Case Based Surveillance Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions
Resource Profile: Case Based Surveillance Condition of Interest Profile
| Defining URL: | http://cbsig.chai.gatech.edu/StructureDefinition/cbs-condition |
| Version: | 0.1.0 |
| Name: | CaseBasedSurveillanceCondition |
| Title: | Case Based Surveillance Condition of Interest Profile |
| Status: | Experimental as of 1/1/21 |
| Definition: | Defines constraints and extensions to the Condition resource in order to meet the needs of public health surveillance programs while providing as much alignment with US Core requirements as possible. |
| Publisher: | Georgia Tech Research Institute (GTRI) |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://cbsig.chai.gatech.edu/StructureDefinition/cbs-condition
The Case Based Surveillance (CBS) Condition of Interest is the core condition by which filtering to programs should occur. To support workflows that are concerned with surveilling additional conditions that are not the condition of interest, the base Condition resource should be used. This means there SHALL only be one (1) Condition of Interest profile.
Mandatory and Must Support Data Elements
The following data-elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements. The “Snapshot Table (Must Support)” tab below displays all the mandatory and must support data elements for this profile.
Each Condition must have:
- a case class status extension
- a code from the Nationally Notifiable Disease Surveillance System (NNDSS) & Other Conditions of Public Health Importance value set
- a patient that conforms to the CBS Patient Profile
Each Condition must support:
- a diagnosis date extension to support reporting of the condition of interest diagnosis date for the patient
- an illness duration extension to support reporting of the illness duration
- a clinical status (which SHALL exist if an abatement datetime exists)
- a body site to support reporting of conditions where a body site is applicable
- an onset datetime
- an abatement datetime
- evidence to support signs and symptoms reporting
Representing Evidence
The representation of signs, symptoms, or manifestations of a condition of interest can be handled using the Condition.evidence element in this profile using either an embedded representation through a codeable concept or with a reference to a separate resource. The following rules apply.
- Condition.evidence.code and Condition.evidence.reference may exist simultaneously.
- For each evidence, either the code or reference element shall exist.
- References shall not be to another Condition of Interest profile. There shall be only one instance of the Condition of Interest profile in a case report. There are no restrictions on other profiles should the evidence be able to meet the requirements for that profile other than that the profile shall be understood by the receiving system. (The base Condition resource is recommended for this reason.)
- Each evidence shall relate directly to a sign, symptom, or manifestation related to either the verification of the condition reported through this profile or to a particular request by a case based surveillance program.
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Condition
This structure is derived from Condition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Condition | I | 0..* | Condition | Detailed information about conditions, problems or diagnoses |
  id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
 cbs-diagnosis-date | S | 0..1 | dateTime | Case Based Surveillance Diagnosis Date Extension URL: http://cbsig.chai.gatech.edu/StructureDefinition/cbs-diagnosis-date |
| cbs-case-class-status | S | 1..1 | CodeableConcept | Case Based Surveillance Case Class Status URL: http://cbsig.chai.gatech.edu/StructureDefinition/cbs-case-class-status Binding: Case Classification Status (required): A code indicating the case class status. |
| cbs-illness-duration | S | 0..1 | Quantity | Case Based Surveillance Illness Duration URL: http://cbsig.chai.gatech.edu/StructureDefinition/cbs-illness-duration |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External Ids for this condition |
| clinicalStatus | ?!SΣI | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. |
| verificationStatus | ?!ΣI | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. |
| 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 | Identification of the condition, problem or diagnosis Binding: Nationally Notifiable Disease Surveillance System (NNDSS) & Other Conditions of Public Health Importance (required) |
| bodySite | SΣ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body site (extensible) |
 subject | SΣ | 1..1 | Reference(Case Based Surveillance Patient Profile) | Who has the condition? |
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of |
  Slices for onset[x] | Σ | 0..1 | dateTime | Estimated or actual date, date-time, or age Slice: Unordered, Closed by type:$this |
  onset[x]:onsetDateTime | SΣ | 0..1 | dateTime | Estimated or actual date, date-time, or age |
| Slices for abatement[x] | I | 0..1 | dateTime | When in resolution/remission Slice: Unordered, Closed by type:$this |
| abatement[x]:abatementDateTime | SI | 0..1 | dateTime | When in resolution/remission |
| 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 | I | 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 | I | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). |
| assessment | I | 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 | SI | 0..* | BackboneElement | Signs and Symptoms of the Condition of Interest |
| 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 | ΣI | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. |
| detail | ΣI | 0..* | Reference(Resource) | Supporting information found elsewhere |
| note | 0..* | Annotation | Additional information about the Condition | |
| Documentation for this format | ||||
This structure is derived from Condition
Differential View
This structure is derived from Condition
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Condition | I | 0..* | Condition | Detailed information about conditions, problems or diagnoses |
| id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| cbs-diagnosis-date | S | 0..1 | dateTime | Case Based Surveillance Diagnosis Date Extension URL: http://cbsig.chai.gatech.edu/StructureDefinition/cbs-diagnosis-date |
| cbs-case-class-status | S | 1..1 | CodeableConcept | Case Based Surveillance Case Class Status URL: http://cbsig.chai.gatech.edu/StructureDefinition/cbs-case-class-status Binding: Case Classification Status (required): A code indicating the case class status. |
