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 Composition: eICR Composition Example: Initial Public Health Case Report - Eve Everywoman, Pertussis and 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
Chief Complaint and 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/us-ph-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/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
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/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