Birth And Fetal Death (BFDR) - STU2-ballot
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This page is part of the Vital Records Birth and Fetal Death Reporting (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

Vital Records Form Mapping

This page provides the mapping from standard forms and worksheets used to exchange birth and fetal death information to the FHIR resources as defined in this IG.

This IG supports communicating information from an EHR system to the jurisdictional vital records offices and to NCHS for standard reporting forms:

Live Birth Forms and Worksheets

Fetal Death Forms and Worksheets

Questionnaires

Information on updates to the live birth and fetal death forms can be found at NVSS Revisions of the U.S. Standard Certificates and Reports and Guide to Completing the Facility Worksheets for the Certificate of Live Birth and Report of Fetal Death

2003 Revision of the U.S. Standard Certificate of Live Birth Mapping

Item # Form Element FHIR Profile FHIR Field
- Local File No. CompositionProviderLiveBirthReport extension:liveBirthLocalFileNumber
- Birth Number CompositionProviderLiveBirthReport extension:liveBirthCertificateNumber
1 Child’s Name PatientChildVitalRecords name
2 Child's Time of Birth PatientChildVitalRecords extension:birthTime
3 Child's Sex PatientChildVitalRecords extension:birthsex
4 Child's Date Of Birth PatientChildVitalRecords birthDate
5 Facility Name / Address EncounterBirth location.location
6 City, Town, Or Location Of Birth PatientChildVitalRecords extension:birthPlace
7 County Of Birth PatientChildVitalRecords extension:birthPlace
8a Mother’s Current Legal Name PatientMotherVitalRecords name:currentLegalName
8b Mother’s Date Of Birth PatientMotherVitalRecords birthDate
8c Mother’s Name Prior To First Marriage PatientMotherVitalRecords name:namePriorToFirstMarriage
8d Mother’s Birthplace PatientMotherVitalRecords extension:birthPlace
9a Residence of Mother - State PatientMotherVitalRecords address.state
9b Mother’s County PatientMotherVitalRecords address.district
9c Mother’s City, Town, or Location PatientMotherVitalRecords address.city
9d Mother’s Street And Number PatientMotherVitalRecords address.line
9e Mother’s Apt. No. PatientMotherVitalRecords address.line
9f Mother’s Zip Code PatientMotherVitalRecords address.postalCode
9g Mother’s Residence Inside City Limits? PatientMotherVitalRecords address.extension:withinCityLimitsIndicator
10a Father’s Current Legal Name RelatedPersonFatherNaturalVitalRecords name:currentLegalName
10b Father’s Date Of Birth RelatedPersonFatherNaturalVitalRecords birthDate
10c Father’s Birthplace RelatedPersonFatherNaturalVitalRecords extension:birthPlace
11 Certifier’s Name PractitionerVitalRecords name
11 Certifier’s Title PractitionerVitalRecords qualification
12 Date Certified EncounterBirth participant:certifier.period.start
13 Date Filed By Registrar CompositionProviderLiveBirthReport extension:dateFiledbyRegistrar
14 Mother’s Mailing Address PatientMotherVitalRecords address
15 Mother Married? ObservationMotherMarriedDuringPregnancy value
15 If not married, has paternity acknowledgement been signed in the hospital? ObservationPaternityAcknowledgementSigned value
16 Social Security Number Requested for Child? ObservationSSNRequestedForChild value
17 Facility Id. EncounterBirth identifier
18 Mother’s Social Security Number PatientMotherVitalRecords identifier:SSN
19 Father’s Social Security Number RelatedPersonFatherNaturalVitalRecords identifier:SSN
20 Mother’s Education ObservationEducationLevelVitalRecords code
21 Mother of Hispanic Origin? PatientMotherVitalRecords extension:ethnicity
22 Mother’s Race PatientMotherVitalRecords extension:race
23 Father’s Education ObservationEducationLevelVitalRecords code
24 Father of Hispanic Origin? PatientChildVitalRecords extension:ethnicity
25 Father’s Race PatientChildVitalRecords extension:race
26 Place Where Birth Occurred EncounterBirth location.physicalType
26.a Home Birth: Planned to deliver at home? ObservationPlannedToDeliverAtHome value
27 Attendant’s Name PractitionerVitalRecords name
27 Attendant’s Title PractitionerVitalRecords qualification
27 Attendant’s NPI PractitionerVitalRecords identifier
28 Mother Transferred for Maternal Medical or Fetal Indications for Delivery? EncounterMaternity hospitalization.admitSource (Y if present, N if not present)
29a Date Of First Prenatal Care Visit ObservationDateOfFirstPrenatalCareVisit value
30 Total Number Of Prenatal Visits For This Pregnancy ObservationNumberPrenatalVisits value
31 Mother’s Height ObservationMotherHeight value
32 Mother’s Prepregnancy Weight ObservationMotherPrepregnancyWeight value
33 Mother’s Weight At Delivery ObservationMotherDeliveryWeight value
34 Did Mother Get WIC Food For Herself During This Pregnancy? ObservationMotherReceivedWICFood value
35 Number of Previous Live Births ObservationNumberBirthsNowDead value
36 Number of Other Pregnancy Outcomes ObservationNumberOtherPregnancyOutcomes value
37 Cigarette Smoking Before And During Pregnancy ObservationCigaretteSmokingBeforeDuringPregnancy value
38 Principal Source of Payment for This Delivery CoveragePrincipalPayerDelivery type
39 Date Last Normal Menses Began ObservationLastMenstrualPeriod value
40 Mother’s Medical Record Number PatientMotherVitalRecords identifier:MRN
41.1 Risk factors in this pregnancy: Diabetes - Prepregnancy ConditionPrepregnancyDiabetes
41.2 Risk factors in this pregnancy: Diabetes - Gestational ConditionGestationalDiabetes
41.3 Risk factors in this pregnancy: Hypertension - Prepregnancy ConditionPrepregnancyHypertension
41.4 Risk factors in this pregnancy: Hypertension - Gestational ConditionGestationalHypertension
41.5 Risk factors in this pregnancy: Eclampsia ConditionEclampsiaHypertension
41.6 Risk factors in this pregnancy: Previous preterm births ObservationPreviousPretermBirth
41.8 Risk factors in this pregnancy: Pregnancy resulted from infertility treatment ProcedureInfertilityTreatment
41.9 Risk factors in this pregnancy: Fertility-enhancing drugs, artificial insemination or intrauterine insemination ProcedureArtificialInsemination
41.10 Risk factors in this pregnancy: Assisted reproductive technology ProcedureAssistedFertilization
41.11 Risk factors in this pregnancy: previous cesarean delivery ObservationPreviousCesarean
41.11 Risk factors in this pregnancy: previous cesarean delivery ObservationNumberPreviousCesareans
41.12 Risk factors in this pregnancy: None of the above ObservationNoneOfSpecifiedPregnancyRiskFactors
42 Infections present and/or treated during this pregnancy ConditionInfectionPresentDuringPregnancy
