Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).
A statement that asserts the value of a property (observable) of the subject. The subject is often the patient, but may be a condition, a physical structure, or another clinical statement. For example, an interpretation is a finding about an observation.
The time the data element was entered into the clinical software. Note, some datatypes include both Relevant Time and Author dateTime attributes. The purpose is to accommodate Author dateTime if the actual start and stop times are not available when evaluating for feasibility, and also to allow specification of a time for Negation Rationale.
DataTypeCardinalityPrevalance Period is the time from onset dateTime to abatement dateTime.
DataTypeCardinalityThe anatomical site or structure where the diagnosis/problem manifests itself (a). The anatomical site or structure where that is the focus of the action represented by the datatype (b).
DataTypeCardinality