HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm
2.1.0 - STU 2 US

This page is part of the electronic Case Reporting (eCR) (v2.1.0: STU 2) 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

Example Bundle: eICR Document Bundle Example: bundle-eicr-document-zika

Generated Narrative: Composition

Resource Composition "composition-eicr-zika" Version "22" Updated "2021-08-17 03:24:45+0000"

Information Source: #vMaRLlyzDNjGkVuc!

Profile: Electronic Initial Case Report Composition

versionNumber: 1

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

status: FINAL

type: Public Health Case Report (LOINC#55751-2)

encounter: Encounter/encounter-eicr-eve-everywoman-outpatient: Ambulatory Office Visit

date: 2018-01-02 10:13:23+0000

author: PractitionerRole/practitionerrole-henry-seven: Henry Seven, MD

title: Initial Public Health Case Report - Zika Example

custodian: Organization/organization-ecr-salem-medical-center: Salem Medical Center "Salem Medical Center"

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 naloxone HCl 0.4 MG in 1 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 Document Content

2. http://example.org/fhir/MedicationAdministration/medicationadministration-eve-everywoman-azithromycin (MedicationAdministration/medicationadministration-eve-everywoman-azithromycin)

Generated Narrative: MedicationAdministration

Resource MedicationAdministration "medicationadministration-eve-everywoman-azithromycin" Version "6" Updated "2021-08-17 07:53:28+0000"

Information Source: #O8n4DNqcDuNHPfTJ!

Profile: US Public Health MedicationAdministration

status: COMPLETED

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

Dosages

-TextRouteMethodDose
*Two tablets at onceOral route (SNOMED CT#26643006)Swallow - dosing instruction imperative (qualifier value) (SNOMED CT#421521009)2 TAB (Details: http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm code TAB = 'Tablet')

3. http://example.org/fhir/Procedure/us-ph-procedure-ecmo (Procedure/us-ph-procedure-ecmo)

Generated Narrative: Procedure

Resource Procedure "us-ph-procedure-ecmo" Version "5" Updated "2021-06-28 08:12:56+0000"

Information Source: #A9FdbPgUT95j7Itd!

Profile: eICR Procedure

identifier: id: urn:uuid:b2a737f2-2fdb-49c1-b097-dac173d07afd

status: COMPLETED

code: Extracorporeal membrane oxygenation (procedure) (SNOMED CT#233573008)

subject: Patient/patient-ecr-eve-everywoman ""

FocalDevices

-Manipulated
*Device/device-ecmo

4. http://example.org/fhir/MedicationAdministration/medicationadministration-eve-everywoman-naloxone-response (MedicationAdministration/medicationadministration-eve-everywoman-naloxone-response)

Generated Narrative: MedicationAdministration

Resource MedicationAdministration "medicationadministration-eve-everywoman-naloxone-response" Version "5" 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) (SNOMED CT#268910001)

status: COMPLETED

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

Dosages

-RouteMethodDose
*Gluteus maximus muscle (SNOMED CT#206007)Inject - dosing instruction imperative (qualifier value) (SNOMED CT#422145002)1 mL (Details: UCUM code mL = 'mL')

5. http://example.org/fhir/ServiceRequest/servicerequest-eicr-zika (ServiceRequest/servicerequest-eicr-zika)

Generated Narrative: ServiceRequest

Resource ServiceRequest "servicerequest-eicr-zika" Version "5" Updated "2021-08-17 08:02:21+0000"

Information Source: #w4zRDqhjQ9EZHgCs!

Profile: eICR ServiceRequest

identifier: id: 061ef612-344f-4e7b-81a8-1059ae7bbe19

status: COMPLETED

intent: ORDER

category: Diagnostics Procedure (SNOMED CT#103693007 "Diagnostic procedure (procedure)")

code: Zika RT-PCR (LOINC#80825-3 "Zika virus envelope E gene [Presence] in Serum by NAA with probe detection")

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

performer: Organization/organization-ecr-acme-laboratory: Acme Labs "Acme_Labs"

6. http://example.org/fhir/Condition/condition-eicr-eve-everywoman-common-cold (Condition/condition-eicr-eve-everywoman-common-cold)

Generated Narrative: Condition

Resource Condition "condition-eicr-eve-everywoman-common-cold" Version "6" Updated "2021-07-15 01:54:14+0000"

Information Source: #4g0ZpTNqldHFYLzr!

Profile: US Public Health Condition

category: Problem List Item (Condition Category Codes#problem-list-item)

code: Common cold (disorder) (SNOMED CT#82272006)

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

onset: 2017-09-23

7. http://example.org/fhir/Encounter/encounter-eicr-eve-everywoman-outpatient (Encounter/encounter-eicr-eve-everywoman-outpatient)

Not done yet

8. http://example.org/fhir/Observation/observation-pregnancy-status-eve-everywoman (Observation/observation-pregnancy-status-eve-everywoman)

Generated Narrative: Observation

Resource Observation "observation-pregnancy-status-eve-everywoman" Version "8" 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 (LOINC#82810-3)

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

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

value: Pregnancy (finding) (SNOMED CT#77386006)

method: Diagnostic ultrasonography (procedure) (SNOMED CT#16310003)

component

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

code: Gestational age Estimated from patient reported estimated date of conception (LOINC#53691-2)

value: 143 d

component

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

code: Delivery date Estimated from date fundal height reaches umb (LOINC#57064-8)

value: 2018-05-01

9. http://example.org/fhir/Observation/observation-vaccine-credential-assertion-eve-everywoman (Observation/observation-vaccine-credential-assertion-eve-everywoman)

Generated Narrative: Observation

Resource Observation "observation-vaccine-credential-assertion-eve-everywoman" Version "2" Updated "2021-08-13 04:25:18+0000"

Information Source: #12yO2DqhRxbXmEOy!

Profile: eICR Vaccine Credential Patient Assertion

status: FINAL

code: Immunization status - Reported (LOINC#11370-4)

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

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

value: Yes (expandedYes-NoIndicator#Y)

10. http://example.org/fhir/Observation/observation-us-ph-emergency-outbreak-info-eve-everywoman (Observation/observation-us-ph-emergency-outbreak-info-eve-everywoman)

Generated Narrative: Observation

Resource Observation "observation-us-ph-emergency-outbreak-info-eve-everywoman" Version "4" 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: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

effective: 2020-11-18 10:33:22+0000

value: 2 m

11. http://example.org/fhir/Observation/observation-country-of-nationality-eve-everywoman (Observation/observation-country-of-nationality-eve-everywoman)

Generated Narrative: Observation

Resource Observation "observation-country-of-nationality-eve-everywoman" Version "1" Updated "2021-08-19 09:30:49+0000"

Information Source: #ABFWLRjmURVC23y1!

Profile: eICR Country of Nationality

status: FINAL

code: Ethnicity / related nationality data (observable entity) (SNOMED CT#186034007)

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

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

value: Australia (unknown#AU)

12. http://example.org/fhir/Patient/patient-ecr-eve-everywoman (Patient/patient-ecr-eve-everywoman)

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

13. http://example.org/fhir/Immunization/immunization-ecr-pneumo (Immunization/immunization-ecr-pneumo)

Generated Narrative: Immunization

Resource Immunization "immunization-ecr-pneumo" Version "8" Updated "2021-08-17 07:51:35+0000"

Information Source: #EdjaILZHXKHi4bdN!

Profile: US Core Immunization Profile

status: COMPLETED

vaccineCode: pneumococcal polysaccharide PPV23 (PH_VaccinesAdministeredCVX_CDC_NIP#33)

patient: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

occurrence: 2018-09-01

primarySource: true

14. http://example.org/fhir/Observation/observation-country-of-residence-eve-everywoman (Observation/observation-country-of-residence-eve-everywoman)

Generated Narrative: Observation

Resource Observation "observation-country-of-residence-eve-everywoman" Version "1" Updated "2021-08-13 12:20:14+0000"

Information Source: #HDoLJzr0kfWKFp3F!

Profile: eICR Country of Residence

status: FINAL

code: Country of usual residence (LOINC#77983-5)

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

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

value: United Kingdom of Great Britain and Northern Ireland (unknown#GB)

15. http://example.org/fhir/PractitionerRole/practitionerrole-henry-seven (PractitionerRole/practitionerrole-henry-seven)

Generated Narrative: PractitionerRole

Resource PractitionerRole "practitionerrole-henry-seven" Version "11" Updated "2021-08-17 08:00:32+0000"

Information Source: #KJ942UxvfdYWoHCF!

Profile: US Public Health PractitionerRole

identifier: id: 9941339108

practitioner: Practitioner/practitioner-us-core-henry-seven: Henry Seven, MD " HENRY"

organization: Organization/organization-ecr-salem-medical-center: Salem Medical Center "Salem Medical Center"

code: Primary Care Clinic/Center (provider-taxonomy#261QP2300X)

specialty: Family practice (SNOMED CT#419772000)

location: Location/location-ecr-salem-medical-center: Salem Medical Center "Clinic Bldg A, Salem Medical Center"

telecom: henry.seven@example.com

16. http://example.org/fhir/Observation/observation-blood-pressure-eve-everywoman (Observation/observation-blood-pressure-eve-everywoman)

Generated Narrative: Observation

Resource Observation "observation-blood-pressure-eve-everywoman" Version "2" Updated "2021-07-19 08:19:31+0000"

Information Source: #2PjceWUbU0gCYVZA!

Profile: US Core Blood Pressure Profile

status: FINAL

category: Vital Signs (Observation Category Codes#vital-signs)

code: Blood pressure systolic and diastolic (LOINC#85354-9 "Blood pressure panel with all children optional")

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

encounter: : GP Visit

effective: 2020-07-02

component

code: Systolic blood pressure (LOINC#8480-6)

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

component

code: Diastolic blood pressure (LOINC#8462-4)

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

17. http://example.org/fhir/Observation/observation-us-ph-exposure-contact-info-football-game (Observation/observation-us-ph-exposure-contact-info-football-game)

Generated Narrative: Observation

Resource Observation "observation-us-ph-exposure-contact-info-football-game" Version "4" 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. (ActClass#EXPOS "exposure")

code: Mass gathering (football game) (Unified Medical Language System#C3841750 "Mass gathering")

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

focus: Location/location-ecr-city-football-stadium: City Football Stadium "City Football Stadium"

effective: 2020-01-11 06:00:00+0000 --> 2020-01-11 09:30:00+0000

value: City Football Stadium (SNOMED CT#264379009 "Sports stadium (environment)")

18. http://example.org/fhir/Observation/observation-travel-history-eve-everywoman-201801 (Observation/observation-travel-history-eve-everywoman-201801)

Generated Narrative: Observation

Resource Observation "observation-travel-history-eve-everywoman-201801" Version "9" Updated "2021-08-17 07:59:01+0000"

Information Source: #d6PrWfFFuxUIiLtX!

Profile: US Public Health Travel History

status: FINAL

code: Travel History (SNOMED CT#420008001 "Travel")

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

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

component

code: Location (ParticipationType#LOC)

value: Fiji (unknown#FJI)

component

code: Location (ParticipationType#LOC)

value: Vanuatu (unknown#VUT)

component

code: Type of activity (attribute) (SNOMED CT#280147009)

value: Active duty military (occupation) (SNOMED CT#702348006)

19. http://example.org/fhir/Observation/observation-disability-status-eve-everywoman (Observation/observation-disability-status-eve-everywoman)

Generated Narrative: Observation

Resource Observation "observation-disability-status-eve-everywoman" Version "2" 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? (LOINC#69856-3)

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

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

value: true

20. http://example.org/fhir/Observation/observation-us-ph-lab-result-eve-everywoman-lymphocytes (Observation/observation-us-ph-lab-result-eve-everywoman-lymphocytes)

Generated Narrative: Observation

Resource Observation "observation-us-ph-lab-result-eve-everywoman-lymphocytes"

Profile: US Public Health Laboratory Result Observation Profile

status: FINAL

category: Laboratory (Observation Category Codes#laboratory)

code: Lymphocytes [#/volume] in Blood by Automated count (LOINC#731-0)

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

effective: 2018-03-07

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

interpretation: High (ObservationInterpretation#H)

ReferenceRanges

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

21. http://example.org/fhir/Organization/organization-ecr-acme-laboratory (Organization/organization-ecr-acme-laboratory)

Generated Narrative: Organization

Resource Organization "organization-ecr-acme-laboratory" Version "4" Updated "2021-06-30 04:13:19+0000"

Information Source: #xp7CXcY2lPaNsDQL!

Profile: US Public Health Organization

identifier: id: 1144221999

active: true

type: outpatient laboratory (RoleCode#OUTLAB)

name: Acme_Labs

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

address: 7777 Laboratory Drive Ann Arbor MI 99999

22. http://example.org/fhir/Location/location-ecr-salem-medical-center (Location/location-ecr-salem-medical-center)

Generated Narrative: Location

Resource Location "location-ecr-salem-medical-center" Version "6" Updated "2021-08-17 07:53:02+0000"

Information Source: #VI2Nm5Ps5HqZ5HXV!

Profile: US Public Health Location

identifier: id: 1144221995

status: ACTIVE

name: Clinic Bldg A, Salem Medical Center

type: Hospital (RoleCode#HOSP)

telecom: ph: (+1) (555)555-3001, fax: (+1) (555)555-3002, mail@smc.org

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

managingOrganization: Organization/organization-ecr-salem-medical-center "Salem Medical Center"

23. http://example.org/fhir/Location/location-ecr-city-football-stadium (Location/location-ecr-city-football-stadium)

Generated Narrative: Location

Resource Location "location-ecr-city-football-stadium" Version "1" 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 (SNOMED CT#264379009 "Sports stadium (environment)")

address: 99 Football Stadium Road My City AZ 8562

24. http://example.org/fhir/Organization/organization-ecr-salem-medical-center (Organization/organization-ecr-salem-medical-center)

Generated Narrative: Organization

Resource Organization "organization-ecr-salem-medical-center" Version "5" Updated "2021-06-30 04:13:19+0000"

Information Source: #xa4yJZjn68xVavoM!

Profile: US Public Health Organization

identifier: id: 55555555

active: true

name: Salem Medical Center

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

address: 22222 Health Authority Drive Ann Arbor MI 99999

25. http://example.org/fhir/Condition/condition-eicr-eve-everywoman-zika (Condition/condition-eicr-eve-everywoman-zika)

Generated Narrative: Condition

Resource Condition "condition-eicr-eve-everywoman-zika" Version "5" Updated "2021-07-15 01:54:14+0000"

Information Source: #rM2Pw6getjoE2UTV!

category: Encounter Diagnosis (Condition Category Codes#encounter-diagnosis)

code: Zika virus disease (disorder) (SNOMED CT#3928002)

subject: Patient/patient-ecr-eve-everywoman: Eve Everywoman ""

onset: 2017-08-23

26. http://example.org/fhir/Practitioner/practitioner-us-core-henry-seven (Practitioner/practitioner-us-core-henry-seven)

Generated Narrative: Practitioner

Resource Practitioner "practitioner-us-core-henry-seven" Version "5" Updated "2021-08-17 08:00:32+0000"

Information Source: #2MfA6kIjmOmtAlIb!

Profile: US Core Practitioner Profile

identifier: id: 9941339108

name: Seven Henry

telecom: henry.seven@example.com

address: BMass Doctors 2100 North Ave Burlington MA 02368 US