HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm CI Build

This page is part of the electronic Case Reporting (eCR) (v1.0.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.1.2. For a full list of available versions, see the Directory of published versions

Bundle: bundle-eicr-document-pertussis-zika

id
composition-eicr-pertussis-zika
meta
versionId
32
lastUpdated
2019-10-20T11:00:43.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition
composition-clinicaldocument-versionNumber
  • 1
identifier
  • 2eec4326-bf29-4428-8d02-a334a19cfc18
status
final
type
subject
encounter
date
2017-11-06T22:13:23Z
author
title
Initial Public Health Case Report - Pertussis/Zika example
section
title
History of Present Illness Section
code
Persistent Cough REPORTED starting on 2016/10/05
Whooping Respiration not reported
Paroxysms Of Coughing REPORTED starting on 2016/11/04
Post-tussive vomiting not reported
section
title
Reason for Visit Section
code

Bad cough
section
title
Problems 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
Pertussis (disorder)
id
condition-eicr-eve-everywoman-pertussis
meta
versionId
14
lastUpdated
2019-10-10T21:14:56.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-condition
category
code
subject
onsetDateTime
2017-09-23
asserter
section
title
Social History Section
code
entry eICR Travel History Example 1
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/travel-history-observation
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
entry ODH Usual Work Example
id
observation-odh-usual-work-eve-everywoman
meta
versionId
2
lastUpdated
2019-10-20T10:53:14.000-04:00
profile
http://hl7.org/fhir/us/odh/StructureDefinition/odh-UsualWork
status
final
code
subject
effectivePeriod
start
2015-01-01
end
2018-03-07
valueCodeableConcept
component
code
valueCodeableConcept
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
section
title
Results 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
Bordetella pertussis Ab [Units/volume] in Serum - Interpretation: High
id
observation-us-core-results-eve-everywoman-pertussis
meta
versionId
8
lastUpdated
2019-10-05T03:15:42.000-04:00
profile
http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab
status
final
category
code
  • Bordetella pertussis Ab [Units/volume] in Serum
subject
effectiveDateTime
2016-11-07
valueQuantity
interpretation
referenceRange
high
value
45
system
code
[iU]/mL
entry Lymphocytes [#/​volume] in Blood by Automated count - Interpretation: High
id
observation-us-core-results-eve-everywoman-lymphocytes
meta
versionId
10
lastUpdated
2019-10-05T02:50:13.000-04:00
profile
http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab
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
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
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/pregnancy-status-observation
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
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/eicr-condition
category
code
subject
onsetDateTime
2017-09-23
asserter
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
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/pregnancy-status-observation
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
id
patient-ecr-eve-everywoman
meta
versionId
13
lastUpdated
2019-10-11T03:45:24.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/ecr-patient
us-core-race
  • White
  • urn:oid:2.16.840.1.113883.6.238
  • 2106-3
  • White
us-core-ethnicity
  • Not Hispanic or Latino
  • urn:oid:2.16.840.1.113883.6.238
  • 2186-5
  • Not Hispanic or Latino
us-core-birthsex
  • F
patient-genderIdentity
identifier
active
true
name
family
Everywoman
given
Eve
given
L
telecom
system
phone
value
1-(404)555-1212
use
home
telecom
system
email
value
eve.everywoman@example.com
gender
female
birthDate
1974-11-24
address
line
5101 Peachtree St NE
city
Atlanta
state
GA
postalCode
30302
country
US
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
id
condition-eicr-eve-everywoman-diabetes
meta
versionId
2
lastUpdated
2019-10-23T13:53:04.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-condition
category
code
subject
onsetDateTime
2017-08-23
asserter
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/travel-history-observation
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
id
observation-odh-usual-work-eve-everywoman
meta
versionId
2
lastUpdated
2019-10-20T10:53:14.000-04:00
profile
http://hl7.org/fhir/us/odh/StructureDefinition/odh-UsualWork
status
final
code
subject
effectivePeriod
start
2015-01-01
end
2018-03-07
valueCodeableConcept
component
code
valueCodeableConcept
id
observation-us-core-results-eve-everywoman-lymphocytes
meta
versionId
10
lastUpdated
2019-10-05T02:50:13.000-04:00
profile
http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab
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
id
observation-us-core-results-eve-everywoman-pertussis
meta
versionId
8
lastUpdated
2019-10-05T03:15:42.000-04:00
profile
http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab
status
final
category
code
  • Bordetella pertussis Ab [Units/volume] in Serum
subject
effectiveDateTime
2016-11-07
valueQuantity
interpretation
referenceRange
high
value
45
system
code
[iU]/mL
id
practitionerrole-henry-seven
meta
versionId
8
lastUpdated
2019-10-14T01:24:13.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/ecr-practitionerrole
identifier
practitioner
organization
code
specialty
location
telecom
system
email
value
henry.seven@example.com
id
practitioner-us-core-henry-seven
meta
versionId
8
lastUpdated
2019-10-14T01:24:13.000-04:00
profile
http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner
identifier
name
family
Henry
given
Seven
suffix
M.D.
telecom
system
email
value
henry.seven@example.com
address
line
BMass Doctors
line
2100 North Ave
city
Burlington
state
MA
postalCode
02368
country
US
id
encounter-eicr-eve-everywoman-outpatient
meta
versionId
3
lastUpdated
2019-10-11T22:32:46.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-encounter
identifier
status
finished
class
type
subject
participant
type
individual
period
start
2018-04-01T10:00:00-05:00
end
2018-04-02T10:15:00-05:00
diagnosis
  • Trigger code
  • Trigger Code: 3928002
  • Trigger Code Display: Zika virus disease (disorder)
  • Trigger Code System: http://snomed.info/sct
  • Trigger Code Value Set: urn:oid:2.16.840.1.114222.4.11.7508
  • Trigger Code Value Set Version: 12/12/2018
  • Condition/condition-eicr-eve-everywoman-zika
diagnosis
location
serviceProvider
id
condition-eicr-eve-everywoman-pertussis
meta
versionId
14
lastUpdated
2019-10-10T21:14:56.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-condition
category
code
subject
onsetDateTime
2017-09-23
asserter
id
organization-ecr-acme-laboratory
meta
versionId
11
lastUpdated
2019-10-23T16:12:36.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/ecr-organization
identifier
active
true
type
name
Acme_Labs
telecom
system
phone
value
+1-555-555-4444
telecom
system
email
value
mail@acme-labs.com
address
line
7777 Laboratory Drive
city
Ann Arbor
state
MI
postalCode
99999
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/ecr-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
id
location-ecr-salem-medical-center
meta
versionId
12
lastUpdated
2019-11-02T02:28:50.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-location
status
active
name
Clinic Bldg A, Salem Medical Center
type
telecom
system
phone
value
(+1) (555)555-3001
telecom
system
fax
value
(+1) (555)555-3002
telecom
system
email
value
mail@smc.org
address
line
Clinic Bldg A
line
4444 Healthcare Drive
city
Ann Arbor
state
MI
postalCode
99999
managingOrganization