| cbs-illness-duration | S | 0..1 | Quantity | Case Based Surveillance Illness Duration URL: http://cbsig.chai.gatech.edu/StructureDefinition/cbs-illness-duration |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External Ids for this condition |
| clinicalStatus | ?!SΣI | 0..1 | CodeableConcept | active | recurrence | relapse | inactive | remission | resolved Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. |
| verificationStatus | ?!ΣI | 0..1 | CodeableConcept | unconfirmed | provisional | differential | confirmed | refuted | entered-in-error Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. |
| 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 | Identification of the condition, problem or diagnosis Binding: Nationally Notifiable Disease Surveillance System (NNDSS) & Other Conditions of Public Health Importance (required) |
| bodySite | SΣ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: Body site (extensible) |
| subject | SΣ | 1..1 | Reference(Case Based Surveillance Patient Profile) | Who has the condition? |
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of |
| Slices for onset[x] | Σ | 0..1 | dateTime | Estimated or actual date, date-time, or age Slice: Unordered, Closed by type:$this |
| onset[x]:onsetDateTime | SΣ | 0..1 | dateTime | Estimated or actual date, date-time, or age |
| Slices for abatement[x] | I | 0..1 | dateTime | When in resolution/remission Slice: Unordered, Closed by type:$this |
| abatement[x]:abatementDateTime | SI | 0..1 | dateTime | When in resolution/remission |
| 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 | I | 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 | I | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). |
| assessment | I | 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 | SI | 0..* | BackboneElement | Signs and Symptoms of the Condition of Interest |
| 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 | ΣI | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. |
| detail | ΣI | 0..* | Reference(Resource) | Supporting information found elsewhere |
| note | 0..* | Annotation | Additional information about the Condition | |
| Documentation for this format | ||||
Other representations of profile: CSV, Excel, Schematron
Terminology Bindings
| Path | Conformance | ValueSet |
| Condition.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Condition.clinicalStatus | required | ConditionClinicalStatusCodes |
| Condition.verificationStatus | required | ConditionVerificationStatus |
| Condition.category | extensible | ConditionCategoryCodes |
| Condition.severity | preferred | Condition/DiagnosisSeverity |
| Condition.code | required | PHVS_NotifiableEvent_Disease_Condition_CDC_NNDSS |
| Condition.bodySite | extensible | PHVS_BodySite_CDC |
| Condition.stage.summary | example | ConditionStage |
| Condition.stage.type | example | ConditionStageType |
| Condition.evidence.code | example | ManifestationAndSymptomCodes |
Constraints
| Id | Grade | Path | Details | Requirements |
| con-3 | Best Practice | Condition | Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item : clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty() | |
| con-4 | error | Condition | If condition is abated, then clinicalStatus must be either inactive, resolved, or remission : abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists() | |
| con-5 | error | Condition | Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error : verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty() | |
| dom-2 | error | Condition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Condition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Condition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | Best Practice | Condition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | Condition.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Condition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Condition.extension:diagnosis-date | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Condition.extension:diagnosis-date | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Condition.extension:case-class-status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Condition.extension:case-class-status | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Condition.extension:illness-duration | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Condition.extension:illness-duration | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Condition.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Condition.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Condition.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.clinicalStatus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.verificationStatus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.severity | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.bodySite | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.onset[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.onset[x]:onsetDateTime | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.abatement[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.abatement[x]:abatementDateTime | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.recordedDate | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.recorder | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.asserter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| con-1 | error | Condition.stage | Stage SHALL have summary or assessment : summary.exists() or assessment.exists() | |
| ele-1 | error | Condition.stage | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.stage.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Condition.stage.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Condition.stage.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Condition.stage.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Condition.stage.summary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.stage.assessment | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.stage.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| con-2 | error | Condition.evidence | evidence SHALL have code or details : code.exists() or detail.exists() | |
| ele-1 | error | Condition.evidence | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.evidence.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Condition.evidence.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Condition.evidence.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | Condition.evidence.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | Condition.evidence.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.evidence.detail | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | Condition.note | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |