Guía de Implementación "cl core" FHIR R4, (Versión Evolutiva)
1.8.4 - ci-build
This page is part of the Chile Core (v1.8.4: STU2 Draft) based on FHIR R4. . For a full list of available versions, see the Directory of published versions
Official URL: https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CoreDiagnosticoCl | Version: 1.8.4 | |||
Active as of 2023-09-01 | 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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
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 |
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 |
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.
| |||||
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 |
Path | Conformance | ValueSet | ||||
Condition.language | preferred | CommonLanguages
| ||||
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
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 |
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 |
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.
| |||||
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 |
Path | Conformance | ValueSet | ||||
Condition.language | preferred | CommonLanguages
| ||||
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
Other representations of profile: CSV, Excel, Schematron