42.6 Infections present and/or treated during this pregnancy ObservationNoneOfSpecifiedInfectionsPresentDuringPregnancy
43 Obstetric Procedures ProcedureObstetric
43.4 Obstetric Procedures ObservationNoneOfSpecifiedObstetricProcedures
45.1 Characteristics of Labor and Delivery: Induction of labor ProcedureInductionOfLabor
45.2 Characteristics of Labor and Delivery: Augmentation of labor ProcedureAugmentationOfLabor
45.4 Characteristics of Labor and Delivery: Steroids for fetal lung maturation ObservationSteroidsFetalLungMaturation
45.5 Characteristics of Labor and Delivery: Antibiotics received by the mother during labor ObservationAntibioticsAdministeredDuringLabor
45.6 Characteristics of Labor and Delivery: Clinical chorioamnionitis ConditionChorioamnionitis
45.9 Characteristics of Labor and Delivery: Epidural or spinal anesthesia during labor ProcedureEpiduralOrSpinalAnesthesia
45.10 Characteristics of Labor and Delivery: None of the above ObservationNoneOfSpecifiedCharacteristicsOfLaborAndDelivery
46.C Fetal presentation at birth ObservationFetalPresentation value
46.D Final route and method of delivery ProcedureFinalRouteMethodDelivery code
46.D.1 If cesarean, was a trial of labor attempted? ObservationLaborTrialAttempted value
47.1 Maternal Morbidity: Maternal transfusion ProcedureBloodTransfusion
47.2 Maternal Morbidity: Third or fourth degree perineal laceration ConditionPerinealLaceration
47.3 Maternal Morbidity: Ruptured uterus ConditionRupturedUterus
47.4 Maternal Morbidity: Unplanned hysterectomy ProcedureUnplannedHysterectomy
47.5 Maternal Morbidity: Admission to intensive care unit ObservationICUAdmission
47.7 Maternal Morbidity: None of the above ObservationNoneOfSpecifiedMaternalMorbidities
48 Newborn Medical Record Number PatientChildVitalRecords identifier:MRN
49 Birthweight ObservationBirthWeight value
50 Obstetric Estimate of Gestation ObservationGestationalAgeAtDelivery value
51 Apgar Score: ObservationApgarScore value
52 Plurality PatientChildVitalRecords multipleBirth[x].extension:multipleBirthTotal
53 If Not Single Birth - Born First, Second, Third, etc. (Specify) PatientChildVitalRecords multipleBirthInteger
54.1 Abnormal Conditions of the Newborn: Assisted ventilation required immediately following delivery ProcedureAssistedVentilationFollowingDelivery
54.2 Abnormal Conditions of the Newborn: Assisted ventilation required for more than six hours ProcedureAssistedVentilationMoreThanSixHours
54.3 Abnormal Conditions of the Newborn: NICU admission ObservationNICUAdmission
54.4 Abnormal Conditions of the Newborn: Newborn given surfactant replacement therapy ProcedureSurfactantReplacementTherapy
54.5 Abnormal Conditions of the Newborn: Antibiotics received by the newborn for suspected neonatal sepsis ProcedureAntibioticSuspectedNeonatalSepsis
54.6 Abnormal Conditions of the Newborn: Seizure or serious neurologic dysfunction ConditionSeizure
54.8 Abnormal Conditions of the Newborn: None of the above ObservationNoneOfSpecifiedAbnormalConditionsOfNewborn
55 Congenital Anomalies of the Newborn ConditionCongenitalAnomalyOfNewborn
56 Was Infant Transferred Within 24 Hours Of Delivery? EncounterBirth hospitalization.dischargeDisposition
57 Is Infant Living At Time of Report? ObservationInfantLiving value
58 Is The Infant Being Breastfed At Discharge? ObservationInfantBreastfedAtDischarge value

