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Condition/Diagnosis/Problem (QDM)
Revision as of 13:49, 9 April 2018 by FEisenberg (talk | contribs)
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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.
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).
Contents
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 |