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Resource Profile: CL Condición-Diagnóstico

Condicion o Diagnósticos de Pacientes para Registro Clínico Electrónico

Usage:

• Examples for this Resource Profile: Condition/DiagnosticoEj

Formal Views of Profile Content

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

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

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
clinicalStatus	S	1..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR
verificationStatus		0..1	CodeableConcept	Estado de verificación de la condición o Diagnóstico Binding: ConditionVerificationStatus (required): unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
code	S	1..1	CodeableConcept	Códigos 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	S	0..1	uri	Dominio de los códigos declarados
code	S	0..1	code	Códoigo del diagnóstico o problema
display	S	0..1	string	Glosa del código en la terminología.
text	S	1..1	string	Se debe al menos notificar el diagnóstico o Problema en Texto
subject	S	1..1	Reference(CL Paciente)	Paciente sobre al que corresponde la condición.
reference	S	1..1	string	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
identifier	S	0..1	Identifier	Identificador del paciente
display	S	0..1	string	Texto alternativo para el recurso
onset[x]	S	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime S
onsetPeriod			Period S
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.code	preferred	VSDiagnosticosSCT

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
clinicalStatus	?!SΣC	1..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR
verificationStatus	?!ΣC	0..1	CodeableConcept	Estado de verificación de la condición o Diagnóstico Binding: ConditionVerificationStatus (required): unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
code	SΣ	1..1	CodeableConcept	Códigos 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	Σ	0..*	Coding	Code defined by a terminology system
system	SΣ	0..1	uri	Dominio de los códigos declarados
code	SΣ	0..1	code	Códoigo del diagnóstico o problema
display	SΣ	0..1	string	Glosa del código en la terminología.
text	SΣ	1..1	string	Se debe al menos notificar el diagnóstico o Problema en Texto
subject	SΣ	1..1	Reference(CL Paciente)	Paciente sobre al que corresponde la condición.
reference	SΣC	1..1	string	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
identifier	SΣ	0..1	Identifier	Identificador del paciente
display	SΣ	0..1	string	Texto alternativo para el recurso
onset[x]	SΣ	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime
onsetPeriod			Period
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.code	preferred	VSDiagnosticosSCT

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses
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
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!SΣC	1..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR
verificationStatus	?!ΣC	0..1	CodeableConcept	Estado de verificación de la condición o Diagnóstico Binding: ConditionVerificationStatus (required): unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
category		0..*	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
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	Códigos 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..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	SΣ	0..1	uri	Dominio de los códigos declarados
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	0..1	code	Códoigo del diagnóstico o problema
display	SΣ	0..1	string	Glosa del código en la terminología.
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	1..1	string	Se debe al menos notificar el diagnóstico o Problema en Texto
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	SΣ	1..1	Reference(CL Paciente)	Paciente sobre al que corresponde la condición.
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	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
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	SΣ	0..1	Identifier	Identificador del paciente
display	SΣ	0..1	string	Texto alternativo para el recurso
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
onset[x]	SΣ	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime S
onsetPeriod			Period S
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
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
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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Condition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.category	extensible	ConditionCategoryCodes
Condition.severity	preferred	Condition/DiagnosisSeverity
Condition.code	preferred	VSDiagnosticosSCT
Condition.bodySite	example	SNOMEDCTBodyStructures
Condition.subject.type	extensible	ResourceType
Condition.stage.summary	example	ConditionStage
Condition.stage.type	example	ConditionStageType
Condition.evidence.code	example	ManifestationAndSymptomCodes

This structure is derived from Condition

Summary

Mandatory: 4 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

• CL Paciente (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CorePacienteCl)

