Vital Records Death Reporting (VRDR) FHIR Implementation Guide
3.0.0-ballot - ballot United States of America flag

This page is part of the Vital Records Death Reporting FHIR Implementation Guide (v3.0.0-ballot: STU 3 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.2.0. For a full list of available versions, see the Directory of published versions

Resource Profile: Death Certification Procedure

Official URL: http://hl7.org/fhir/us/vrdr/StructureDefinition/vrdr-death-certification Version: 3.0.0-ballot
Draft as of 2024-04-05 Computable Name: DeathCertification
Other Identifiers: OID:2.16.840.1.113883.4.642.40.10.42.26

Death Certification Procedure (USCoreProcedure). The procedure where the certification of death was performed by the certifier (USCoreProcedure).

Note:

  • The DeathCertification.performed and DeathCertificateDocument.attester.time should both be set to the death certification time.
  • The DeathCertification.performer.actor is required by the USCore Procedure Profile, but is not required by the death record submission use case.

The Death Certification profile includes:

IJE Mapping

Mortality (Decedent)
Use Case # Description IJE Name Field Type Value Set/Comments
Mortality 119 Title of Certifier CERTL performer.function (note that if value is "OTH" then performed.function.text should contain 'Full Text for Other Individual Legally Allowed to Certify') codeable CertifierTypesVS
Mortality 235 Certifier Date Signed CERTDATE performed dateTime -

Form Mapping

Form Mapping
Item # Form Field FHIR Profile Field Reference
45 Certifier performer.function Certificate of Death
49 Date Certified performed Certificate of Death

Usage:

Changes since version true:

  • No changes

    • Formal Views of Profile Content

    Description of Profiles, Differentials, Snapshots and how the different presentations work.

    This structure is derived from USCoreProcedureProfile

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure USCoreProcedureProfile
    ... code 1..1 CodeableConcept Death certification
    Required Pattern: At least the following
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://snomed.info/sct
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 308646001
    ... performed[x] 0..1 dateTime certification Datetime
    ... performer
    .... function 1..1 CodeableConcept Type of performance
    Binding: Certifier Types Value Set (required)
    .... actor 1..1 Reference(Practitioner - Vital Records) The reference to the practitioner

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Procedure.performer.functionrequiredCertifierTypesVS
    http://hl7.org/fhir/us/vrdr/ValueSet/vrdr-certifier-types-vs
    from this IG
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
    us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... status ?!SΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    Binding: EventStatus (required)
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://snomed.info/sct
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 308646001
    ... subject SΣ 1..1 Reference(US Core Patient Profile) Who the procedure was performed on
    ... performed[x] SΣC 0..1 dateTime certification Datetime

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status
    from the FHIR Standard
    Procedure.codeextensiblePattern: SNOMED CT code 308646001
    http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
    us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
    ... id Σ 0..1 id Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... extension 0..* Extension Additional content defined by implementations
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier External Identifiers for this procedure
    ... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition
    ... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
    ... basedOn Σ 0..* Reference(CarePlan | ServiceRequest) A request for this procedure
    ... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) Part of referenced event
    ... status ?!SΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    Binding: EventStatus (required)
    ... statusReason Σ 0..1 CodeableConcept Reason for current status
    Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

    ... category Σ 0..1 CodeableConcept Classification of the procedure
    Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

    ... code SΣ 1..1 CodeableConcept Death certification
    Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure


    Required Pattern: At least the following
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://snomed.info/sct
    ..... version 0..1 string Version of the system - if relevant
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 308646001
    ..... display 0..1 string Representation defined by the system
    ..... userSelected 0..1 boolean If this coding was chosen directly by the user
    .... text 0..1 string Plain text representation of the concept
    ... subject SΣ 1..1 Reference(US Core Patient Profile) Who the procedure was performed on
    ... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
    ... performed[x] SΣC 0..1 dateTime S certification Datetime
    ... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
    ... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this procedure
    ... performer Σ 0..* BackboneElement The people who performed the procedure
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... function Σ 1..1 CodeableConcept Type of performance
    Binding: Certifier Types Value Set (required)
    .... actor Σ 1..1 Reference(Practitioner - Vital Records) The reference to the practitioner
    .... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
    ... location Σ 0..1 Reference(Location) Where the procedure happened
    ... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
    Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


    ... reasonReference Σ 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
    ... bodySite Σ 0..* CodeableConcept Target body sites
    Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


    ... outcome Σ 0..1 CodeableConcept The result of procedure
    Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

    ... report 0..* Reference(DiagnosticReport | DocumentReference | Composition) Any report resulting from the procedure
    ... complication 0..* CodeableConcept Complication following the procedure
    Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


    ... complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure
    ... followUp 0..* CodeableConcept Instructions for follow up
    Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


    ... note 0..* Annotation Additional information about the procedure
    ... focalDevice 0..* BackboneElement Manipulated, implanted, or removed device
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... action 0..1 CodeableConcept Kind of change to device
    Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

    .... manipulated 1..1 Reference(Device) Device that was changed
    ... usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure
    ... usedCode 0..* CodeableConcept Coded items used during the procedure
    Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Procedure.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status
    from the FHIR Standard
    Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
    http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
    from the FHIR Standard
    Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-category
    from the FHIR Standard
    Procedure.codeextensiblePattern: SNOMED CT code 308646001
    http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
    Procedure.performer.functionrequiredCertifierTypesVS
    http://hl7.org/fhir/us/vrdr/ValueSet/vrdr-certifier-types-vs
    from this IG
    Procedure.reasonCodeexampleProcedureReasonCodes
    http://hl7.org/fhir/ValueSet/procedure-reason
    from the FHIR Standard
    Procedure.bodySiteexampleSNOMEDCTBodyStructures
    http://hl7.org/fhir/ValueSet/body-site
    from the FHIR Standard
    Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-outcome
    from the FHIR Standard
    Procedure.complicationexampleCondition/Problem/DiagnosisCodes
    http://hl7.org/fhir/ValueSet/condition-code
    from the FHIR Standard
    Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-followup
    from the FHIR Standard
    Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
    http://hl7.org/fhir/ValueSet/device-action
    from the FHIR Standard
    Procedure.usedCodeexampleFHIRDeviceTypes
    http://hl7.org/fhir/ValueSet/device-kind
    from the FHIR Standard

    This structure is derived from USCoreProcedureProfile

    Summary

    Mandatory: 0 element(1 nested mandatory element)

    Structures

    This structure refers to these other structures:

    Differential View

    This structure is derived from USCoreProcedureProfile

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure USCoreProcedureProfile
    ... code 1..1 CodeableConcept Death certification
    Required Pattern: At least the following
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://snomed.info/sct
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 308646001
    ... performed[x] 0..1 dateTime certification Datetime
    ... performer
    .... function 1..1 CodeableConcept Type of performance
    Binding: Certifier Types Value Set (required)
    .... actor 1..1 Reference(Practitioner - Vital Records) The reference to the practitioner

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Procedure.performer.functionrequiredCertifierTypesVS
    http://hl7.org/fhir/us/vrdr/ValueSet/vrdr-certifier-types-vs
    from this IG

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
    us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... status ?!SΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    Binding: EventStatus (required)
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://snomed.info/sct
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 308646001
    ... subject SΣ 1..1 Reference(US Core Patient Profile) Who the procedure was performed on
    ... performed[x] SΣC 0..1 dateTime certification Datetime