2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births Mapping

Item # Form Element FHIR Profile FHIR Field
- Mother’s medical record # PatientMotherVitalRecords identifier:MRN
- Mother’s name PatientMotherVitalRecords name
- Child’s name/medical record # PatientChildVitalRecords identifier
9 Number of previous live births now living ObservationNumberBirthsNowLiving value
10 Number of previous live births now dead ObservationNumberBirthsNowDead value
12 Number of other pregnancy outcomes ObservationNumberOtherPregnancyOutcomes value
17 Date of birth PatientChildVitalRecords birthDate
18 Time of birth PatientChildVitalRecords birthDate.extension:birthTime
34 Order delivered in the pregnancy PatientChildVitalRecords multipleBirthInteger
26.1 Characteristics of Labor and Delivery: Induction of labor ProcedureInductionOfLabor
26.2 Characteristics of Labor and Delivery: Augmentation of labor ProcedureAugmentationOfLabor
26.3 Characteristics of Labor and Delivery: Steroids for fetal lung maturation ObservationSteroidsFetalLungMaturation
26.4 Characteristics of Labor and Delivery: Antibiotics received by the mother during labor ObservationAntibioticsAdministeredDuringLabor
26.5 Characteristics of Labor and Delivery: Clinical chorioamnionitis ConditionChorioamnionitis
26.6 Characteristics of Labor and Delivery: Epidural or spinal anesthesia during labor ProcedureEpiduralOrSpinalAnesthesia
26.7 Characteristics of Labor and Delivery: None of the above ObservationNoneOfSpecifiedCharacteristicsOfLaborAndDelivery
27.C Method of delivery: Fetal presentation at birth ObservationFetalPresentation value
27.D Method of delivery: Final route and method of delivery ProcedureFinalRouteMethodDelivery code
27.D.1 If cesarean, was a trial of labor attempted? ObservationLaborTrialAttempted value
28.1 Maternal Morbidity: Maternal transfusion ProcedureBloodTransfusion
28.2 Maternal Morbidity: Third or fourth degree perineal laceration ConditionPerinealLaceration
28.3 Maternal Morbidity: Ruptured uterus ConditionRupturedUterus
28.4 Maternal Morbidity: Unplanned hysterectomy ProcedureUnplannedHysterectomy
28.5 Maternal Morbidity: Admission to intensive care unit ObservationICUAdmission
28.6 Maternal Morbidity: None of the above ObservationNoneOfSpecifiedMaternalMorbidities
29 Birthweight ObservationBirthWeight
30 Obstetric estimate of gestation at delivery ObservationGestationalAgeAtDelivery value
31 Sex PatientChildVitalRecords extension:birthsex
32 Apgar score ObservationApgarScore value
36.1 Abnormal Conditions of the Newborn: Assisted ventilation required immediately following delivery ProcedureAssistedVentilationFollowingDelivery
36.2 Abnormal Conditions of the Newborn: Assisted ventilation required for more than six hours ProcedureAssistedVentilationMoreThanSixHours
36.3 Abnormal Conditions of the Newborn: NICU admission ObservationNICUAdmission
36.4 Abnormal Conditions of the Newborn: Newborn given surfactant replacement therapy ProcedureSurfactantReplacementTherapy
36.5 Abnormal Conditions of the Newborn: Antibiotics received by the newborn for suspected neonatal sepsis ProcedureAntibioticSuspectedNeonatalSepsis
36.6 Abnormal Conditions of the Newborn: Seizure or serious neurologic dysfunction ConditionSeizure
36.7 Abnormal Conditions of the Newborn: None of the above ObservationNoneOfSpecifiedAbnormalConditionsOfNewborn
37 Congenital anomalies of the newborn ConditionCongenitalAnomalyOfNewborn
38 Was infant transferred within 24 hours of delivery? EncounterBirth hospitalization.dischargeDisposition
39 Is infant living at time of report? ObservationInfantLiving value
40 Is infant being breastfed at discharge? ObservationInfantBreastfedAtDischarge value

2016 US Standard Facility Worksheet for the Live Birth Certificate Mapping

Item # Form Element FHIR Profile FHIR Field
- Mother’s medical record # PatientMotherVitalRecords identifier:MRN
- Mother’s name PatientMotherVitalRecords name
1 Facility name / address EncounterBirth name/address
2 Facility I.D. EncounterBirth identifier
3 City, Town or Location of birth PatientChildVitalRecords extension:birthPlace
4 County of birth PatientChildVitalRecords extension:birthPlace
5 Place where birth occurred EncounterBirth location.physicalType
5.a Home Birth: Planned to deliver at home? ObservationPlannedToDeliverAtHome value
6 Date of first prenatal care visit ObservationDateOfFirstPrenatalCareVisit value
7 Total number of prenatal care visits for this pregnancy ObservationNumberPrenatalVisits value
8 Date last normal menses began ObservationLastMenstrualPeriod value
9 Number of previous live births now living ObservationNumberBirthsNowLiving value
10 Number of previous live births now dead ObservationNumberBirthsNowDead value
11 Date of last live birth ObservationDateOfLastLiveBirth value
12 Number of other pregnancy outcomes ObservationNumberOtherPregnancyOutcomes value
13 Date of last other pregnancy outcome ObservationDateOfLastOtherPregnancyOutcome value
14.1 Risk factors in this pregnancy: Diabetes - Prepregnancy ConditionPrepregnancyDiabetes
14.2 Risk factors in this pregnancy: Diabetes - Gestational ConditionGestationalDiabetes
14.3 Risk factors in this pregnancy: Hypertension - Prepregnancy ConditionPrepregnancyHypertension
14.4 Risk factors in this pregnancy: Hypertension - Gestational ConditionGestationalHypertension
14.5 Risk factors in this pregnancy: Eclampsia ConditionEclampsiaHypertension
14.6 Risk factors in this pregnancy: Previous preterm births ObservationPreviousPretermBirth
14.7 Risk factors in this pregnancy: Pregnancy resulted from infertility treatment ProcedureInfertilityTreatment
14.8 Risk factors in this pregnancy: Fertility-enhancing drugs, artificial insemination or intrauterine insemination ProcedureArtificialInsemination
14.9 Risk factors in this pregnancy: Assisted reproductive technology ProcedureAssistedFertilization
14.10 Risk factors in this pregnancy: previous cesarean delivery ObservationPreviousCesarean
14.10 Risk factors in this pregnancy: previous cesarean delivery ObservationNumberPreviousCesareans
14.11 Risk factors in this pregnancy: None of the above ObservationNoneOfSpecifiedPregnancyRiskFactors
15 Infections present and/or treated during this pregnancy ConditionInfectionPresentDuringPregnancy
15.6 Infections present and/or treated during this pregnancy ObservationNoneOfSpecifiedInfectionsPresentDuringPregnancy
16 Obstetric procedures ProcedureObstetric
16.4 Obstetric procedures ObservationNoneOfSpecifiedObstetricProcedures
17 Date of birth PatientChildVitalRecords birthDate
18 Time of birth PatientChildVitalRecords birthDate.extension:birthTime
19 Certifier’s name PractitionerVitalRecords name
19 Certifier’s title PractitionerVitalRecords qualification
20 Date certified EncounterBirth participant:certifier.period.start
21 Principal source of payment for this delivery CoveragePrincipalPayerDelivery type
22 Infant’s medical record number PatientChildVitalRecords identifier:MRN
23 Was the mother transferred to this facility for maternal medical or fetal indications for delivery? EncounterMaternity hospitalization.admitSource (Y if present, N if not present)
24 Attendant’s name PractitionerVitalRecords name
24 Attendant’s title PractitionerVitalRecords qualification
24 Attendant’s N.P.I. PractitionerVitalRecords identifier
25 Mother’s weight at delivery ObservationMotherDeliveryWeight value
26.1 Characteristics of Labor and Delivery: Induction of labor ProcedureInductionOfLabor
26.2 Characteristics of Labor and Delivery: Augmentation of labor ProcedureAugmentationOfLabor
26.3 Characteristics of Labor and Delivery: Steroids for fetal lung maturation ObservationSteroidsFetalLungMaturation
26.4 Characteristics of Labor and Delivery: Antibiotics received by the mother during labor ObservationAntibioticsAdministeredDuringLabor
26.5 Characteristics of Labor and Delivery: Clinical chorioamnionitis ConditionChorioamnionitis
26.6 Characteristics of Labor and Delivery: Epidural or spinal anesthesia during labor ProcedureEpiduralOrSpinalAnesthesia
26.7 Characteristics of Labor and Delivery: None of the above ObservationNoneOfSpecifiedCharacteristicsOfLaborAndDelivery
27.C Method of delivery: Fetal presentation at birth ObservationFetalPresentation value
27.D Method of delivery: Final route and method of delivery ProcedureFinalRouteMethodDelivery code
27.D.1 Method of delivery: If cesarean, was a trial of labor attempted? ObservationLaborTrialAttempted value
28.1 Maternal Morbidity: Maternal transfusion ProcedureBloodTransfusion
28.2 Maternal Morbidity: Third or fourth degree perineal laceration ConditionPerinealLaceration
28.3 Maternal Morbidity: Ruptured uterus ConditionRupturedUterus
28.4 Maternal Morbidity: Unplanned hysterectomy ProcedureUnplannedHysterectomy
28.5 Maternal Morbidity: Admission to intensive care unit ObservationICUAdmission
28.6 Maternal Morbidity: None of the above ObservationNoneOfSpecifiedMaternalMorbidities
29 Birthweight ObservationBirthWeight value
30 Obstetric estimate of gestation at delivery ObservationGestationalAgeAtDelivery value
31 Sex: PatientChildVitalRecords extension:birthsex
32 Apgar score ObservationApgarScore value
33 Plurality PatientChildVitalRecords multipleBirthInteger.extension:multipleBirthTotal
34 If not single birth, order delivered in the pregnancy PatientChildVitalRecords multipleBirthInteger
35 If not single birth, specify number of infants in this delivery born alive: ObservationNumberLiveBirthsThisDelivery value
36.1 Abnormal Conditions of the Newborn: Assisted ventilation required immediately following delivery ProcedureAssistedVentilationFollowingDelivery
36.2 Abnormal Conditions of the Newborn: Assisted ventilation required for more than six hours ProcedureAssistedVentilationMoreThanSixHours
36.3 Abnormal Conditions of the Newborn: NICU admission ObservationNICUAdmission
36.4 Abnormal Conditions of the Newborn: Newborn given surfactant replacement therapy ProcedureSurfactantReplacementTherapy
36.5 Abnormal Conditions of the Newborn: Antibiotics received by the newborn for suspected neonatal sepsis ProcedureAntibioticSuspectedNeonatalSepsis
36.6 Abnormal Conditions of the Newborn: Seizure or serious neurologic dysfunction ConditionSeizure
54.7 Abnormal Conditions of the Newborn: None of the above ObservationNoneOfSpecifiedAbnormalConditionsOfNewborn
37 Congenital anomalies of the newborn ConditionCongenitalAnomalyOfNewborn
38 Was infant transferred within 24 hours of delivery? EncounterBirth hospitalization.dischargeDisposition
39 Is infant living at time of report? ObservationInfantLiving value
40 Is infant being breastfed at discharge? ObservationInfantBreastfedAtDischarge value

