CDA On FHIR England - End of Life Care Document

COFE-Diagnosis-Condition-1

This diagnosis resource details information about conditions, problems or diagnoses.

NameCard.TypeDescription & Constraints
..ConditionConditionDetailed information about conditions, problems or diagnoses

...Diagnosis Awareness0..*ExtensionIndicates if the patient is aware of the diagnosis given.
Extension http://fhir.nhs.net/StructureDefinition/extension-cofe-diagnosisawareness-1

...identifier1..1IdentifierExternal Ids for this condition

....value1..1StringA UUID which is an identifier for the diagnosis condition
Example Value 98d29b5a-da2b-4f48-99b8-53924642c9fd

...patient1..1Reference (cofe-patient-1)Who has the condition?

....reference1..1StringRelative URL reference

....display0..1StringText alternative for the resource

...encounter0..1Reference (cofe-encounter-1)Encounter when condition first asserted

....reference1..1StringRelative URL reference

....display0..1StringText alternative for the resource

...asserter0..1Reference (cofe-practitioner-1)Person who asserts this condition

...dateRecorded0..1DateTime the diagnosis was valid

...code1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding A Snomed subset that describes a diagnosis. (http://fhir.nhs.net/ValueSet/diagnosis-type-snct-1)
Binding Strength Required

....coding1..1CodingCode defined by a terminology system
Binding A Snomed subset that describes a diagnosis (http://fhir.nhs.net/ValueSet/diagnosis-type-snct-1)
Binding Strength Required

.....system1..1UriIdentity of the terminology system
Fixed Value http://snomed.info/sct

.....code1..1CodeSymbol in syntax defined by the system
Binding A Snomed subset that describes a diagnosis (http://fhir.nhs.net/ValueSet/diagnosis-type-snct-1)
Binding Strength Required
Example Value 405843009 | : 106229004 | = 8319008

.....display1..1StringRepresentation defined by the system
Example Value 405843009 | Widespread metastatic malignant neoplastic disease | : 106229004 | Qualifier for type of diagnosis | = 8319008 | Principal diagnosis |

....text0..1StringPlain text representation of the concept

...category1..1CodeableConceptcomplaint | symptom | finding | diagnosis
Binding A category assigned to the condition. (http://hl7.org/fhir/ValueSet/condition-category)
Binding Strength Required

....coding1..1CodingCode defined by a terminology system

.....system1..1UriIdentity of the terminology system
Fixed Value http://hl7.org/fhir/ValueSet/condition-category

.....code1..1CodeSymbol in syntax defined by the system
Fixed Value diagnosis

.....display1..1StringRepresentation defined by the system
Fixed Value Diagnosis

...verificationStatus1..1Codeprovisional | differential | confirmed | refuted | entered-in-error | unknown
Binding The verification status to support or decline the clinical status of the condition or diagnosis. (http://hl7.org/fhir/ValueSet/condition-ver-status)
Binding Strength Required

...onset[x]Estimated or actual date, date-time, or age
Slice: Ordering: Ordered, Rules: Open

...stage0..1BackboneElementStage/grade, usually assessed formally

....summary1..1CodeableConceptSimple summary (disease specific)
Binding Codes describing condition stages (e.g. Cancer stages). (http://hl7.org/fhir/ValueSet/condition-stage)
Binding Strength Example

.....text1..1StringText to describe the stage of a diagnosis.

...notes0..1StringAdditional information about the Condition

Name Type Description & Constraints
. . Extension-COFE-DiagnosisAwareness-1 Extension Indicates if the patient is aware of the diagnosis given.
. . iso21090-nullFlavor Extension An extension to represent a nullFlavor
Path Name Binding Strength ValueSet
.Condition.code code Required http://fhir.nhs.net/ValueSet/diagnosis-type-snct-1
.Condition.code.coding coding Required http://fhir.nhs.net/ValueSet/diagnosis-type-snct-1
.Condition.category category Required http://hl7.org/fhir/ValueSet/condition-category
.Condition.stage.summary summary Example http://hl7.org/fhir/ValueSet/condition-stage

COFE-Diagnosis-Condition-1

Examples Description XML File JSON File
COFE-Diagnosis-Condition-1-Example-1 Example message for end of life principal diagnoses
COFE-Diagnosis-Condition-1-Example-2 Example message for end of life secondary diagnoses