Guía de Implementación "cl core" FHIR R4, (Versión Evolutiva)
1.8.1 - ci-build Chile flag

This page is part of the Chile Core (v1.8.1: STU2 Draft) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: CL Condición-Diagnóstico

Official URL: https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CoreDiagnosticoCl Version: 1.8.1
Active as of 2023-06-27 Computable Name: DiagnosticoCl

Copyright/Legal: Usado con el permiso de HL7 International, todos los derechos resevados en los Licencias de HL7 Internacional.

Condicion o Diagnósticos de Pacientes para Registro Clínico Electrónico

Usage:

Formal Views of Profile Content

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

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... clinicalStatus S1..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR

... verificationStatus 0..1CodeableConceptEstado de verificación de la condición o Diagnóstico
Binding: ConditionVerificationStatus (required): unconfirmed | provisional | differential | confirmed | refuted | entered-in-error

... code S1..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (preferred): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

.... coding
..... system S0..1uriDominio de los códigos declarados
..... code S0..1codeCódoigo del diagnóstico o problema
..... display S0..1stringGlosa del código en la terminología.
.... text S1..1stringSe debe al menos notificar el diagnóstico o Problema en Texto
.... reference S1..1stringReferencia al recurso del Paciente al cual se indica el diagnóstico o condicón
.... identifier S0..1IdentifierIdentificador del paciente
.... display S0..1stringTexto alternativo para el recurso
... onset[x] S0..1Fecha para determinación Diagnóstica a definir entre fecha única o período
.... onsetDateTimedateTime S
.... onsetPeriodPeriod S

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.codepreferredVSDiagnosticosSCT
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... clinicalStatus ?!SΣC1..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR

... code SΣ1..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (preferred): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

.... coding Σ0..*CodingCode defined by a terminology system
..... system SΣ0..1uriDominio de los códigos declarados
..... code SΣ0..1codeCódoigo del diagnóstico o problema
..... display SΣ0..1stringGlosa del código en la terminología.
.... text SΣ1..1stringSe debe al menos notificar el diagnóstico o Problema en Texto
... subject SΣ1..1Reference(CL Paciente)Paciente sobre al que corresponde la condición.
.... reference SΣC1..1stringReferencia al recurso del Paciente al cual se indica el diagnóstico o condicón
.... identifier SΣ0..1IdentifierIdentificador del paciente
.... display SΣ0..1stringTexto alternativo para el recurso
... onset[x] SΣ0..1Fecha para determinación Diagnóstica a definir entre fecha única o período
.... onsetDateTimedateTime
.... onsetPeriodPeriod

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.codepreferredVSDiagnosticosSCT
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... 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
... 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 ?!SΣC1..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR

... verificationStatus ?!ΣC0..1CodeableConceptEstado de verificación de la condición o Diagnóstico
Binding: ConditionVerificationStatus (required): unconfirmed | provisional | differential | confirmed | refuted | entered-in-error

... category 0..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ1..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (preferred): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣ0..1uriDominio de los códigos declarados
..... version Σ0..1stringVersion of the system - if relevant
..... code SΣ0..1codeCódoigo del diagnóstico o problema
..... display SΣ0..1stringGlosa del código en la terminología.
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ1..1stringSe debe al menos notificar el diagnóstico o Problema en Texto
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ1..1Reference(CL Paciente)Paciente sobre al que corresponde la condición.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC1..1stringReferencia al recurso del Paciente al cual se indica el diagnóstico o condicón
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier SΣ0..1IdentifierIdentificador del paciente
.... display SΣ0..1stringTexto alternativo para el recurso
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... onset[x] SΣ0..1Fecha para determinación Diagnóstica a definir entre fecha única o período
.... onsetDateTimedateTime S
.... onsetPeriodPeriod S
... abatement[x] C0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
... asserter Σ0..1Reference(Practitioner | PractitionerRole | Patient | 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: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codepreferredVSDiagnosticosSCT
Condition.bodySiteexampleSNOMEDCTBodyStructures
Condition.subject.typeextensibleResourceType
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleManifestationAndSymptomCodes

This structure is derived from Condition

Summary

Mandatory: 4 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*ConditionDetailed information about conditions, problems or diagnoses
... clinicalStatus S1..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR

... verificationStatus 0..1CodeableConceptEstado de verificación de la condición o Diagnóstico
Binding: ConditionVerificationStatus (required): unconfirmed | provisional | differential | confirmed | refuted | entered-in-error

... code S1..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (preferred): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

.... coding
..... system S0..1uriDominio de los códigos declarados
..... code S0..1codeCódoigo del diagnóstico o problema
..... display S0..1stringGlosa del código en la terminología.
.... text S1..1stringSe debe al menos notificar el diagnóstico o Problema en Texto
.... reference S1..1stringReferencia al recurso del Paciente al cual se indica el diagnóstico o condicón
.... identifier S0..1IdentifierIdentificador del paciente
.... display S0..1stringTexto alternativo para el recurso
... onset[x] S0..1Fecha para determinación Diagnóstica a definir entre fecha única o período
.... onsetDateTimedateTime S
.... onsetPeriodPeriod S

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.codepreferredVSDiagnosticosSCT

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... clinicalStatus ?!SΣC1..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR

... code SΣ1..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (preferred): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

.... coding Σ0..*CodingCode defined by a terminology system
..... system SΣ0..1uriDominio de los códigos declarados
..... code SΣ0..1codeCódoigo del diagnóstico o problema
..... display SΣ0..1stringGlosa del código en la terminología.
.... text SΣ1..1stringSe debe al menos notificar el diagnóstico o Problema en Texto
... subject SΣ1..1Reference(CL Paciente)Paciente sobre al que corresponde la condición.
.... reference SΣC1..1stringReferencia al recurso del Paciente al cual se indica el diagnóstico o condicón
.... identifier SΣ0..1IdentifierIdentificador del paciente
.... display SΣ0..1stringTexto alternativo para el recurso
... onset[x] SΣ0..1Fecha para determinación Diagnóstica a definir entre fecha única o período
.... onsetDateTimedateTime
.... onsetPeriodPeriod

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.codepreferredVSDiagnosticosSCT

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed information about conditions, problems or diagnoses
... 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
... 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 ?!SΣC1..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR

... verificationStatus ?!ΣC0..1CodeableConceptEstado de verificación de la condición o Diagnóstico
Binding: ConditionVerificationStatus (required): unconfirmed | provisional | differential | confirmed | refuted | entered-in-error

... category 0..*CodeableConceptproblem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.


... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ1..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (preferred): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣ0..1uriDominio de los códigos declarados
..... version Σ0..1stringVersion of the system - if relevant
..... code SΣ0..1codeCódoigo del diagnóstico o problema
..... display SΣ0..1stringGlosa del código en la terminología.
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ1..1stringSe debe al menos notificar el diagnóstico o Problema en Texto
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ1..1Reference(CL Paciente)Paciente sobre al que corresponde la condición.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC1..1stringReferencia al recurso del Paciente al cual se indica el diagnóstico o condicón
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier SΣ0..1IdentifierIdentificador del paciente
.... display SΣ0..1stringTexto alternativo para el recurso
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... onset[x] SΣ0..1Fecha para determinación Diagnóstica a definir entre fecha única o período
.... onsetDateTimedateTime S
.... onsetPeriodPeriod S
... abatement[x] C0..1When in resolution/remission
.... abatementDateTimedateTime
.... abatementAgeAge
.... abatementPeriodPeriod
.... abatementRangeRange
.... abatementStringstring
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
... asserter Σ0..1Reference(Practitioner | PractitionerRole | Patient | 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: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleConditionCategoryCodes
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codepreferredVSDiagnosticosSCT
Condition.bodySiteexampleSNOMEDCTBodyStructures
Condition.subject.typeextensibleResourceType
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleManifestationAndSymptomCodes

This structure is derived from Condition

Summary

Mandatory: 4 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron