Vital Records Birth and Fetal Death Reporting
1.0.0 - STU 1
Vital Records Birth and Fetal Death Reporting
1.0.0 - STU 1
This page is part of the Vital Records Birth and Fetal Death Reporting (v1.0.0: STU 1 on FHIR R4) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
{
"resourceType" : "QuestionnaireResponse",
"id" : "QuestionnaireResponse-patients-fetal-death-carmen-lee",
"meta" : {
"versionId" : "10",
"lastUpdated" : "2021-07-09T03:16:14.037+00:00",
"source" : "#VCyPJiBNgzmYZ0iz"
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>questionnaire</b>: <a href=\"http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-patients-fetal-death\">http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-patients-fetal-death</a></p><p><b>status</b>: completed</p><p><b>subject</b>: <a href=\"Patient-patient-decedent-fetus-not-named.html\">Patient - Decedent Fetus (Fetus Not Named). Generated Summary: Medical Record Number: 9932702 (USUAL); UNK ; gender: female; birthDate: 2019-01-09; deceased: true</a></p><p><b>source</b>: <a href=\"Patient-patient-mother-carmen-teresa-lee.html\">Patient - Mother (Carmen Teresa Lee). Generated Summary: Medical Record Number: 9992702 (USUAL); Carmen Teresa Lee (OFFICIAL), Carmen Teresa Santos (MAIDEN); gender: female; birthDate: 1986-02-15</a></p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-current-legal-name</p><p><b>text</b>: What is your current legal name?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-first-name</p><p><b>text</b>: First</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-middle-name</p><p><b>text</b>: Middle</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-last-name</p><p><b>text</b>: Last</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-address</p><p><b>text</b>: Where do you usually live - that is - where is your household/residence located?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-nbr-street</p><p><b>text</b>: Complete number and street (do not enter rural route numbers)</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-city</p><p><b>text</b>: City, Town, or Location</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-state</p><p><b>text</b>: State (or U.S. Territory, Canadian Province)</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-zip</p><p><b>text</b>: Zip Code</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: inside-city-limits</p><p><b>text</b>: Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?</p><h3>Answers</h3><table class=\"grid\"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td><span title=\"{http://terminology.hl7.org/CodeSystem/v2-0532 N}\">No</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-mail</p><p><b>text</b>: What is your mailing address</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-mail-same</p><p><b>text</b>: Same as residence [Go to next question]</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-dob</p><p><b>text</b>: What is your date of birth?</p><h3>Answers</h3><table class=\"grid\"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>1986-02-15</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-birthplace</p><p><b>text</b>: In what State, U.S. territory, or foreign country were you born? Please specify one of the following:</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-birthplace-territory</p><p><b>text</b>: or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-education</p><p><b>text</b>: What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).</p><h3>Answers</h3><table class=\"grid\"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td><span title=\"{urn:oid:2.16.840.1.114222.4.5.274 PHC1449}\">9th through 12th grade; no diploma</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-ethnicity</p><p><b>text</b>: Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-shl</p><p><b>text</b>: Are you Spanish/Hispanic/Latina</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-race</p><p><b>text</b>: What is your race? (Please check one or more races to indicate what you consider yourself to be).</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mother-race-category</p><p><b>text</b>: Race categories</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-current-legal-name</p><p><b>text</b>: What is the current legal name of your baby's father?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: father-first-name</p><p><b>text</b>: First</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-middle-name</p><p><b>text</b>: Middle</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-last-name</p><p><b>text</b>: Last</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-dob</p><p><b>text</b>: What is the father's date of birth?</p><h3>Answers</h3><table class=\"grid\"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>1984-02-27</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: father-birthplace</p><p><b>text</b>: In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:</p><blockquote><p><b>item</b></p><p><b>linkId</b>: father-birthplace-state</p><p><b>text</b>: State</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: receive-wic</p><p><b>text</b>: Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?</p><h3>Answers</h3><table class=\"grid\"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td><span title=\"{http://terminology.hl7.org/CodeSystem/v2-0532 N}\">No</span></td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-height</p><p><b>text</b>: What is your height?</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-height-inches</p><p><b>text</b>: Inches</p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-prepregnancy-weight</p><p><b>text</b>: lbs</p><h3>Answers</h3><table class=\"grid\"><tr><td>-</td><td><b>Value[x]</b></td></tr><tr><td>*</td><td>180 [lb_av]</td></tr></table></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-smoking</p><p><b>text</b>: How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.</p><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-smoking-3-months-prior</p><p><b>text</b>: Three months before pregnancy</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-smoking-trimester-1</p><p><b>text</b>: First three months of pregnancy</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-smoking-trimester-2</p><p><b>text</b>: Second three months of pregnancy</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: mothers-smoking-trimester-3</p><p><b>text</b>: Third trimester of pregnancy</p></blockquote></blockquote></div>"
},
"questionnaire" : "http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-patients-fetal-death",
"status" : "completed",
"subject" : {
"reference" : "Patient/patient-decedent-fetus-not-named",
"display" : "Patient - Decedent Fetus (Fetus Not Named)"
},
"source" : {
"reference" : "Patient/patient-mother-carmen-teresa-lee",
"display" : "Patient - Mother (Carmen Teresa Lee)"
},
"item" : [
{
"linkId" : "mother-current-legal-name",
"text" : "What is your current legal name?",
"item" : [
{
"linkId" : "mother-first-name",
"text" : "First",
"answer" : [
{
"valueString" : "Carmen"
}
]
},
{
"linkId" : "mother-middle-name",
"text" : "Middle",
"answer" : [
{
"valueString" : "Teresa"
}
]
},
{
"linkId" : "mother-last-name",
"text" : "Last",
"answer" : [
{
"valueString" : "Lee"
}
]
}
]
},
{
"linkId" : "mother-address",
"text" : "Where do you usually live - that is - where is your household/residence located?",
"item" : [
{
"linkId" : "mother-nbr-street",
"text" : "Complete number and street (do not enter rural route numbers)",
"answer" : [
{
"valueString" : "3670 Miller Road"
}
]
},
{
"linkId" : "mother-city",
"text" : "City, Town, or Location"
},
{
"linkId" : "mother-state",
"text" : "State (or U.S. Territory, Canadian Province)",
"answer" : [
{
"valueString" : "MI"
}
]
},
{
"linkId" : "mother-zip",
"text" : "Zip Code",
"answer" : [
{
"valueString" : "48103"
}
]
}
]
},
{
"linkId" : "inside-city-limits",
"text" : "Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?",
"answer" : [
{
"valueCoding" : {
"system" : "http://terminology.hl7.org/CodeSystem/v2-0532",
"code" : "N",
"display" : "No"
}
}
]
},
{
"linkId" : "mother-mail",
"text" : "What is your mailing address",
"item" : [
{
"linkId" : "mother-mail-same",
"text" : "Same as residence [Go to next question]",
"answer" : [
{
"valueBoolean" : true
}
]
}
]
},
{
"linkId" : "mother-dob",
"text" : "What is your date of birth?",
"answer" : [
{
"valueDate" : "1986-02-15"
}
]
},
{
"linkId" : "mother-birthplace",
"text" : "In what State, U.S. territory, or foreign country were you born? Please specify one of the following:",
"item" : [
{
"linkId" : "mother-birthplace-territory",
"text" : "or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas",
"answer" : [
{
"valueString" : "PR"
}
]
}
]
},
{
"linkId" : "mother-education",
"text" : "What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).",
"answer" : [
{
"valueCoding" : {
"system" : "urn:oid:2.16.840.1.114222.4.5.274",
"code" : "PHC1449",
"display" : "9th through 12th grade; no diploma"
}
}
]
},
{
"linkId" : "mother-ethnicity",
"text" : "Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.",
"item" : [
{
"linkId" : "mother-shl",
"text" : "Are you Spanish/Hispanic/Latina",
"answer" : [
{
"valueCoding" : {
"system" : "urn:oid:2.16.840.1.113883.6.238",
"code" : "2135-2",
"display" : "Hispanic or Latino"
}
}
]
}
]
},
{
"linkId" : "mother-race",
"text" : "What is your race? (Please check one or more races to indicate what you consider yourself to be).",
"item" : [
{
"linkId" : "mother-race-category",
"text" : "Race categories",
"answer" : [
{
"valueCoding" : {
"system" : "urn:oid:2.16.840.1.113883.6.238",
"code" : "2054-5",
"display" : "Black or African American"
}
}
]
}
]
},
{
"linkId" : "father-current-legal-name",
"text" : "What is the current legal name of your baby's father?",
"item" : [
{
"linkId" : "father-first-name",
"text" : "First",
"answer" : [
{
"valueString" : "Tom"
}
]
},
{
"linkId" : "father-middle-name",
"text" : "Middle",
"answer" : [
{
"valueString" : "Yan"
}
]
},
{
"linkId" : "father-last-name",
"text" : "Last",
"answer" : [
{
"valueString" : "Lee"
}
]
}
]
},
{
"linkId" : "father-dob",
"text" : "What is the father's date of birth?",
"answer" : [
{
"valueDate" : "1984-02-27"
}
]
},
{
"linkId" : "father-birthplace",
"text" : "In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:",
"item" : [
{
"linkId" : "father-birthplace-state",
"text" : "State",
"answer" : [
{
"valueString" : "NY"
}
]
}
]
},
{
"linkId" : "receive-wic",
"text" : "Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?",
"answer" : [
{
"valueCoding" : {
"system" : "http://terminology.hl7.org/CodeSystem/v2-0532",
"code" : "N",
"display" : "No"
}
}
]
},
{
"linkId" : "mothers-height",
"text" : "What is your height?",
"item" : [
{
"linkId" : "mothers-height-inches",
"text" : "Inches",
"answer" : [
{
"valueQuantity" : {
"value" : 65,
"unit" : "[in_i]",
"system" : "http://unitsofmeasure.org",
"code" : "[in_i]"
}
}
]
}
]
},
{
"linkId" : "mothers-prepregnancy-weight",
"text" : "lbs",
"answer" : [
{
"valueQuantity" : {
"value" : 180,
"unit" : "[lb_av]",
"system" : "http://unitsofmeasure.org",
"code" : "[lb_av]"
}
}
]
},
{
"linkId" : "mothers-smoking",
"text" : "How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.",
"item" : [
{
"linkId" : "mothers-smoking-3-months-prior",
"text" : "Three months before pregnancy",
"item" : [
{
"linkId" : "mothers-smoking-3-months-prior-cig",
"text" : "# of cigarettes*",
"answer" : [
{
"valueInteger" : 0
}
]
},
{
"linkId" : "mothers-smoking-3-months-prior-pck",
"text" : "# of packs",
"answer" : [
{
"valueInteger" : 0
}
]
}
]
},
{
"linkId" : "mothers-smoking-trimester-1",
"text" : "First three months of pregnancy",
"item" : [
{
"linkId" : "mothers-smoking-trimester-1-cig",
"text" : "# of cigarettes*",
"answer" : [
{
"valueInteger" : 0
}
]
},
{
"linkId" : "mothers-smoking-trimester-1-pck",
"text" : "# of packs",
"answer" : [
{
"valueInteger" : 0
}
]
}
]
},
{
"linkId" : "mothers-smoking-trimester-2",
"text" : "Second three months of pregnancy",
"item" : [
{
"linkId" : "mothers-smoking-trimester-2-cig",
"text" : "# of cigarettes*",
"answer" : [
{
"valueInteger" : 0
}
]
},
{
"linkId" : "mothers-smoking-trimester-2-pck",
"text" : "# of packs",
"answer" : [
{
"valueInteger" : 0
}
]
}
]
},
{
"linkId" : "mothers-smoking-trimester-3",
"text" : "Third trimester of pregnancy",
"item" : [
{
"linkId" : "mothers-smoking-trimester-3-cig",
"text" : "# of cigarettes*",
"answer" : [
{
"valueInteger" : 0
}
]
},
{
"linkId" : "mothers-smoking-trimester-3-pck",
"text" : "# of packs",
"answer" : [
{
"valueInteger" : 0
}
]
}
]
}
]
}
]
}
IG © 2020+ HL7 International - Public Health Work Group. Package hl7.fhir.us.bfdr#1.0.0 based on FHIR 4.0.1. Generated 2021-10-22
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