Vital Records Birth and Fetal Death Reporting
0.1.0 - STU 1 Ballot
Vital Records Birth and Fetal Death Reporting
0.1.0 - STU 1 Ballot
This page is part of the Vital Records Birth and Fetal Death Reporting (v0.1.0: STU 1 on FHIR R4 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
| Defining URL: | http://hl7.org/fhir/us/bfdr/StructureDefinition/Composition-provider-facility-live-birth-report |
| Version: | 0.1.0 |
| Name: | CompositionProviderFacilityLiveBirthReport |
| Title: | Composition - Provider Facility Live Birth Report |
| Status: | Active as of 2020-12-16T19:12:11+00:00 |
| Definition: | This Composition profile defines constraints to address the use case in which information for labor and delivery and the condition of the newborn collected by healthcare provider staff, as primarily defined using the Facility Worksheet, is managed independently for communication to the jurisdictional Vital Records Office. |
| Publisher: | HL7 International - Public Health Work Group |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/us/bfdr/StructureDefinition/Composition-provider-facility-live-birth-report
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
Summary
Mandatory: 1 element
Must-Support: 32 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Composition | This composition represents the provider supplied facility live birth report. | |
  extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
 Extension-birth-certificate-id | 0..1 | Identifier | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-birth-certificate-id | |
| Extension-birth-certificate-file-number | 0..1 | Identifier | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-birth-certificate-file-number | |
  type | 1..1 | CodeableConcept | Provider supplied facility live birth report Document Required Pattern: At least the following | |
   coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92020-7 | |
 subject | 1..1 | Reference(Patient - Child) | The subject of the composition is the newborn baby | |
| encounter | S | 0..1 | Reference(Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. |
 section | 0..* | (Slice Definition) | The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Slice: Unordered, Open by pattern:code | |
 section:motherPrenatal | S | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate |
  code | 0..1 | CodeableConcept | Prenatal records Required Pattern: At least the following | |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57073-9 | |
 focus | 0..1 | Reference(Patient - Mother) | The focus of this section is the mother | |
 entry | 0..* | (Slice Definition) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() | |
 entry:plannedToDeliverAtHome | S | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit | S | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits | S | 0..1 | Reference(Observation - Number of Prenatal Visits) | Number of prenatal care visits |
| entry:dateLastNormalMenses | S | 0..1 | Reference(Observation - Last Menstrual Period) | Date last normal menses began |
| entry:numberNowLiving | S | 0..1 | Reference(Observation - Number of Births Now Living) | Number of previous live births now living |
| entry:numberNowDead | S | 0..1 | Reference(Observation - Number of Births Now Dead) | Number of previous live births now dead |
| entry:dateLastLiveBirth | S | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes | S | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome | S | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment | S | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
 entry:mothersWeightAtDelivery | S | 0..1 | Reference(Observation - Mother Delivery Weight) | Mother's weight at delivery |
| section:medicalHealthInformation | S | 0..1 | BackboneElement | Medical and Health Informatino section on the Live Birth Certificate |
| code | 0..1 | CodeableConcept | Clinical information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55752-0 | |
| focus | 0..1 | Reference(Patient - Mother) | The focus of this section is the mother | |
| entry | 0..* | (Slice Definition) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() | |
| entry:pregnancyRiskFactors | S | 0..* | Reference(Observation - Pregnancy Risk Factor) | Risk factors in this pregnancy |
| entry:numberPreviousCesareans | S | 0..1 | Reference(Observation - Number of Previous Cesareans) | If mother had a previous cesarean delivery, how many |
| entry:infectionsDuringPregnancy | S | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| entry:obstetricProcedures | S | 0..* | Reference(Procedure - Obstetric) | Obstetric procedures |
| entry:characteristicsLaborDelivery | S | 0..* | Reference(Observation - Characteristic of Labor and Delivery) | Characteristics fo labor and delivery |
| entry:fetalPresentation | S | 0..1 | Reference(Condition - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| entry:finalRouteMethodDelivery | S | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| entry:trialLaborAttempted | S | 0..1 | Reference(Observation - Labor Trial Attempted) | If cesearean, was a trial of labor attempted? |
| entry:maternalMorbidity | S | 0..* | Reference(Condition - Maternal Morbidity) | Maternal morbidity (complications associated with labor and delivery) |
 section:newborn | S | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate |
| code | 0..1 | CodeableConcept | Newborn delivery information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57075-4 | |
| entry | 0..* | (Slice Definition) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() | |
| entry:birthWeight | S | 0..1 | Reference(Observation - Birth Weight) | Birthweight |
| entry:gestationalAgeAtDelivery | S | 0..1 | Reference(Observation - Gestational Age at Delivery) | Obstetric estimate of gestation |
| entry:APGARScore | S | 0..2 | Reference(Observation - APGAR Score) | APGAR Score |
| entry:plurality | S | 0..1 | Reference(Observation - Plurality) | Plurality - Single, Twin, Triplet, etc. |
| entry:abnormalConditionsNewborn | S | 0..* | Reference(Condition - Abnormal Condition of Newborn) | Abnormal conditions of the newborn |
