ProblemHeader (Condition)

Guidance for populating and consuming the ProblemHeader (Condition) profile

Introduction

The headings below list the elements of the ProblemHeader (Condition) profile and describe how to populate and consume them.

Important: Any element not specifically listed below MUST NOT be populated or consumed.

Tip: You’ll find it helpful to read it in conjunction with the underlying ProblemHeader profile definition.

ProblemHeader (Condition) elements

id

Data type: Id Optionality: Mandatory Cardinality: 1..1

The logical identifier of the ProblemHeader (Condition) profile.

meta.profile

Data type: uri Optionality: Mandatory Cardinality: 1..1

The ProblemHeader (Condition) profile URL.

Fixed value https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-GPC-ProblemHeader-Condition-1

extension[actualProblem]

Data type: reference Optionality: Required Cardinality: 0..1

A reference to the profile containing the clinical item that has been escalated to create the Problem.

References may be created to MedicationRequest, AllergyIntolerance, Immunization, Observation - Uncategorised, ReferralRequest, DocumentReference, DiagnosticReport or ProcedureRequest.

extension[relatedProblemHeader]

Data type: extension Optionality: Required Cardinality: 0..*

A complex extension that details the relationship of this ProblemHeader (Condition) profile to another or a number of other ProblemHeader (Condition) profile.

extension[relatedProblemHeader.type]

Data type: code Optionality: Mandatory Cardinality: 1..1

A complex extension that details the type of relationship this ProblemHeader (Condition) profile to another ProblemHeader (Condition) profile.

For each relatedProblemHeader.target the provider MUST supply a value of parent, child or sibling.

extension[relatedProblemHeader.target]

Data type: reference Optionality: Mandatory Cardinality: 1..1

A complex extension that contains a reference to a related ProblemHeader (Condition) profile.

extension[relatedClinicalContent]

Data type:reference Optionality: Required Cardinality: 0..*

Contains references to clinical items and consultations that a user in the sending clinical system has chosen to link to this Problem.

When populating this field the provider system must include every clinical item in the patient record that provides information about the problem and includes:

Clinical items that are directly linked to the problem in the provider system; and
Clinical items that are within a consultation topic that is linked to the problem

When populating this field the provider system must include every consultation where the problem was discussed or information about the problem was recorded. This includes:

consultations that are directly linked to the problem in the provider system; and
consultations that created/updated a clinical item that has been linked to the problem

References may be created to Encounter, MedicationRequest, AllergyIntolerance, Immunization, Observation - Uncategorised, ReferralRequest, DocumentReference, DiagnosticReport or ProcedureRequest.

extension[problemSignificance]

Data type:CodeableConcept Optionality: Mandatory Cardinality: 1..1

The significance of the Problem. All Problems MUST have a severity of major or minor. Where a provider system records more than two levels of severity any level of severity above minor is mapped to major.

identifier

Data type: Identifier Optionality: Mandatory Cardinality: 1..1

This MUST be populated with a globally unique and persistent identifier (that is, it doesn’t change between requests and therefore stored with the source data). This MUST be scoped by a provider specific namespace for the identifier.

There may be more than one identifier where data has been migrated across practices or provider systems and different provider specific identifiers have been assigned.

Where consuming systems are integrating data from this resource to their local system, they MUST also persist this identifier at the same time.

clinicalStatus

Data type: Code Optionality: Mandatory Cardinality: 1..1

All problems MUST have a clinicalStatus of active or inactive.

code

Data type: CodeableConcept Optionality: Mandatory Cardinality: 1..1

The clinical code or text that represents the Problem.

These will be the same values that are held in the FHIR® profile referenced by extension[actualProblem].

subject

Data type: Reference(Patient) Optionality: Mandatory Cardinality: 1..1

A reference to the patient who has, or had, the Problem.

context

Data type: Reference Optionality: Required Cardinality: 0..1

Reference to the encounter where the Problem was initially created.

onset

Data type: dateTime Optionality: Required Cardinality: 0..1

The datetime when the Problem was first encountered.

For example if the patient reported a persistent cough started on the 1st May during a consultation on the 20th May, the onset date would be the 1st May.

abatement

Data type: dateTime Optionality: Required Cardinality: 0..1

The datetime when the Problem was no longer considered active.

assertedDate

Data type: dateTime Optionality: Mandatory Cardinality: 1..1

The datetime that the Problem was recorded on the clinical system.

asserter

Data type: Reference (Practitioner) Optionality: Mandatory Cardinality: 1..1

Reference to the profile for the practitioner who recorded the Problem.

note

Data type: Annotation Optionality: Required Cardinality: 0..*

Notes about the Problem.

Condition elements not in use

The following elements MUST NOT be populated:

severity

Data type: CodeableConcept

verificationStatus

Data type: Boolean

bodysite

Data type: BackboneElement

stage