HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm
2.1.2 - STU 2 United States of America flag

This page is part of the electronic Case Reporting (eCR) (v2.1.2: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Example Bundle: US Public Health Reporting Bundle Example: bundle-ecr-message-zika

Generated Narrative: Bundle bundle-ecr-message-zika

Bundle bundle-ecr-message-zika of type message


Entry 1 - fullUrl = http://example.org/fhir/MessageHeader/messageheader-ecr-requested-eicr

Resource MessageHeader:

Generated Narrative: MessageHeader messageheader-ecr-requested-eicr

US Public Health Data Encrypted Extension: false

US Public Health Message Processing Category Extension: consequence

event: US Public Health Message Types CodeSystem eicr-case-report-message: Indicates a message containing electronic case report healthcare data sent from clinical care.

Destinations

-NameTarget
*YMCA Acme Message GatewayDevice: identifier = http://acme.com/software/client-ids#goodhealth_id; manufacturer = Acme Devices, Inc; type = ; contact = http://acme.com; url = http://acme.com/ymca/software/

sender: Organization Salem Medical Center

Sources

-NameSoftwareVersionContact
*Acme Central Patient RegistryFooBar Patient Manager3.1.45.AABB+1 (555) 123 4567

reason: Indicates the close of an encounter

focus: Bundle: identifier = UUID:2be4b4e4-6df1-4cb2-a947-c70fa0eda54b; type = document; timestamp = 2021-08-02 22:13:23+0000


Entry 2 - fullUrl = http://example.org/fhir/Bundle/bundle-eicr-document-zika

Resource Bundle:

Document Details

Generated Narrative: Bundle Initial Public Health Case Report - Zika Example

Document Subject

Unable to resolve subject ''


Document Content

Reason for Visit Section

title
Reason for Visit Section
code

Reason for Visit: Bad cough

Chief Complaint

title
Chief complaint Narrative - Reported
code

Chief Complaint: Bad cough

History of Present Illness Section

title
History of Present Illness Section
code
Persistent Cough REPORTED starting on 2018/03/05
Whooping Respiration not reported
Paroxysms Of Coughing REPORTED starting on 2018/03/06
Post-tussive vomiting not reported

Problems Section

title
Problems Section
code
entry Common cold (disorder)
id
condition-eicr-eve-everywoman-common-cold
meta
versionId
15
lastUpdated
2019-10-10T21:21:49.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-condition
category
code
subject
onsetDateTime
2017-09-23
asserter

Medications Administered Section

title
Medications Administered Section
code
entry Azithromycin 500 MG Oral Tablet
id
medicationadministration-eve-everywoman-azithromycin
meta
versionId
10
lastUpdated
2019-10-05T03:11:22.000-04:00
status
completed
medicationCodeableConcept
subject
effectivePeriod
start
2018-03-07
end
2018-03-07
dosage
route
method
dose
value
2
unit
TAB
system
code
TAB

Admission Medications Section

title
Admission Medications Section
code
entry 1 ML naloxone hydrochloride 0.4 MG/ML Injection

Medications Section

title
Medications Section
code
entry Azithromycin 500 MG Oral Tablet

Results Section

title
Results Section
code
entry Lymphocytes [#/​volume] in Blood by Automated count - Interpretation: High
id
observation-us-ph-lab-result-eve-everywoman-lymphocytes
meta
versionId
10
lastUpdated
2019-10-05T02:50:13.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-lab-result-observation
status
final
category
code
subject
effectiveDateTime
2018-03-07
valueQuantity
interpretation
referenceRange
low
value
1
system
code
10*3/uL
high
value
4.8
system
code
10*3/uL

Plan of Treatment Section

title
Plan of Treatment Section
code
entry
  • Trigger code
  • Trigger Code:
  • Trigger Code Display:
  • Trigger Code System:
  • Trigger Code Value Set: urn:oid:2.16.840.1.114222.4.11.7508
  • Trigger Code Value Set Version: 19/05/2018
Request for Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method
id
servicerequest-eicr-zika
meta
versionId
9
lastUpdated
2019-10-23T13:56:36.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-servicerequest
status
completed
intent
order
category
code
  • Zika RT-PCR
    • Zika virus envelope E gene [Presence] in Serum by NAA with probe detection
      (
      80825-3
      )
subject
performer

