Condition ProblemHeader resource

Guidance for populating and consuming the ProblemHeader resource

Introduction

The headings below list the elements of the Immunization resource and describe how to populate and consume them.

Important: Any element not specifically listed below MUST NOT be populated or consumed. A full list of elements not used is available here.

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

Condition - problem header elements

id

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

The logical identifier of the ProblemHeader resource.

meta.profile

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

The ProblemHeader 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 resource containing the clinical item that has been escalated to create the problem.

References may be created to MedicationRequest, AllergyIntolerance, Immunization, Observation - Uncategorised.

extension[relatedProblemHeader]

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

A complex extension that details the relationship of this problem header resources to another or a number of other problem header resources.

extension[relatedProblemHeader.type]

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

A complex extension that details the type of relationship this problem header resources to another problem header resources.

For each relatedProblemHeader.target the provider MUST supply a value of Parent, Childor Sibling.

extension[relatedProblemHeader.target]

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

A complex extension that contains a reference to a related problem header resource.

extension[relatedClinicalContent]

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

References to other resources that a user in the sending clinical system has chosen to link to this problem header resource.

When populating this field the provider system must include every 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

References may be created to MedicationRequest, AllergyIntolerance, Immunization, Observation - Uncategorised.

extension[problemSignificance]

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

The significance of the problem contained in the resource. 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 is for business identifiers.

This is sliced to include a cross-care setting identifier which MUST be populated. The codeSystem for this identifier is https://fhir.nhs.uk/Id/cross-care-setting-identifier.

This MUST be a GUID.

Providing systems MUST ensure this GUID is globally unique and a persistent identifier (that is, it doesn’t change between requests and therefore stored with the source data).

Where consuming systems are integrating data from this resource to their local system, they MUST also persist this GUID 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: CodableConcept Optionality: Mandatory Cardinality: 1..1

The clinical code or text that represents the problem header.

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

subject

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

A reference to the patient who has, or had, the allergy or intolerance specified.

context

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

References to encounters that a user in the sending clinical system has chosen to link to this problem header resource.

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

onset

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

The datetime when the problem was first encountered.

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 resource for the practitioner who recorded the problem.

note

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

Notes about the problem.

Elements not in use

The following elements MUST NOT be populated:

severity

Data type: CodeableConcept

verificationStatus

Data type: Boolean

bodysite

Data type: BackboneElement

stage