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status
    from the FHIR Standard
    Procedure.codeextensiblePattern: SNOMED CT code 308646001
    http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
    us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
    ... id Σ 0..1 id Logical id of this artifact
    ... meta Σ 0..1 Meta Metadata about the resource
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... extension 0..* Extension Additional content defined by implementations
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier External Identifiers for this procedure
    ... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition
    ... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
    ... basedOn Σ 0..* Reference(CarePlan | ServiceRequest) A request for this procedure
    ... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) Part of referenced event
    ... status ?!SΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    Binding: EventStatus (required)
    ... statusReason Σ 0..1 CodeableConcept Reason for current status
    Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

    ... category Σ 0..1 CodeableConcept Classification of the procedure
    Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

    ... code SΣ 1..1 CodeableConcept Death certification
    Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure


    Required Pattern: At least the following
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... coding 1..* Coding Code defined by a terminology system
    Fixed Value: (complex)
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    ..... system 1..1 uri Identity of the terminology system
    Fixed Value: http://snomed.info/sct
    ..... version 0..1 string Version of the system - if relevant
    ..... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: 308646001
    ..... display 0..1 string Representation defined by the system
    ..... userSelected 0..1 boolean If this coding was chosen directly by the user
    .... text 0..1 string Plain text representation of the concept
    ... subject SΣ 1..1 Reference(US Core Patient Profile) Who the procedure was performed on
    ... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
    ... performed[x] SΣC 0..1 dateTime S certification Datetime
    ... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
    ... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this procedure
    ... performer Σ 0..* BackboneElement The people who performed the procedure
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... function Σ 1..1 CodeableConcept Type of performance
    Binding: Certifier Types Value Set (required)
    .... actor Σ 1..1 Reference(Practitioner - Vital Records) The reference to the practitioner
    .... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
    ... location Σ 0..1 Reference(Location) Where the procedure happened
    ... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
    Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


    ... reasonReference Σ 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
    ... bodySite Σ 0..* CodeableConcept Target body sites
    Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


    ... outcome Σ 0..1 CodeableConcept The result of procedure
    Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

    ... report 0..* Reference(DiagnosticReport | DocumentReference | Composition) Any report resulting from the procedure
    ... complication 0..* CodeableConcept Complication following the procedure
    Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


    ... complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure
    ... followUp 0..* CodeableConcept Instructions for follow up
    Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


    ... note 0..* Annotation Additional information about the procedure
    ... focalDevice 0..* BackboneElement Manipulated, implanted, or removed device
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... action 0..1 CodeableConcept Kind of change to device
    Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

    .... manipulated 1..1 Reference(Device) Device that was changed
    ... usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure
    ... usedCode 0..* CodeableConcept Coded items used during the procedure
    Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Procedure.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status
    from the FHIR Standard
    Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
    http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
    from the FHIR Standard
    Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-category
    from the FHIR Standard
    Procedure.codeextensiblePattern: SNOMED CT code 308646001
    http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
    Procedure.performer.functionrequiredCertifierTypesVS
    http://hl7.org/fhir/us/vrdr/ValueSet/vrdr-certifier-types-vs
    from this IG
    Procedure.reasonCodeexampleProcedureReasonCodes
    http://hl7.org/fhir/ValueSet/procedure-reason
    from the FHIR Standard
    Procedure.bodySiteexampleSNOMEDCTBodyStructures
    http://hl7.org/fhir/ValueSet/body-site
    from the FHIR Standard
    Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-outcome
    from the FHIR Standard
    Procedure.complicationexampleCondition/Problem/DiagnosisCodes
    http://hl7.org/fhir/ValueSet/condition-code
    from the FHIR Standard
    Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-followup
    from the FHIR Standard
    Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
    http://hl7.org/fhir/ValueSet/device-action
    from the FHIR Standard
    Procedure.usedCodeexampleFHIRDeviceTypes
    http://hl7.org/fhir/ValueSet/device-kind
    from the FHIR Standard

    This structure is derived from USCoreProcedureProfile

    Summary

    Mandatory: 0 element(1 nested mandatory element)

    Structures

    This structure refers to these other structures:

     

    Other representations of profile: CSV, Excel, Schematron