| entry:congenitalAnomaliesNewborn | S | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| entry:infantLiving | S | 0..1 | Reference(Observation - Infant Living) | Is infant living at time of report? |
| entry:infantBreastfedAtDischarge | S | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | This composition represents the provider supplied facility live birth report. | |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| Extension-birth-certificate-id | 0..1 | Identifier | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-birth-certificate-id | |
| Extension-birth-certificate-file-number | 0..1 | Identifier | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-birth-certificate-file-number | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | Σ | 1..1 | CodeableConcept | Provider supplied facility live birth report Document Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92020-7 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| subject | Σ | 1..1 | Reference(Patient - Child) | The subject of the composition is the newborn baby |
| encounter | SΣ | 0..1 | Reference(Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. |
| date | Σ | 1..1 | dateTime | Composition editing time |
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title | Σ | 1..1 | string | Human Readable name/title |
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
| attester | 0..* | BackboneElement | Attests to accuracy of composition | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| time | 0..1 | dateTime | When the composition was attested | |
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |
 target[x] | 1..1 | Target of the relationship | ||
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period | Σ | 0..1 | Period | The period covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
| section | I | 0..* | (Slice Definition) | The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:motherPrenatal | SI | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Prenatal records Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57073-9 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Patient - Mother) | The focus of this section is the mother | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | (Slice Definition) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() |
| entry:plannedToDeliverAtHome | SI | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit | SI | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits | SI | 0..1 | Reference(Observation - Number of Prenatal Visits) | Number of prenatal care visits |
| entry:dateLastNormalMenses | SI | 0..1 | Reference(Observation - Last Menstrual Period) | Date last normal menses began |
| entry:numberNowLiving | SI | 0..1 | Reference(Observation - Number of Births Now Living) | Number of previous live births now living |
| entry:numberNowDead | SI | 0..1 | Reference(Observation - Number of Births Now Dead) | Number of previous live births now dead |
| entry:dateLastLiveBirth | SI | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes | SI | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome | SI | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment | SI | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery | SI | 0..1 | Reference(Observation - Mother Delivery Weight) | Mother's weight at delivery |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
 section | I | 0..* | See section (Composition) | Nested Section |
| section:medicalHealthInformation | SI | 0..1 | BackboneElement | Medical and Health Informatino section on the Live Birth Certificate |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Clinical information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55752-0 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Patient - Mother) | The focus of this section is the mother | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | (Slice Definition) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() |
| entry:pregnancyRiskFactors | SI | 0..* | Reference(Observation - Pregnancy Risk Factor) | Risk factors in this pregnancy |
| entry:numberPreviousCesareans | SI | 0..1 | Reference(Observation - Number of Previous Cesareans) | If mother had a previous cesarean delivery, how many |
| entry:infectionsDuringPregnancy | SI | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| entry:obstetricProcedures | SI | 0..* | Reference(Procedure - Obstetric) | Obstetric procedures |
| entry:characteristicsLaborDelivery | SI | 0..* | Reference(Observation - Characteristic of Labor and Delivery) | Characteristics fo labor and delivery |
| entry:fetalPresentation | SI | 0..1 | Reference(Condition - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| entry:finalRouteMethodDelivery | SI | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| entry:trialLaborAttempted | SI | 0..1 | Reference(Observation - Labor Trial Attempted) | If cesearean, was a trial of labor attempted? |
| entry:maternalMorbidity | SI | 0..* | Reference(Condition - Maternal Morbidity) | Maternal morbidity (complications associated with labor and delivery) |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:newborn | SI | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Newborn delivery information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57075-4 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | (Slice Definition) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() |
| entry:birthWeight | SI | 0..1 | Reference(Observation - Birth Weight) | Birthweight |
| entry:gestationalAgeAtDelivery | SI | 0..1 | Reference(Observation - Gestational Age at Delivery) | Obstetric estimate of gestation |
| entry:APGARScore | SI | 0..2 | Reference(Observation - APGAR Score) | APGAR Score |
| entry:plurality | SI | 0..1 | Reference(Observation - Plurality) | Plurality - Single, Twin, Triplet, etc. |
| entry:abnormalConditionsNewborn | SI | 0..* | Reference(Condition - Abnormal Condition of Newborn) | Abnormal conditions of the newborn |
| entry:congenitalAnomaliesNewborn | SI | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| entry:infantLiving | SI | 0..1 | Reference(Observation - Infant Living) | Is infant living at time of report? |
| entry:infantBreastfedAtDischarge | SI | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| Documentation for this format | ||||
This structure is derived from Composition
Summary
Mandatory: 1 element
Must-Support: 32 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | This composition represents the provider supplied facility live birth report. | |
| extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| Extension-birth-certificate-id | 0..1 | Identifier | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-birth-certificate-id | |
| Extension-birth-certificate-file-number | 0..1 | Identifier | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-birth-certificate-file-number | |
| type | 1..1 | CodeableConcept | Provider supplied facility live birth report Document Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92020-7 | |
| subject | 1..1 | Reference(Patient - Child) | The subject of the composition is the newborn baby | |
| encounter | S | 0..1 | Reference(Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. |
| section | 0..* | (Slice Definition) | The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Slice: Unordered, Open by pattern:code | |
| section:motherPrenatal | S | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate |
| code | 0..1 | CodeableConcept | Prenatal records Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57073-9 | |
| focus | 0..1 | Reference(Patient - Mother) | The focus of this section is the mother | |
| entry | 0..* | (Slice Definition) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() | |
| entry:plannedToDeliverAtHome | S | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit | S | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits | S | 0..1 | Reference(Observation - Number of Prenatal Visits) | Number of prenatal care visits |
| entry:dateLastNormalMenses | S | 0..1 | Reference(Observation - Last Menstrual Period) | Date last normal menses began |
| entry:numberNowLiving | S | 0..1 | Reference(Observation - Number of Births Now Living) | Number of previous live births now living |
| entry:numberNowDead | S | 0..1 | Reference(Observation - Number of Births Now Dead) | Number of previous live births now dead |
| entry:dateLastLiveBirth | S | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes | S | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome | S | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment | S | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery | S | 0..1 | Reference(Observation - Mother Delivery Weight) | Mother's weight at delivery |
| section:medicalHealthInformation | S | 0..1 | BackboneElement | Medical and Health Informatino section on the Live Birth Certificate |
| code | 0..1 | CodeableConcept | Clinical information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55752-0 | |
| focus | 0..1 | Reference(Patient - Mother) | The focus of this section is the mother | |
| entry | 0..* | (Slice Definition) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() | |
| entry:pregnancyRiskFactors | S | 0..* | Reference(Observation - Pregnancy Risk Factor) | Risk factors in this pregnancy |
| entry:numberPreviousCesareans | S | 0..1 | Reference(Observation - Number of Previous Cesareans) | If mother had a previous cesarean delivery, how many |
| entry:infectionsDuringPregnancy | S | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| entry:obstetricProcedures | S | 0..* | Reference(Procedure - Obstetric) | Obstetric procedures |
| entry:characteristicsLaborDelivery | S | 0..* | Reference(Observation - Characteristic of Labor and Delivery) | Characteristics fo labor and delivery |
| entry:fetalPresentation | S | 0..1 | Reference(Condition - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| entry:finalRouteMethodDelivery | S | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| entry:trialLaborAttempted | S | 0..1 | Reference(Observation - Labor Trial Attempted) | If cesearean, was a trial of labor attempted? |
| entry:maternalMorbidity | S | 0..* | Reference(Condition - Maternal Morbidity) | Maternal morbidity (complications associated with labor and delivery) |
| section:newborn | S | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate |
| code | 0..1 | CodeableConcept | Newborn delivery information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57075-4 | |
| entry | 0..* | (Slice Definition) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() | |
| entry:birthWeight | S | 0..1 | Reference(Observation - Birth Weight) | Birthweight |
| entry:gestationalAgeAtDelivery | S | 0..1 | Reference(Observation - Gestational Age at Delivery) | Obstetric estimate of gestation |
| entry:APGARScore | S | 0..2 | Reference(Observation - APGAR Score) | APGAR Score |
| entry:plurality | S | 0..1 | Reference(Observation - Plurality) | Plurality - Single, Twin, Triplet, etc. |
| entry:abnormalConditionsNewborn | S | 0..* | Reference(Condition - Abnormal Condition of Newborn) | Abnormal conditions of the newborn |
| entry:congenitalAnomaliesNewborn | S | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| entry:infantLiving | S | 0..1 | Reference(Observation - Infant Living) | Is infant living at time of report? |
| entry:infantBreastfedAtDischarge | S | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | This composition represents the provider supplied facility live birth report. | |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| Extension-birth-certificate-id | 0..1 | Identifier | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-birth-certificate-id | |
| Extension-birth-certificate-file-number | 0..1 | Identifier | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-birth-certificate-file-number | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | Σ | 1..1 | CodeableConcept | Provider supplied facility live birth report Document Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92020-7 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| subject | Σ | 1..1 | Reference(Patient - Child) | The subject of the composition is the newborn baby |
| encounter | SΣ | 0..1 | Reference(Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. |
| date | Σ | 1..1 | dateTime | Composition editing time |
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title | Σ | 1..1 | string | Human Readable name/title |
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
| attester | 0..* | BackboneElement | Attests to accuracy of composition | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| time | 0..1 | dateTime | When the composition was attested | |
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |
| target[x] | 1..1 | Target of the relationship | ||
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period | Σ | 0..1 | Period | The period covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
| section | I | 0..* | (Slice Definition) | The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:motherPrenatal | SI | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Prenatal records Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57073-9 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Patient - Mother) | The focus of this section is the mother | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | (Slice Definition) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() |
| entry:plannedToDeliverAtHome | SI | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit | SI | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits | SI | 0..1 | Reference(Observation - Number of Prenatal Visits) | Number of prenatal care visits |
| entry:dateLastNormalMenses | SI | 0..1 | Reference(Observation - Last Menstrual Period) | Date last normal menses began |
| entry:numberNowLiving | SI | 0..1 | Reference(Observation - Number of Births Now Living) | Number of previous live births now living |
| entry:numberNowDead | SI | 0..1 | Reference(Observation - Number of Births Now Dead) | Number of previous live births now dead |
| entry:dateLastLiveBirth | SI | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes | SI | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome | SI | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment | SI | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery | SI | 0..1 | Reference(Observation - Mother Delivery Weight) | Mother's weight at delivery |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:medicalHealthInformation | SI | 0..1 | BackboneElement | Medical and Health Informatino section on the Live Birth Certificate |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Clinical information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55752-0 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Patient - Mother) | The focus of this section is the mother | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | (Slice Definition) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() |
| entry:pregnancyRiskFactors | SI | 0..* | Reference(Observation - Pregnancy Risk Factor) | Risk factors in this pregnancy |
| entry:numberPreviousCesareans | SI | 0..1 | Reference(Observation - Number of Previous Cesareans) | If mother had a previous cesarean delivery, how many |
| entry:infectionsDuringPregnancy | SI | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| entry:obstetricProcedures | SI | 0..* | Reference(Procedure - Obstetric) | Obstetric procedures |
| entry:characteristicsLaborDelivery | SI | 0..* | Reference(Observation - Characteristic of Labor and Delivery) | Characteristics fo labor and delivery |
| entry:fetalPresentation | SI | 0..1 | Reference(Condition - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| entry:finalRouteMethodDelivery | SI | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| entry:trialLaborAttempted | SI | 0..1 | Reference(Observation - Labor Trial Attempted) | If cesearean, was a trial of labor attempted? |
| entry:maternalMorbidity | SI | 0..* | Reference(Condition - Maternal Morbidity) | Maternal morbidity (complications associated with labor and delivery) |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:newborn | SI | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Newborn delivery information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57075-4 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | (Slice Definition) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() |
| entry:birthWeight | SI | 0..1 | Reference(Observation - Birth Weight) | Birthweight |
| entry:gestationalAgeAtDelivery | SI | 0..1 | Reference(Observation - Gestational Age at Delivery) | Obstetric estimate of gestation |
| entry:APGARScore | SI | 0..2 | Reference(Observation - APGAR Score) | APGAR Score |
| entry:plurality | SI | 0..1 | Reference(Observation - Plurality) | Plurality - Single, Twin, Triplet, etc. |
| entry:abnormalConditionsNewborn | SI | 0..* | Reference(Condition - Abnormal Condition of Newborn) | Abnormal conditions of the newborn |
| entry:congenitalAnomaliesNewborn | SI | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| entry:infantLiving | SI | 0..1 | Reference(Observation - Infant Living) | Is infant living at time of report? |
| entry:infantBreastfedAtDischarge | SI | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet / Code |
| Composition.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: LOINC code 92020-7 |
| Composition.category | example | DocumentClassValueSet |
| Composition.confidentiality | required | v3.ConfidentialityClassification |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.relatesTo.code | required | DocumentRelationshipType |
| Composition.event.code | example | v3.ActCode |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section.mode | required | ListMode |
| Composition.section.orderedBy | preferred | ListOrderCodes |
| Composition.section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:motherPrenatal.code | example | Pattern: LOINC code 57073-9 |
| Composition.section:motherPrenatal.mode | required | ListMode |
| Composition.section:motherPrenatal.orderedBy | preferred | ListOrderCodes |
| Composition.section:motherPrenatal.emptyReason | preferred | ListEmptyReasons |
| Composition.section:medicalHealthInformation.code | example | Pattern: LOINC code 55752-0 |
| Composition.section:medicalHealthInformation.mode | required | ListMode |
| Composition.section:medicalHealthInformation.orderedBy | preferred | ListOrderCodes |
| Composition.section:medicalHealthInformation.emptyReason | preferred | ListEmptyReasons |
| Composition.section:newborn.code | example | Pattern: LOINC code 57075-4 |
| Composition.section:newborn.mode | required | ListMode |
| Composition.section:newborn.orderedBy | preferred | ListOrderCodes |
| Composition.section:newborn.emptyReason | preferred | ListEmptyReasons |
| Id | Path | Details | Requirements |
| dom-2 | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | Composition.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:sliceBirthCertificateId | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:sliceBirthCertificateId | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.extension:sliceBirthCertificateFileNumber | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension:sliceBirthCertificateFileNumber | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.date | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.confidentiality | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.time | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.party | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.custodian | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.relatesTo.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.relatesTo.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.relatesTo.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.relatesTo.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo.target[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.event.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.event.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.event.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.event.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.detail | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:motherPrenatal | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:motherPrenatal | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:motherPrenatal | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:motherPrenatal.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:motherPrenatal.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:motherPrenatal.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:motherPrenatal.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:plannedToDeliverAtHome | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:firstPrenatalCareVisit | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:numberPrenatalCareVisits | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:dateLastNormalMenses | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:numberNowLiving | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:numberNowDead | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:dateLastLiveBirth | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:numberOtherOutcomes | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:dateLastOtherOutcome | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:principalSourceOfPayment | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.entry:mothersWeightAtDelivery | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:motherPrenatal.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:medicalHealthInformation | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:medicalHealthInformation | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:medicalHealthInformation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:medicalHealthInformation.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:medicalHealthInformation.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:medicalHealthInformation.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:medicalHealthInformation.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.entry:pregnancyRiskFactors | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.entry:numberPreviousCesareans | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.entry:infectionsDuringPregnancy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.entry:obstetricProcedures | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.entry:characteristicsLaborDelivery | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.entry:fetalPresentation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.entry:finalRouteMethodDelivery | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.entry:trialLaborAttempted | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.entry:maternalMorbidity | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicalHealthInformation.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:newborn | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:newborn | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:newborn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:newborn.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:newborn.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:newborn.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:newborn.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.entry:birthWeight | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.entry:gestationalAgeAtDelivery | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.entry:APGARScore | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.entry:plurality | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.entry:abnormalConditionsNewborn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.entry:congenitalAnomaliesNewborn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.entry:infantLiving | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.entry:infantBreastfedAtDischarge | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:newborn.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
IG © 2020+ HL7 International - Public Health Work Group. Package hl7.fhir.us.bfdr#0.1.0 based on FHIR 4.0.1. Generated 2020-12-16
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