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

This page is part of the Chile Core (v1.8.10: STU2 Draft) based on FHIR (HL7® FHIR® Standard) 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: 1.8.10
Active as of 2024-03-19 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

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 S0..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

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

... code S0..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

.... reference S0..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)

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.codeexampleVSDiagnosticosSCT
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed 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
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... clinicalStatus ?!SΣC0..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

... code SΣ0..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

... subject SΣ1..1Reference(CL Paciente)Paciente sobre al que corresponde la condición.
.... reference SΣC0..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

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.codeexampleVSDiagnosticosSCT
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed 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 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 ?!SΣC0..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

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

... 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 SΣ0..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

... 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 SΣC0..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
con-1: Stage SHALL have summary or assessment
.... 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
con-2: evidence SHALL have code or details
.... 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

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severitypreferredCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleVSDiagnosticosSCT
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT
from this IG
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Condition.stage.summaryexampleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

This structure is derived from Condition

Summary

Must-Support: 7 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 S0..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

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

... code S0..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

.... reference S0..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)

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.codeexampleVSDiagnosticosSCT
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed 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
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... clinicalStatus ?!SΣC0..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

... code SΣ0..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

... subject SΣ1..1Reference(CL Paciente)Paciente sobre al que corresponde la condición.
.... reference SΣC0..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

PathConformanceValueSetURI
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.codeexampleVSDiagnosticosSCT
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*ConditionDetailed 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 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 ?!SΣC0..1CodeableConceptEl estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

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

... 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 SΣ0..1CodeableConceptCódigos de SOMED-CT y adicionales de ausente o desconocido
Binding: Diagnósticos SNOMED y Ausente o Desconocido (example): Diagósticos en SNOMED-CT. El ValueSet trae toda la terminología + Problema Ausente o Desconocido

... 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 SΣC0..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
con-1: Stage SHALL have summary or assessment
.... 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
con-2: evidence SHALL have code or details
.... 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

PathConformanceValueSetURI
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
http://hl7.org/fhir/ValueSet/condition-clinical
from the FHIR Standard
Condition.verificationStatusrequiredConditionVerificationStatus
http://hl7.org/fhir/ValueSet/condition-ver-status
from the FHIR Standard
Condition.categoryextensibleConditionCategoryCodes
http://hl7.org/fhir/ValueSet/condition-category
from the FHIR Standard
Condition.severitypreferredCondition/DiagnosisSeverity
http://hl7.org/fhir/ValueSet/condition-severity
from the FHIR Standard
Condition.codeexampleVSDiagnosticosSCT
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSDiagnosticosSCT
from this IG
Condition.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Condition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Condition.stage.summaryexampleConditionStage
http://hl7.org/fhir/ValueSet/condition-stage
from the FHIR Standard
Condition.stage.typeexampleConditionStageType
http://hl7.org/fhir/ValueSet/condition-stage-type
from the FHIR Standard
Condition.evidence.codeexampleManifestationAndSymptomCodes
http://hl7.org/fhir/ValueSet/manifestation-or-symptom
from the FHIR Standard

This structure is derived from Condition

Summary

Must-Support: 7 elements

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron