Clinical Resources

Diagnosis

Overview

The Diagnosis section captures medical conditions that have been identified, assessed, or treated for the patient.

Structuring this information enables accurate clinical decision-making, treatment planning, and seamless exchange with other healthcare systems.

Clinical Data in Source Documents

Diagnoses are typically documented in sections such as Assessment/Plan, Problem List, or Impression within clinical records (PDFs or C-CDAs).

They may appear as:

• Problem Lists summarizing active and historical conditions.
• Narrative Plans detailing provider assessments, treatment recommendations, and follow-up actions.
• Supporting Notes that include lab results, medication adjustments, or evaluation summaries.

JSON Output

After processing, the platform extracts and organizes diagnoses into a standardized structure.

Each diagnosis record includes:

• Name: The clinical name of the condition.
• Description: Context or narrative describing the condition, such as lab values or disease progression.
• Clinical Context (MEAT): Notes capturing Monitoring, Evaluation, Assessment, and Treatment, which help identify whether the condition is active, stable, or resolved.
• Section Reference: Indicates the originating document section to provide clinical context.

This structure ensures not only the identification of the condition but also insight into its status and supporting details.

{
  "diagnoses": [
    {
      "name": "COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)",
      "description": "COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE) (J44.9)",
      "meat": "Moderate obstruction on PFT; on supplemental 02",
      "section_header": "Diagnosis",
      "page_number": 3
    }
  ]
}

FHIR Output

The extracted diagnoses are transformed into a FHIR Condition resource to support interoperability with EHRs and healthcare applications.

Key mappings include:

• Condition Name & Description → Condition.code.text - Stores the primary diagnosis term or description.
• Clinical Status → Condition.clinicalStatus - Reflects whether the condition is active, inactive, or resolved.
• Verification Status → Condition.verificationStatus - Indicates confirmation level (e.g., confirmed, unconfirmed).
• Section Context → Condition.category - Specifies the document category such as encounter-diagnosis or problem-list-item .
• Patient Reference → Condition.subject - Links the diagnosis to the associated patient record.
• Encounter Reference → Condition.encounter - Connects the diagnosis to the clinical encounter in which it was recorded.

{
  "fullUrl": "urn:uuid:688ebe3c-9faa-4d1a-98b7-fbcd7b500346",
  "resource": {
    "resourceType": "Condition",
    "id": "688ebe3c-9faa-4d1a-98b7-fbcd7b500346",
    "clinicalStatus": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
          "code": "active"
        }
      ]
    },
    "verificationStatus": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
          "code": "confirmed"
        }
      ]
    },
    "category": [
      {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/condition-category",
            "code": "encounter-diagnosis"
          }
        ]
      }
    ],
    "code": {
      "text": "COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)"
    },
    "subject": {
      "reference": "Patient/b17aaab1-311c-4d98-9c93-030277d0aeb0"
    },
    "encounter": {
      "reference": "Encounter/714b97f7-c3f0-4b5b-8338-0f86d6978dc2"
    },
    "note": [
      {
        "text": "Moderate obstruction on PFT; on supplemental 02"
      }
    ]
  }
}