Diagnosis

A clinical condition, problem, or diagnosis identified in a patient including disease states, injuries, and health concerns. Captures clinical status, verification level, severity, and temporal information about onset and resolution.

Overview

Diagnosis represents any clinical condition affecting a patient, from acute illnesses to chronic diseases to injuries. Each diagnosis is coded (ICD-10, SNOMED-CT), has a clinical status (active, resolved, remission), verification level (provisional, confirmed), and severity. Temporal information tracks onset and resolution. Diagnoses can be categorized as encounter-specific, problem list items for longitudinal tracking, or general health concerns.

Key Concepts

Clinical Status

The clinicalStatus field tracks the condition's current state:

Status	Description	Clinical Meaning
`active`	Currently present	Requires ongoing management
`recurrence`	Returned after resolution	Previous condition has reappeared
`relapse`	Worsening after improvement	Condition deteriorated from remission
`inactive`	Not currently active	Quiescent but not resolved
`remission`	Symptoms diminished	Disease under control, may return
`resolved`	No longer present	Condition has ended

Verification Status

Links to HealthReferenceVerificationStatus:

Unconfirmed - Provisional diagnosis
Provisional - Working diagnosis
Differential - Part of differential
Confirmed - Verified diagnosis
Refuted - Ruled out

Diagnosis Categories

The category field indicates the diagnostic context:

Category	Use Case	Duration
`encounter-diagnosis`	Visit-specific diagnosis	Single encounter
`problem-list-item`	Longitudinal tracking	Ongoing
`health-concern`	Broader health issue	Variable

Diagnostic Coding

The code field uses Coding:

ICD-10 for billing and statistics
ICD-11 for newer implementations
SNOMED-CT for clinical precision
Multiple systems support interoperability

Severity Assessment

Links to HealthReferenceSeverity:

Mild, Moderate, Severe, Life-threatening
Guides treatment intensity
Affects resource allocation
Supports triage decisions

Temporal Information

Multiple onset options:

onsetDateTime - Specific date/time
onsetAge - Patient age at onset
onsetString - Descriptive ("childhood", "2 years ago")

Abatement for resolved conditions:

abatementDateTime - When resolved
abatementAge - Age at resolution

Body Site

The bodySite array links to HealthReferenceBodySite:

Anatomical location of condition
Supports laterality (left/right)
Multiple sites for systemic conditions

Use Cases

New Diagnosis Documentation

When diagnosing a condition:

Code diagnosis with ICD-10/SNOMED-CT
Set clinicalStatus: "active"
Set initial verificationStatus (provisional or confirmed)
Document onsetDateTime or onsetString
Assess and record severity
Specify body site if localized
Link to encounter where diagnosed

Chronic Disease Management

For ongoing conditions:

Set category: "problem-list-item"
Maintain as clinicalStatus: "active"
Update severity as condition evolves
Track with ProblemListItem
Review and update periodically
Document changes in notes

Condition Resolution

When condition resolves:

Update clinicalStatus: "resolved"
Set abatementDateTime
Document resolution in notes
Calculate durationDays for analytics
Update problem list status

Provisional Diagnosis

For unconfirmed conditions:

Create diagnosis with verificationStatus: "provisional"
Document supporting evidence
Order confirmatory testing
Update to confirmed or refuted
Link to DiagnosisEvidence

Differential Diagnosis

When considering multiple possibilities:

Create diagnosis for each possibility
Set verificationStatus: "differential"
Document evidence for/against each
Update as workup progresses
Confirm one, refute others

Related Entities

Entity	Relationship	Description
Patient	References	Subject of diagnosis
Encounter	References	When diagnosis made
Coding	Contains	Diagnostic code
HealthReferenceVerificationStatus	References	Confirmation level
HealthReferenceSeverity	References	Severity assessment
HealthReferenceBodySite	References many	Anatomical location(s)
Practitioner	References	Recorder and asserter
DiagnosisEvidence	Referenced by	Supporting evidence
ProblemListItem	Referenced by	Problem list tracking

Calculated Fields

Field	Type	Description
`isActive`	boolean	True when clinicalStatus is active, recurrence, or relapse
`isResolved`	boolean	True when clinicalStatus is resolved
`durationDays`	number	Days from onset to abatement

