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 
<QuestionnaireResponse xmlns="http://hl7.org/fhir">
<id value="QuestionnaireResponse-patients-fetal-death-carmen-lee"/>
<meta>
<versionId value="10"/>
<lastUpdated value="2021-07-09T03:16:14.037+00:00"/>
<source value="#VCyPJiBNgzmYZ0iz"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<questionnaire
value="http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-patients-fetal-death"/>
<status value="completed"/>
<subject>
<reference value="Patient/patient-decedent-fetus-not-named"/>
<display value="Patient - Decedent Fetus (Fetus Not Named)"/>
</subject>
<source>
<reference value="Patient/patient-mother-carmen-teresa-lee"/>
<display value="Patient - Mother (Carmen Teresa Lee)"/>
</source>
<item>
<linkId value="mother-current-legal-name"/>
<text value="What is your current legal name?"/>
<item>
<linkId value="mother-first-name"/>
<text value="First"/>
<answer>
<valueString value="Carmen"/>
</answer>
</item>
<item>
<linkId value="mother-middle-name"/>
<text value="Middle"/>
<answer>
<valueString value="Teresa"/>
</answer>
</item>
<item>
<linkId value="mother-last-name"/>
<text value="Last"/>
<answer>
<valueString value="Lee"/>
</answer>
</item>
</item>
<item>
<linkId value="mother-address"/>
<text
value="Where do you usually live - that is - where is your household/residence located?"/>
<item>
<linkId value="mother-nbr-street"/>
<text
value="Complete number and street (do not enter rural route numbers)"/>
<answer>
<valueString value="3670 Miller Road"/>
</answer>
</item>
<item>
<linkId value="mother-city"/>
<text value="City, Town, or Location"/>
</item>
<item>
<linkId value="mother-state"/>
<text value="State (or U.S. Territory, Canadian Province)"/>
<answer>
<valueString value="MI"/>
</answer>
</item>
<item>
<linkId value="mother-zip"/>
<text value="Zip Code"/>
<answer>
<valueString value="48103"/>
</answer>
</item>
</item>
<item>
<linkId value="inside-city-limits"/>
<text
value="Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?"/>
<answer>
<valueCoding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0532"/>
<code value="N"/>
<display value="No"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="mother-mail"/>
<text value="What is your mailing address"/>
<item>
<linkId value="mother-mail-same"/>
<text value="Same as residence [Go to next question]"/>
<answer>
<valueBoolean value="true"/>
</answer>
</item>
</item>
<item>
<linkId value="mother-dob"/>
<text value="What is your date of birth?"/>
<answer>
<valueDate value="1986-02-15"/>
</answer>
</item>
<item>
<linkId value="mother-birthplace"/>
<text
value="In what State, U.S. territory, or foreign country were you born? Please specify one of the following:"/>
<item>
<linkId value="mother-birthplace-territory"/>
<text
value="or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas"/>
<answer>
<valueString value="PR"/>
</answer>
</item>
</item>
<item>
<linkId value="mother-education"/>
<text
value="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 value="urn:oid:2.16.840.1.114222.4.5.274"/>
<code value="PHC1449"/>
<display value="9th through 12th grade; no diploma"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="mother-ethnicity"/>
<text
value="Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box."/>
<item>
<linkId value="mother-shl"/>
<text value="Are you Spanish/Hispanic/Latina"/>
<answer>
<valueCoding>
<system value="urn:oid:2.16.840.1.113883.6.238"/>
<code value="2135-2"/>
<display value="Hispanic or Latino"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="mother-race"/>
<text
value="What is your race? (Please check one or more races to indicate what you consider yourself to be)."/>
<item>
<linkId value="mother-race-category"/>
<text value="Race categories"/>
<answer>
<valueCoding>
<system value="urn:oid:2.16.840.1.113883.6.238"/>
<code value="2054-5"/>
<display value="Black or African American"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="father-current-legal-name"/>
<text value="What is the current legal name of your baby's father?"/>
<item>
<linkId value="father-first-name"/>
<text value="First"/>
<answer>
<valueString value="Tom"/>
</answer>
</item>
<item>
<linkId value="father-middle-name"/>
<text value="Middle"/>
<answer>
<valueString value="Yan"/>
</answer>
</item>
<item>
<linkId value="father-last-name"/>
<text value="Last"/>
<answer>
<valueString value="Lee"/>
</answer>
</item>
</item>
<item>
<linkId value="father-dob"/>
<text value="What is the father's date of birth?"/>
<answer>
<valueDate value="1984-02-27"/>
</answer>
</item>
<item>
<linkId value="father-birthplace"/>
<text
value="In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:"/>
<item>
<linkId value="father-birthplace-state"/>
<text value="State"/>
<answer>
<valueString value="NY"/>
</answer>
</item>
</item>
<item>
<linkId value="receive-wic"/>
<text
value="Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?"/>
<answer>
<valueCoding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0532"/>
<code value="N"/>
<display value="No"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="mothers-height"/>
<text value="What is your height?"/>
<item>
<linkId value="mothers-height-inches"/>
<text value="Inches"/>
<answer>
<valueQuantity>
<value value="65"/>
<unit value="[in_i]"/>
<system value="http://unitsofmeasure.org"/>
<code value="[in_i]"/>
</valueQuantity>
</answer>
</item>
</item>
<item>
<linkId value="mothers-prepregnancy-weight"/>
<text value="lbs"/>
<answer>
<valueQuantity>
<value value="180"/>
<unit value="[lb_av]"/>
<system value="http://unitsofmeasure.org"/>
<code value="[lb_av]"/>
</valueQuantity>
</answer>
</item>
<item>
<linkId value="mothers-smoking"/>
<text
value="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 value="mothers-smoking-3-months-prior"/>
<text value="Three months before pregnancy"/>
<item>
<linkId value="mothers-smoking-3-months-prior-cig"/>
<text value="# of cigarettes*"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
<item>
<linkId value="mothers-smoking-3-months-prior-pck"/>
<text value="# of packs"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
</item>
<item>
<linkId value="mothers-smoking-trimester-1"/>
<text value="First three months of pregnancy"/>
<item>
<linkId value="mothers-smoking-trimester-1-cig"/>
<text value="# of cigarettes*"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
<item>
<linkId value="mothers-smoking-trimester-1-pck"/>
<text value="# of packs"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
</item>
<item>
<linkId value="mothers-smoking-trimester-2"/>
<text value="Second three months of pregnancy"/>
<item>
<linkId value="mothers-smoking-trimester-2-cig"/>
<text value="# of cigarettes*"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
<item>
<linkId value="mothers-smoking-trimester-2-pck"/>
<text value="# of packs"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
</item>
<item>
<linkId value="mothers-smoking-trimester-3"/>
<text value="Third trimester of pregnancy"/>
<item>
<linkId value="mothers-smoking-trimester-3-cig"/>
<text value="# of cigarettes*"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
<item>
<linkId value="mothers-smoking-trimester-3-pck"/>
<text value="# of packs"/>
<answer>
<valueInteger value="0"/>
</answer>
</item>
</item>
</item>
</QuestionnaireResponse>
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
Links: Table of Contents |
QA Report
| Version History |
Search |
|
Propose a change