioner-my-core)

Extensions

This structure refers to these extensions:

• http://fhir.hie.moh.gov.my/StructureDefinition/audit-my-core

Other representations of profile: CSV, Excel, Schematron