Enums

clinicalStatus

Value	Description
`active`	Condition is currently present and requires management
`recurrence`	Condition has returned after previously being resolved
`relapse`	Condition has worsened after a period of improvement
`inactive`	Condition is not currently active but has not resolved
`remission`	Symptoms have diminished, condition under control
`resolved`	Condition is no longer present

Value	Description
`problem-list-item`	Diagnosis tracked on patient's longitudinal problem list
`encounter-diagnosis`	Diagnosis specific to a single healthcare encounter
`health-concern`	Broader health issue or concern being addressed

Properties

Property	Type	Mode	Description	Required
patient	Patient	stored	The patient who has the diagnosis - establishes the primary subject relationship for this clinical condition Example: `"Patient/12345"`	Required
encounter	Encounter	stored	The healthcare encounter during which the diagnosis was made or first documented - links the condition to the specific clinical context of discovery Example: `"Encounter/67890"`	Optional
clinicalStatus	string	stored	The current clinical state of the condition indicating whether it is currently active, in remission, or resolved Values: `active, recurrence, relapse, inactive, remission, resolved` Example: `"active"`	Required
verificationStatus	HealthReferenceVerificationStatus	stored	The confirmation level of the diagnosis ranging from unconfirmed provisional diagnosis to confirmed verified condition or refuted ruled-out diagnosis Example: `"HealthReferenceVerificationStatus/CONFIRMED"`	Optional
category	string	stored	The type or context of the diagnosis classification - whether it is a problem list item for longitudinal tracking, an encounter-specific diagnosis, or a broader health concern Values: `problem-list-item, encounter-diagnosis, health-concern` Example: `"encounter-diagnosis"`	Optional
severity	HealthReferenceSeverity	stored	The assessed severity level of the condition ranging from mild to life-threatening - critical for clinical prioritization and treatment planning Example: `"HealthReferenceSeverity/MODERATE"`	Optional
code	Coding	stored	The standardized diagnostic code identifying the specific condition using terminologies such as ICD-10, ICD-11, or SNOMED-CT - enables consistent clinical documentation and data exchange Example: `"Coding/ICD10-J18.9"`	Required
bodySite	HealthReferenceBodySite[]	stored	The anatomical location or locations where the condition is present - supports precise localization for conditions affecting specific body regions or organs Example: `["HealthReferenceBodySite/LUNG_LEFT","HealthReferenceBodySite/LUNG_RIGHT"]`	Optional
onsetDateTime	DateTime	stored	The date and time when the condition first began or was first noticed - provides temporal context for disease onset Example: `"2024-01-15T08:30:00Z"`	Optional
onsetAge	number	stored	The age of the patient when the condition began - useful for age-dependent conditions and epidemiological analysis Example: `45`	Optional
onsetString	string	stored	A textual description of when the condition began when exact dates are unknown - allows for qualitative temporal expressions like 'childhood' or 'approximately 2 years ago' Example: `"Approximately 3 weeks ago"`	Optional
abatementDateTime	DateTime	stored	The date and time when the condition resolved or went into remission - marks the clinical endpoint of the active disease state Example: `"2024-02-01T14:00:00Z"`	Optional
abatementAge	number	stored	The age of the patient when the condition resolved - tracks resolution timing for age-related analysis Example: `45`	Optional
recordedDate	DateTime	stored	The date when the diagnosis was first recorded in the system - establishes the documentation timeline independent of onset Example: `"2024-01-15T10:00:00Z"`	Required
recorder	Practitioner	stored	The healthcare practitioner who documented the diagnosis in the medical record - tracks documentation responsibility Example: `"Practitioner/doc-smith"`	Optional
asserter	Practitioner	stored	The healthcare practitioner who clinically asserted or confirmed the diagnosis - may differ from the recorder, identifying the clinical authority behind the diagnosis Example: `"Practitioner/dr-jones"`	Optional
note	string	stored	Additional clinical notes, context, or observations about the diagnosis - captures free-text information not represented in structured fields Example: `"Patient reports worsening symptoms in cold weather. Family history of similar condition."`	Optional
isActive	boolean	calculated	Computed flag indicating whether the condition is currently clinically active - true when clinicalStatus is active, recurrence, or relapse	Optional
isResolved	boolean	calculated	Computed flag indicating whether the condition has been resolved - true when clinicalStatus is resolved	Optional
durationDays	number	calculated	Calculated number of days from onset to abatement - provides quantitative measure of condition duration when both onset and abatement dates are available	Optional

