Schema: ProblemHeader (Condition)

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 will 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

The logical identifier of the ProblemHeader (Condition) profile.

meta. profile

The ProblemHeader (Condition) profile URL.

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

extension[actualProblem]

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, DiagnosticReport or ProcedureRequest.

extension[relatedProblemHeader]

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]

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

For each relatedProblemHeader.target Medicus will supply a value of parent, child or sibling.

extension[relatedProblemHeader.target]

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

extension[relatedClinicalContent]

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 Medicus system will 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 Medicus system; and

• Clinical items that are within a consultation topic that is linked to the problem

When populating this field Medicus system will 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 Medicus 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, DiagnosticReport or ProcedureRequest.

extension[problemSignificance]

The significance of the Problem. All Problems will have a severity of major or minor.

identifier

This will be populated with a globally unique and persistent identifier (that is, it doesn’t change between requests and therefore stored with the source data).

clinicalStatus

All problems will have a clinicalStatus of active or inactive.

category

Fixed value of problem-list-item.

code

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

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

context

Reference to the encounter where the Problem was initially created.

onset

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

The datetime when the Problem was no longer considered active.

assertedDate

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

asserter

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

note

Notes about the Problem.