Immunizations Section

title
Immunizations Section
code
entry pneumococcal polysaccharide vaccine
entry Vaccine Credential Patient Assertion Observation Example

Procedures Section

title
Procedures Section
code
entry Extracorporeal membrane oxygenation (procedure)

Vital Signs Section

title
Vital Signs Section
code
entry Blood pressure systolic and diastolic

Social History Section

title
Social History Section
code
entry eICR Travel History: Eve Everywoman 2018-01
id
observation-travel-history-eve-everywoman-201801
meta
versionId
11
lastUpdated
2019-10-05T03:15:42.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-travel-history
status
final
code
subject
effectivePeriod
start
2018-01-15
end
2018-01-30
component
code
valueCodeableConcept
    • Fiji
      (
      FJI
      )
    • urn:iso:std:iso:3166
component
code
valueCodeableConcept

Pregnancy Section

title
Pregnancy Section
code
entry eICR Pregnancy Status Example
id
observation-pregnancy-status-eve-everywoman
meta
versionId
13
lastUpdated
2019-10-05T03:15:42.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-pregnancy-status-observation
us-ph-date-recorded-extension
  • 2017-10-01
date-determined-extension
  • 2017-10-01
status
final
code
subject
effectivePeriod
start
2017-08-26
valueCodeableConcept
method
component
date-determined-extension
  • 2017-10-01
code
    • Gestational age Estimated from patient reported estimated date of conception
      (
      53691-2
      )
valueQuantity
  • 143
  • d
component
date-determined-extension
  • 2017-10-01
code
    • Delivery date Estimated from date fundal height reaches umb
      (
      57064-8
      )
valueDateTime
2018-05-01

Emergency Outbreak Information Section

title
Emergency Outbreak Information Section
code
entry US Public Health Emergency Outbreak Information Example

Past Medical History Section

title
Past Medical History Section
code

Past medical history

Review of Systems Section

title
Review of Systems Section
code

Review of systems


Additional Resources Included in Document


Entry 1 - fullUrl = http://example.org/fhir/Composition/composition-eicr-zika

Resource Composition:

Generated Narrative: Composition composition-eicr-zika

version: 22; Last updated: 2021-08-17 03:24:45+0000;

Information Source: #vMaRLlyzDNjGkVuc

Profile: Electronic Initial Case Report Composition

Composition Version Number: 1

identifier: c03eab8c-11e8-4d0c-ad2a-b385395e27db

status: Final

type: Public Health Case Report

encounter: Ambulatory Office Visit

date: 2018-01-02 22:13:23+0000

author: Henry Seven, MD

title: Initial Public Health Case Report - Zika Example

custodian: Salem Medical Center


Entry 2 - fullUrl = http://example.org/fhir/MedicationAdministration/medicationadministration-eve-everywoman-azithromycin

Resource MedicationAdministration:

Generated Narrative: MedicationAdministration medicationadministration-eve-everywoman-azithromycin

version: 6; Last updated: 2021-08-17 07:53:28+0000;

Information Source: #O8n4DNqcDuNHPfTJ

Profile: US Public Health MedicationAdministration

status: completed

subject: Eve Everywoman

Dosages

-TextRouteMethodDose
*Two tablets at onceOral routeSwallow - dosing instruction imperative (qualifier value)2 TAB (Details: Orderable Drug Form codeTAB = 'Tablet')

Entry 3 - fullUrl = http://example.org/fhir/Procedure/us-ph-procedure-ecmo

Resource Procedure:

Generated Narrative: Procedure us-ph-procedure-ecmo

version: 5; Last updated: 2021-06-28 08:12:56+0000;

Information Source: #A9FdbPgUT95j7Itd

Profile: eICR Procedure

identifier: Uniform Resource Identifier (URI)/urn:uuid:b2a737f2-2fdb-49c1-b097-dac173d07afd

status: Completed

code: Extracorporeal membrane oxygenation (procedure)

subject: Female, DoB: 1974-11-24 ( Medical Record Number: 1032702 (use: usual, ))

FocalDevices

-Manipulated
*Device: status = active; manufacturer = ACME Biomedical; expirationDate = 2022-01-01; lotNumber = M320; serialNumber = AC222; modelNumber = 4.0; type = Extracorporeal membrane oxygenator (physical object)

Entry 4 - fullUrl = http://example.org/fhir/MedicationAdministration/medicationadministration-eve-everywoman-naloxone-response

Resource MedicationAdministration:

Generated Narrative: MedicationAdministration medicationadministration-eve-everywoman-naloxone-response

version: 5; Last updated: 2021-08-17 07:53:28+0000;

Information Source: #5sOf7BOr595JpyG7

Profile: US Public Health MedicationAdministration

US Public Health Therapeutic Medication Response Extension: Patient's condition improved (finding)

status: completed

subject: Eve Everywoman

Dosages

-RouteMethodDose
*Gluteus maximus muscleInject - dosing instruction imperative (qualifier value)1 mL (Details: UCUM codemL = 'mL')

Entry 5 - fullUrl = http://example.org/fhir/ServiceRequest/servicerequest-eicr-zika

Resource ServiceRequest:

Generated Narrative: ServiceRequest servicerequest-eicr-zika

version: 5; Last updated: 2021-08-17 08:02:21+0000;

Information Source: #w4zRDqhjQ9EZHgCs

Profile: eICR ServiceRequest

identifier: http://lab.smarthealthit.org/061ef612-344f-4e7b-81a8-1059ae7bbe19

status: Completed

intent: Order

category: Diagnostics Procedure

code: No display for ServiceRequest.code (concept: Zika virus envelope E gene [Presence] in Serum by NAA with probe detection)

subject: Eve Everywoman

performer: Acme Labs


Entry 6 - fullUrl = http://example.org/fhir/Condition/condition-eicr-eve-everywoman-common-cold

Resource Condition:

Generated Narrative: Condition condition-eicr-eve-everywoman-common-cold

version: 6; Last updated: 2021-07-15 01:54:14+0000;

Information Source: #4g0ZpTNqldHFYLzr

Profile: US Public Health Condition

category: Problem List Item

code: Common cold (disorder)

subject: Eve Everywoman

onset: 2017-09-23


Entry 7 - fullUrl = http://example.org/fhir/Encounter/encounter-eicr-eve-everywoman-outpatient

Resource Encounter:

Generated Narrative: Encounter encounter-eicr-eve-everywoman-outpatient

version: 5; Last updated: 2021-07-19 03:02:05+0000;

Information Source: #Q5dlT8eND2UI2D6e

Profile: eICR Encounter

identifier: http://hospital.smarthealthit.org/9937012

status: completed

class: ambulatory

type: Office Visit

subject: Eve Everywoman

serviceProvider: Salem Medical Center, 22222 Health Authority Drive, Ann Arbor MI, 99999

Participants

-Type
*attender

diagnosis

eICR Trigger Code Flag Extension

  • triggerCodeValueSet: urn:oid:2.16.840.1.114222.4.11.7508
  • triggerCodeValueSetVersion: 12/12/2018
  • triggerCode: SNOMED CT 3928002: Zika virus disease (disorder)

condition: No display for Encounter.diagnosis.condition (reference: ->Condition Zika virus disease (disorder))

diagnosis

condition: No display for Encounter.diagnosis.condition (reference: ->Condition Common cold (disorder))

Locations

-Location
*Clinic Bldg A, Salem Medical Center, 4646 Brown Rd, Salem, MA 02368

Entry 8 - fullUrl = http://example.org/fhir/Observation/observation-pregnancy-status-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-pregnancy-status-eve-everywoman

version: 8; Last updated: 2021-08-17 07:59:00+0000;

Information Source: #bBlVx7OsNPsZVCbu

Profile: US Public Health Pregnancy Status Observation

US Public Health Date Recorded Extension: 2017-10-01

US Public Health Date Determined Extension: 2017-10-01

status: Final

code: Pregnancy status

subject: Eve Everywoman

effective: 2017-08-26 --> (ongoing)

value: Pregnancy (finding)

method: Ultrasonography (procedure)

component

US Public Health Date Determined Extension: 2017-10-01

code: Gestational age Estimated from patient reported estimated date of conception

value: 143 d

component

US Public Health Date Determined Extension: 2017-10-01

code: Delivery date Estimated from date fundal height reaches umb

value: 2018-05-01


Entry 9 - fullUrl = http://example.org/fhir/Observation/observation-vaccine-credential-assertion-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-vaccine-credential-assertion-eve-everywoman

version: 2; Last updated: 2021-08-13 04:25:18+0000;

Information Source: #12yO2DqhRxbXmEOy

Profile: eICR Vaccine Credential Patient Assertion

status: Final

code: Immunization status - Reported

subject: Eve Everywoman

effective: 2020-11-10 22:33:22+0000

value: Yes


Entry 10 - fullUrl = http://example.org/fhir/Observation/observation-us-ph-emergency-outbreak-info-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-us-ph-emergency-outbreak-info-eve-everywoman

version: 4; Last updated: 2021-07-15 01:22:52+0000;

Information Source: #oAXhG2HyvbL70uEB

Profile: US Public Health Emergency Outbreak Information

status: Final

code: Employee desk distance from mail sorter

subject: Eve Everywoman

effective: 2020-11-18 22:33:22+0000

value: 2 m


Entry 11 - fullUrl = http://example.org/fhir/Observation/observation-country-of-nationality-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-country-of-nationality-eve-everywoman

version: 1; Last updated: 2021-08-19 21:30:49+0000;

Information Source: #ABFWLRjmURVC23y1

Profile: eICR Country of Nationality

status: Final

code: Ethnicity / related nationality data (observable entity)

subject: Eve Everywoman

effective: 2020-11-10 22:33:22+0000

value: Australia


Entry 12 - fullUrl = http://example.org/fhir/Patient/patient-ecr-eve-everywoman

Resource Patient:

Eve L EVERYWOMAN
Identifier 1032702
Address 5101 Peachtree St NE
Atlanta GA US
Date of birth 24 November 1974

Entry 13 - fullUrl = http://example.org/fhir/Immunization/immunization-ecr-pneumo

Resource Immunization:

Generated Narrative: Immunization immunization-ecr-pneumo

version: 8; Last updated: 2021-08-17 07:51:35+0000;

Information Source: #EdjaILZHXKHi4bdN

Profile: US Core Immunization Profile

status: Completed

vaccineCode: pneumococcal polysaccharide PPV23

patient: Eve Everywoman

occurrence: 2018-09-01

primarySource: true


Entry 14 - fullUrl = http://example.org/fhir/Observation/observation-country-of-residence-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-country-of-residence-eve-everywoman

version: 1; Last updated: 2021-08-13 00:20:14+0000;

Information Source: #HDoLJzr0kfWKFp3F

Profile: eICR Country of Residence

status: Final

code: Country of usual residence

subject: Eve Everywoman

effective: 2020-11-10 22:33:22+0000

value: United Kingdom of Great Britain and Northern Ireland


Entry 15 - fullUrl = http://example.org/fhir/PractitionerRole/practitionerrole-henry-seven

Resource PractitionerRole:

Generated Narrative: PractitionerRole practitionerrole-henry-seven

version: 11; Last updated: 2021-08-17 08:00:32+0000;

Information Source: #KJ942UxvfdYWoHCF

Profile: US Public Health PractitionerRole

identifier: United States National Provider Identifier/9941339108

practitioner: Henry Seven, MD

organization: Salem Medical Center

code: Primary Care Clinic/Center

specialty: Family practice

location: Salem Medical Center


Entry 16 - fullUrl = http://example.org/fhir/Observation/observation-blood-pressure-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-blood-pressure-eve-everywoman

version: 2; Last updated: 2021-07-19 08:19:31+0000;

Information Source: #2PjceWUbU0gCYVZA

Profile: US Core Blood Pressure Profile

status: Final

category: Vital Signs

code: Blood pressure systolic and diastolic

subject: Eve Everywoman

encounter: GP Visit

effective: 2020-07-02

component

code: Systolic blood pressure

value: 109 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

component

code: Diastolic blood pressure

value: 44 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')


Entry 17 - fullUrl = http://example.org/fhir/Observation/observation-us-ph-exposure-contact-info-football-game

Resource Observation:

Generated Narrative: Observation observation-us-ph-exposure-contact-info-football-game

version: 4; Last updated: 2020-12-01 07:17:32+0000;

Information Source: #pMvWUdCWz4XOnrDf

Profile: US Public Health Exposure Contact Information

status: Final

category: An interaction between entities that provides opportunity for transmission of a physical, chemical, or biological agent from an exposure source entity to an exposure target entity.

code: Mass gathering (football game)

subject: Eve Everywoman

focus: City Football Stadium

effective: 2020-01-11 18:00:00+0000 --> 2020-01-11 21:30:00+0000

value: City Football Stadium


Entry 18 - fullUrl = http://example.org/fhir/Observation/observation-travel-history-eve-everywoman-201801

Resource Observation:

Generated Narrative: Observation observation-travel-history-eve-everywoman-201801

version: 9; Last updated: 2021-08-17 07:59:01+0000;

Information Source: #d6PrWfFFuxUIiLtX

Profile: US Public Health Travel History

status: Final

code: Travel History

subject: Eve Everywoman

effective: 2018-01-15 --> 2018-01-30

component

code: Location

value: Fiji

component

code: Location

value: Vanuatu

component

code: Type of activity (attribute)

value: Active duty military (occupation)


Entry 19 - fullUrl = http://example.org/fhir/Observation/observation-disability-status-eve-everywoman

Resource Observation:

Generated Narrative: Observation observation-disability-status-eve-everywoman

version: 2; Last updated: 2021-06-30 05:33:12+0000;

Information Source: #AVCvf6gXu6hyNuWr

Profile: US Public Health Disability Status

status: Final

code: Are you deaf, or do you have serious difficulty hearing

subject: Eve Everywoman

effective: 2020-11-10 22:33:22+0000

value: true


Entry 20 - fullUrl = http://example.org/fhir/Observation/observation-us-ph-lab-result-eve-everywoman-lymphocytes

Resource Observation:

Generated Narrative: Observation observation-us-ph-lab-result-eve-everywoman-lymphocytes

status: Final

category: Laboratory

code: Lymphocytes [#/volume] in Blood by Automated count

subject: Eve Everywoman

effective: 2018-03-07

value: 5.2 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')

interpretation: High

ReferenceRanges

-LowHigh
*1 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')4.8 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')

Entry 21 - fullUrl = http://example.org/fhir/Organization/organization-ecr-acme-laboratory

Resource Organization:

Generated Narrative: Organization organization-ecr-acme-laboratory

version: 4; Last updated: 2021-06-30 04:13:19+0000;

Information Source: #xp7CXcY2lPaNsDQL

Profile: US Public Health Organization

identifier: http://hl7.org.fhir/sid/us-npi/1144221999

active: true

type: outpatient laboratory

name: Acme_Labs

contact

telecom: +1-555-555-4444, mail@acme-labs.com

address: 7777 Laboratory Drive Ann Arbor MI 99999


Entry 22 - fullUrl = http://example.org/fhir/Location/location-ecr-salem-medical-center

Resource Location:

Generated Narrative: Location location-ecr-salem-medical-center

version: 6; Last updated: 2021-08-17 07:53:02+0000;

Information Source: #VI2Nm5Ps5HqZ5HXV

Profile: US Public Health Location

identifier: http://hl7.org.fhir/sid/us-npi/1144221995

status: Active

name: Clinic Bldg A, Salem Medical Center

type: Hospital

address: Clinic Bldg A 4444 Healthcare Drive Ann Arbor MI 99999

managingOrganization: Organization Salem Medical Center


Entry 23 - fullUrl = http://example.org/fhir/Location/location-ecr-city-football-stadium

Resource Location:

Generated Narrative: Location location-ecr-city-football-stadium

version: 1; Last updated: 2020-12-01 01:55:32+0000;

Information Source: #KLUFk4w6CXKqrFEC

Profile: US Core Location Profile

status: Active

name: City Football Stadium

type: City Football Stadium

address: 99 Football Stadium Road My City AZ 8562


Entry 24 - fullUrl = http://example.org/fhir/Organization/organization-ecr-salem-medical-center

Resource Organization:

Generated Narrative: Organization organization-ecr-salem-medical-center

version: 5; Last updated: 2021-06-30 04:13:19+0000;

Information Source: #xa4yJZjn68xVavoM

Profile: US Public Health Organization

identifier: http://hl7.org.fhir/sid/us-npi/55555555

active: true

name: Salem Medical Center

contact

telecom: +1-555-555-1111, mail@salemmedicalcenter.com

address: 22222 Health Authority Drive Ann Arbor MI 99999


Entry 25 - fullUrl = http://example.org/fhir/Condition/condition-eicr-eve-everywoman-zika

Resource Condition:

Generated Narrative: Condition condition-eicr-eve-everywoman-zika

version: 5; Last updated: 2021-07-15 01:54:14+0000;

Information Source: #rM2Pw6getjoE2UTV

category: Encounter Diagnosis

code: Zika virus disease (disorder)

subject: Eve Everywoman

onset: 2017-08-23


Entry 26 - fullUrl = http://example.org/fhir/Practitioner/practitioner-us-core-henry-seven

Resource Practitioner:

Generated Narrative: Practitioner practitioner-us-core-henry-seven

version: 5; Last updated: 2021-08-17 08:00:32+0000;

Information Source: #2MfA6kIjmOmtAlIb

Profile: US Core Practitioner Profile

identifier: United States National Provider Identifier/9941339108

name: Seven Henry

telecom: henry.seven@example.com

address: BMass Doctors 2100 North Ave Burlington MA 02368 US


Entry 27 - fullUrl = http://example.org/fhir/Device/device-ecmo

Resource Device:

Manually Created Narrative

UDI

Device Identifier: 99863313444317

CarrierHRF: (01)99863313444316(17)220101(10)M320(21)AC222

EntryType: rfid

Name: ACME Extracorporeal membrane oxygenator

Type: udi-label-name

status: active

manufacturer: ACME Biomedical

expirationDate: 2024-01-01

lotNumber: M321

serialNumber: AC222

modelNumber: 4.0

patient: Eve Everywoman. Generated Summary: Medical Record Number: 1032702 (USUAL); active; Eve L Everywoman ; Phone: 1-(404)555-1212, eve.everywoman@example.com; gender: female; birthDate: 1974-11-24


Entry 3 - fullUrl = http://example.org/fhir/Device/device-ecr-software-ymca

Resource Device:

id:
device-ecr-software-ymca
meta:
  • 4
  • 2019-10-03T05:07:48.000-04:00
identifier:
manufacturer:
Acme Devices, Inc
type:
EHR
version:
value:
10.23-23423
contact:
  • url
  • http://acme.com
url:
http://acme.com/ymca/software/

Entry 4 - fullUrl = http://example.org/fhir/Organization/organization-ecr-salem-medical-center

Resource Organization:

id
organization-ecr-salem-medical-center
meta
versionId
16
lastUpdated
2019-10-05T03:15:41.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-organization
identifier
active
true
type
name
Salem Medical Center
telecom
system
phone
value
+1-555-555-1111
telecom
system
email
value
mail@salemmedicalcenter.com
address
line
22222 Health Authority Drive
city
Ann Arbor
state
MI
postalCode
99999