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Diagnoses Section

Gives information about the Diagnoses section

Diagnoses Section Content

The Diagnoses section carries information about Diagnoses. PRSB Elements should be formatted as subheadings in any HTML sent.

Section Description Card. MRO* FHIR Target and Guidance
Diagnoses A list of the patient's diagnoses. 1 only M Carried in the CodeableConcept of Composition.section.code FHIR element.
PRSB Element Description Card. MRO* FHIR Target and Guidance
Diagnosis name Confirmed diagnosis (or symptom); active diagnosis being treated. 1 only M Text and if available a SNOMED CT concept carried in the CodeableConcept of the Condition.code FHIR element. See Constructing Diagnosis Lists (Diagnosis code) for further guidance.
Stage Stage of the disease, where relevant 0 to 1 O Text and if available a SNOMED CT concept carried in the CodeableConcept of the Condition.stage.summary (using the CodeableContext text to hold the stage of disease text)
Comment Supporting text may be given covering diagnosis confirmation, active diagnosis being treated. 0 to 1 O Free text. Supporting text may be given covering diagnosis confirmation, active diagnosis being treated. The section text should be repeated in the text of the Condition.note FHIR element to record Free differential and excluded diagnosis.
* M=Mandatory R=Required O=Optional

Example Diagnoses Section

This section example includes a reference to a coded diagnosis.

Coded Resources

This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.

  • Condition

See constructing clinical coded structures - Condition

Tags: fhir

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