Examples

Example 1

{
  "@type": "Diagnosis",
  "patient": "Patient/p-12345",
  "encounter": "Encounter/enc-67890",
  "clinicalStatus": "active",
  "verificationStatus": "HealthReferenceVerificationStatus/CONFIRMED",
  "category": "encounter-diagnosis",
  "severity": "HealthReferenceSeverity/MODERATE",
  "code": {
    "@type": "Coding",
    "code": "J18.9",
    "system": "ICD-10",
    "display": "Pneumonia, unspecified organism"
  },
  "bodySite": [
    {
      "@type": "HealthReferenceBodySite",
      "code": "LUNG_LEFT",
      "label": "Left Lung"
    }
  ],
  "onsetDateTime": "2024-01-10T00:00:00Z",
  "recordedDate": "2024-01-12T09:30:00Z",
  "recorder": "Practitioner/dr-williams",
  "asserter": "Practitioner/dr-williams",
  "note": "Acute onset with fever and productive cough. Chest X-ray shows left lower lobe infiltrate.",
  "_comment": "isActive: true, isResolved: false"
}

Example 2

{
  "@type": "Diagnosis",
  "patient": "Patient/p-23456",
  "encounter": "Encounter/enc-78901",
  "clinicalStatus": "active",
  "verificationStatus": "HealthReferenceVerificationStatus/CONFIRMED",
  "category": "problem-list-item",
  "severity": "HealthReferenceSeverity/HIGH",
  "code": {
    "@type": "Coding",
    "code": "E11.9",
    "system": "ICD-10",
    "display": "Type 2 diabetes mellitus without complications"
  },
  "onsetAge": 52,
  "onsetString": "Diagnosed approximately 8 years ago",
  "recordedDate": "2016-03-15T00:00:00Z",
  "recorder": "Practitioner/dr-garcia",
  "asserter": "Practitioner/dr-garcia",
  "note": "Well-controlled on metformin. Regular HbA1c monitoring shows good glycemic control. Patient follows dietary guidelines.",
  "_comment": "isActive: true, isResolved: false, chronic condition with no abatement"
}

Example 3

{
  "@type": "Diagnosis",
  "patient": "Patient/p-34567",
  "encounter": "Encounter/enc-89012",
  "clinicalStatus": "resolved",
  "verificationStatus": "HealthReferenceVerificationStatus/CONFIRMED",
  "category": "encounter-diagnosis",
  "severity": "HealthReferenceSeverity/MODERATE",
  "code": {
    "@type": "Coding",
    "code": "S52.501A",
    "system": "ICD-10",
    "display": "Unspecified fracture of the lower end of right radius, initial encounter"
  },
  "bodySite": [
    {
      "@type": "HealthReferenceBodySite",
      "code": "WRIST_RIGHT",
      "label": "Right Wrist"
    }
  ],
  "onsetDateTime": "2023-11-05T14:30:00Z",
  "abatementDateTime": "2024-01-20T00:00:00Z",
  "recordedDate": "2023-11-05T16:00:00Z",
  "recorder": "Practitioner/dr-ortho",
  "asserter": "Practitioner/dr-ortho",
  "note": "Closed fracture from fall. Treated with cast immobilization for 6 weeks. Follow-up X-rays show complete healing with good alignment.",
  "_comment": "isActive: false, isResolved: true, durationDays: 76"
}

Example 4

{
  "@type": "Diagnosis",
  "patient": "Patient/p-45678",
  "encounter": "Encounter/enc-90123",
  "clinicalStatus": "active",
  "verificationStatus": "HealthReferenceVerificationStatus/PROVISIONAL",
  "category": "encounter-diagnosis",
  "code": {
    "@type": "Coding",
    "code": "R07.9",
    "system": "ICD-10",
    "display": "Chest pain, unspecified"
  },
  "bodySite": [
    {
      "@type": "HealthReferenceBodySite",
      "code": "CHEST",
      "label": "Chest"
    }
  ],
  "onsetDateTime": "2024-01-28T06:00:00Z",
  "recordedDate": "2024-01-28T11:45:00Z",
  "recorder": "Practitioner/dr-emergency",
  "note": "Patient presents with chest pain. Cardiac enzymes pending. EKG shows no acute changes. Awaiting stress test for further evaluation. Currently under observation.",
  "_comment": "isActive: true, isResolved: false, provisional diagnosis pending confirmation"
}