Guía de Implementación ''cl core'' FHIR R4, (Versión Evolutiva)
1.9.1 - draft Chile flag

This page is part of the Chile Core (v1.9.1: 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: 1.9.1
Active as of 2024-09-26 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..* Condition Detailed information about conditions, problems or diagnoses
... clinicalStatus S 0..1 CodeableConcept El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

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

... code S 0..1 CodeableConcept Códigos 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 S 0..1 string Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
... onset[x] S 0..1 Fecha para determinación Diagnóstica a definir entre fecha única o período
.... onsetDateTime dateTime S
.... onsetPeriod Period 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 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
... 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 0..1 CodeableConcept El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

... code SΣ 0..1 CodeableConcept Códigos 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 SΣ 1..1 Reference(CL Paciente | Group) Paciente sobre al que corresponde la condición.
.... reference SΣC 0..1 string Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
... onset[x] SΣ 0..1 Fecha para determinación Diagnóstica a definir entre fecha única o período
.... onsetDateTime dateTime
.... onsetPeriod Period

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 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
... 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 0..1 CodeableConcept El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

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

... 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 0..1 CodeableConcept Códigos 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 Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ 1..1 Reference(CL Paciente | Group) 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 0..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 Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... 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
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

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: 6 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..* Condition Detailed information about conditions, problems or diagnoses
... clinicalStatus S 0..1 CodeableConcept El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

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

... code S 0..1 CodeableConcept Códigos 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 S 0..1 string Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
... onset[x] S 0..1 Fecha para determinación Diagnóstica a definir entre fecha única o período
.... onsetDateTime dateTime S
.... onsetPeriod Period 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 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
... 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 0..1 CodeableConcept El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

... code SΣ 0..1 CodeableConcept Códigos 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 SΣ 1..1 Reference(CL Paciente | Group) Paciente sobre al que corresponde la condición.
.... reference SΣC 0..1 string Referencia al recurso del Paciente al cual se indica el diagnóstico o condicón
... onset[x] SΣ 0..1 Fecha para determinación Diagnóstica a definir entre fecha única o período
.... onsetDateTime dateTime
.... onsetPeriod Period

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 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
... 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 0..1 CodeableConcept El estatus en el cual se encuentra la condición: active| recurrece | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required): Códigos definidos por estándar

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

... 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 0..1 CodeableConcept Códigos 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 Σ 0..* CodeableConcept Anatomical location, if relevant
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... subject SΣ 1..1 Reference(CL Paciente | Group) 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 0..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 Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... 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
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

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: 6 elements

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron