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

This page is part of the electronic Case Reporting (eCR) (v2.0.0: STU 2 on FHIR R4) based on FHIR R4. The current version which supercedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions

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

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-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

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