Differential View

This structure is derived from Condition

Name	Flags	Card.	Type	Description & Constraints
Condition		0..*	Condition	Detailed information about conditions, problems or diagnoses
clinicalStatus	S	1..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR
verificationStatus		0..1	CodeableConcept	Estado de verificación de la condición o Diagnóstico Binding: ConditionVerificationStatus (required): unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
code	S	1..1	CodeableConcept	Códigos 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	S	0..1	uri	Dominio de los códigos declarados
code	S	0..1	code	Códoigo del diagnóstico o problema
display	S	0..1	string	Glosa del código en la terminología.
text	S	1..1	string	Se debe al menos notificar el diagnóstico o Problema en Texto
subject	S	1..1	Reference(CL Paciente)	Paciente sobre al que corresponde la condición.
reference	S	1..1	string	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
identifier	S	0..1	Identifier	Identificador del paciente
display	S	0..1	string	Texto alternativo para el recurso
onset[x]	S	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime S
onsetPeriod			Period S
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.code	preferred	VSDiagnosticosSCT

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
clinicalStatus	?!SΣC	1..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR
verificationStatus	?!ΣC	0..1	CodeableConcept	Estado de verificación de la condición o Diagnóstico Binding: ConditionVerificationStatus (required): unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
code	SΣ	1..1	CodeableConcept	Códigos 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	Σ	0..*	Coding	Code defined by a terminology system
system	SΣ	0..1	uri	Dominio de los códigos declarados
code	SΣ	0..1	code	Códoigo del diagnóstico o problema
display	SΣ	0..1	string	Glosa del código en la terminología.
text	SΣ	1..1	string	Se debe al menos notificar el diagnóstico o Problema en Texto
subject	SΣ	1..1	Reference(CL Paciente)	Paciente sobre al que corresponde la condición.
reference	SΣC	1..1	string	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
identifier	SΣ	0..1	Identifier	Identificador del paciente
display	SΣ	0..1	string	Texto alternativo para el recurso
onset[x]	SΣ	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime
onsetPeriod			Period
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.code	preferred	VSDiagnosticosSCT

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Condition	C	0..*	Condition	Detailed information about conditions, problems or diagnoses
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
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this condition
clinicalStatus	?!SΣC	1..1	CodeableConcept	El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): Códigos requeridos por HL7-FHIR
verificationStatus	?!ΣC	0..1	CodeableConcept	Estado de verificación de la condición o Diagnóstico Binding: ConditionVerificationStatus (required): unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
category		0..*	CodeableConcept	problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
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	Códigos 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..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	SΣ	0..1	uri	Dominio de los códigos declarados
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	0..1	code	Códoigo del diagnóstico o problema
display	SΣ	0..1	string	Glosa del código en la terminología.
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	1..1	string	Se debe al menos notificar el diagnóstico o Problema en Texto
bodySite	Σ	0..*	CodeableConcept	Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
subject	SΣ	1..1	Reference(CL Paciente)	Paciente sobre al que corresponde la condición.
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	Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
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	SΣ	0..1	Identifier	Identificador del paciente
display	SΣ	0..1	string	Texto alternativo para el recurso
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
onset[x]	SΣ	0..1		Fecha para determinación Diagnóstica a definir entre fecha única o período
onsetDateTime			dateTime S
onsetPeriod			Period S
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
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
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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Condition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Condition.clinicalStatus	required	ConditionClinicalStatusCodes
Condition.verificationStatus	required	ConditionVerificationStatus
Condition.category	extensible	ConditionCategoryCodes
Condition.severity	preferred	Condition/DiagnosisSeverity
Condition.code	preferred	VSDiagnosticosSCT
Condition.bodySite	example	SNOMEDCTBodyStructures
Condition.subject.type	extensible	ResourceType
Condition.stage.summary	example	ConditionStage
Condition.stage.type	example	ConditionStageType
Condition.evidence.code	example	ManifestationAndSymptomCodes

This structure is derived from Condition

Summary

Mandatory: 4 elements
Must-Support: 11 elements

Structures

This structure refers to these other structures:

• CL Paciente (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CorePacienteCl)

Other representations of profile: CSV, Excel, Schematron