Condition Resource clinicalStatus and verificationStatus requirements

Question

I am extracting entities from unstructured medical data. The entities are then standardized to a standard code such as SNOMED CT or LOINC. Once standardized these standard codes are sent via FHIR R4 to a receiving entity.

I am having a very difficult time confidently extracting the clinical status. My understanding is that if Condition.verificationStatus is anything other than "entered-in-error" I must populate Condition.clinicalStatus.

My question is, can I simply not return Condition.clinicalStatus and Condition.verificationStatus? They both have cardinalities of 0..1. What I'm not certain of is if I populate a Condition.code am I required to populate Condition.clinicalStatus and Condition.verificationStatus?

Thank you, ajohn1121

I read HL7 - R4 Condition Resource. I was hoping to find my answer but didn't.

Answer 1

can I simply not return Condition.clinicalStatus and Condition.verificationStatus?

Sure, if you are intending to create base R4 resources only, then Conditions without either of those elements populated are technically valid. However, the more important question is whether the receiving entity needs one or both of those elements to be populated in order to derive value from the information you are sending. It may be content with just knowing the patient and diagnosis code, or it may need to know the clinicalStatus and verificationStatus in order to utilize the data effectively.

Similarly, you should consider whether base R4 resources are sufficient or if you need to be conforming to a specific profile defined in an implementation guide. For example, if you need resources that conform to the International Patient Summary Implementation Guide, then clinicalStatus must be populated on each profiled Condition resource.

My understanding is that if Condition.verificationStatus is anything other than "entered-in-error" I must populate Condition.clinicalStatus.

This is true for a base R4 Condition but only for ones with a category of problem-list-item. This invariant may not apply if you are working with a particular Implementation Guide