C.38 - EHDS refined base model for Condition HDR

Condition identifier

Indicates the patient or group who the condition record is associated with.

Condition specification in narrative form

Code identifying the condition, problem or diagnosis

ICD-10*, SNOMED CT, Orphacode if rare disease is diagnosed

Onset date of a problem/condition

The date or estimated date that the condition resolved or went into remission.

Category or categories of the problem.

Status of the condition/problem (active, resolved, inactive, ...)

HL7 Condition-clinical

This field includes free text if the resolution circumstances are not already included in other fields such as surgical procedure, medical device, etc., e.g. hepatic cystectomy (this will be the resolution circumstances for the problem "hepatic cyst" and will be included in surgical procedures).

A subjective assessment of the severity of the condition as evaluated by the clinician.

HL7 Condition-severity

The anatomical location including laterality where this condition manifests itself.

SNOMED CT

Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.

e.g. TNM, ICD-O-3, Bi-Rads, Li-Rads, …

Assertion about the certainty associated with a diagnosis. Diagnostic and/or clinical evidence of condition.

HL7 Condition-ver-status

The asserter of the condition

Date and time of the diagnosis assertion

Category of the problem allows flagging for conditions acquired during hospital stay.-   Present on admission [POA])-   Hospital acquired condition [HAC]'- Not applicable or unknown

Class of the problem (treated, other) in relation to the hospital encounter. Treated problems were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the hospital encounter. At least one problem should be marked as Treated. Other problems are recorded only if they are important for continuity of care (after discharge).

C.38 - EHDS refined base model for Condition HDR

Category of the problem allows flagging for conditions acquired during hospital stay.-   Present on admission [POA])-   Hospital acquired condition [HAC]'- Not applicable or unknown

Class of the problem (treated, other) in relation to the hospital encounter. Treated problems were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the hospital encounter. At least one problem should be marked as Treated. Other problems are recorded only if they are important for continuity of care (after discharge).

C.38 - EHDS refined base model for Condition HDR

Condition identifier

Indicates the patient or group who the condition record is associated with.

Condition specification in narrative form

Code identifying the condition, problem or diagnosis

ICD-10*, SNOMED CT, Orphacode if rare disease is diagnosed

Onset date of a problem/condition

The date or estimated date that the condition resolved or went into remission.

Category or categories of the problem.

Status of the condition/problem (active, resolved, inactive, ...)

HL7 Condition-clinical

This field includes free text if the resolution circumstances are not already included in other fields such as surgical procedure, medical device, etc., e.g. hepatic cystectomy (this will be the resolution circumstances for the problem "hepatic cyst" and will be included in surgical procedures).

A subjective assessment of the severity of the condition as evaluated by the clinician.

HL7 Condition-severity

The anatomical location including laterality where this condition manifests itself.

SNOMED CT

Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.

e.g. TNM, ICD-O-3, Bi-Rads, Li-Rads, …

Assertion about the certainty associated with a diagnosis. Diagnostic and/or clinical evidence of condition.

HL7 Condition-ver-status

The asserter of the condition

Date and time of the diagnosis assertion

Category of the problem allows flagging for conditions acquired during hospital stay.-   Present on admission [POA])-   Hospital acquired condition [HAC]'- Not applicable or unknown

Class of the problem (treated, other) in relation to the hospital encounter. Treated problems were treated or affected provisioning of care (diagnostics, therapy, nursing, monitoring) during the hospital encounter. At least one problem should be marked as Treated. Other problems are recorded only if they are important for continuity of care (after discharge).