Condition/Diagnosis/Problem (QDM)

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This QDM to QI Core Mapping for the QDM Datatype "Diagnosis" was updated 3 April 2018 based on discussion in the CQI WG on March 30, 2018. Posted 9 April 2018.

QDM defines Condition/Diagnosis/Problem as 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).

Condition/Diagnosis/Problem

QDM Attribute	QI Core Metadata Element	Comment
Diagnosis	Condition (the .clinicalstatus metadata allows conformance to the specific QDM datatype context)	QDM defaults the status to active and prevalence period provides the evidence of activity.
Prevalence Period	Condition.onset[x], OR Condition.asserted	Use whichever is the earlier date. QDM matched to QI Core / FHIR for start of Prevalence Period
	Condition.abatement[x]	QDM matched to QI Core / FHIR for end of Prevalence Period
Anatomical Location Site	Condition.bodySite	QDM matched to QI Core / FHIR
Severity	Condition.severity	QDM matched to QI Core / FHIR
Code	Condition.code	QDM matched to QI Core / FHIR
Author dateTime	FHIR Provenance.recorded	FHIR provenance addressed author time, Condition.assertedDate may be closer to the onset of the QDM Prevalence Period. Consider - the software may default assertedDate to the date entered requiring manual editing to enter a different date. Further, does it reflect the date the assertion is made or the date the patient asserted that the condition began? Seeking guidance - due to potential ambiguity, should QDM map to FHIR provenance?
id	Condition.id	QDM matched to QI Core / FHIR
Source	Condition.asserter	QDM matched to QI Core / FHIR