2016 US Standard Mothers Worksheet for Child’s Birth Certificate Mapping

Item # Form Element FHIR Profile FHIR Field
1 What is your current legal name? PatientMotherVitalRecords name
2 What will be your baby’s legal name? PatientChildVitalRecords name
3 Where do you usually live--that is--where is your household/residence located? PatientMotherVitalRecords address
4 Is this household inside city limits? PatientMotherVitalRecords address.extension:withinCityLimitsIndicator
5 What is your mailing address? PatientMotherVitalRecords address
6 What is your date of birth? PatientMotherVitalRecords birthDate
7 In what State, U.S. territory, or foreign country were you born? PatientMotherVitalRecords extension:birthPlace
8 What is the highest level of schooling that you will have completed at the time of delivery? ObservationEducationLevelVitalRecords code
9 Are you Spanish/Hispanic/Latina? PatientMotherVitalRecords extension:ethnicity
10 What is your race? PatientMotherVitalRecords extension:race
11 Did you receive WIC food for yourself because you were pregnant with this child? ObservationMotherReceivedWICFood value
12 Did this pregnancy result from infertility treatment? QuestionnaireMothersWorksheetChildsBirthCertificate
13 What is your height? ObservationMotherHeight value
14 What was your prepregnancy weight, that is, your weight immediately before you became pregnant with this child? ObservationMotherPrepregnancyWeight value
15 How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? ObservationCigaretteSmokingBeforeDuringPregnancy value
17 What name did you use prior to your first marriage? PatientMotherVitalRecords name
18 Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? ObservationMotherMarriedDuringPregnancy value
18 If not married, has a paternity acknowledgment been completed? ObservationPaternityAcknowledgementSigned value
19 What is the current legal name of your baby’s father? RelatedPersonFatherNaturalVitalRecords name
20 What is the father’s date of birth? RelatedPersonFatherNaturalVitalRecords birthDate
21 In what State, U.S. territory, or foreign country was the father born? RelatedPersonFatherNaturalVitalRecords extension:birthPlace
22 What is the highest level of schooling that the father will have completed at the time of delivery? ObservationEducationLevelVitalRecords code
23 Is the father Spanish/Hispanic/Latino? RelatedPersonFatherNaturalVitalRecords extension:ethnictiy
24 What is the father’s race? RelatedPersonFatherNaturalVitalRecords extension:ethnicity
25a What is your Social Security Number? PatientMotherVitalRecords identifier:SSN
25b What is the father’s Social Security Number? RelatedPersonFatherNaturalVitalRecords identifier:SSN
26a Do you want a Social Security Number issued for your baby? ObservationSSNRequestedForChild value
26b I request that the Social Security Administration assign a Social Security number to the child named on this form and authorize the State to provide the Social Security Administration with the information from this form which is needed to assign a number. QuestionnaireMothersWorksheetChildsBirthCertificate
27a If other than the mother, what is the name of the person providing information for this worksheet? QuestionnaireMothersWorksheetChildsBirthCertificate
27b What is your relationship to the baby’s mother? QuestionnaireMothersWorksheetChildsBirthCertificate

2003 Revision of the U.S. Standard Report of Fetal Death Mapping

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Item # Form Element FHIR Profile FHIR Field
- Local File No. CompositionProviderFetalDeathReport extension:fetalDeathLocalFileNumber
- State File Number CompositionProviderFetalDeathReport extension:fetalDeathReportNumber
1 Name of Fetus PatientDecedentFetusVitalRecords name
2 Time of Delivery PatientDecedentFetusVitalRecords birthDate.extension:birthTime
3 Sex PatientDecedentFetusVitalRecords extension:birthsex
4 Date of Delivery PatientDecedentFetusVitalRecords birthDate
5a City, Town, or Location of Delivery PatientDecedentFetusVitalRecords extension:birthPlace
5b Zip Code of Delivery PatientDecedentFetusVitalRecords extension:birthPlace
6 County of Delivery PatientDecedentFetusVitalRecords extension:birthPlace
7 Place Where Delivery Occurred EncounterMaternity location.physicalType
7.a Home Birth: Planned to deliver at home? ObservationPlannedToDeliverAtHome value
8 Facility Name / address EncounterMaternity identifier
9 Facility Id EncounterMaternity identifier
10a Mother’s Current Legal Name PatientMotherVitalRecords name:currentLegalName
10b Mother's Date of Birth PatientMotherVitalRecords birthDate
10c Mother’s Name Prior to First Marriage PatientMotherVitalRecords name:namePriorToFirstMarriage
10d Mother's Birthplace PatientMotherVitalRecords extension:birthPlace
11a Residence of Mother-State PatientMotherVitalRecords address.state
11b Residence of Mother-County PatientMotherVitalRecords address.district
11c Residence of Mother-City, Town, Or Location PatientMotherVitalRecords address.city
11d Residence of Mother-Street And Number PatientMotherVitalRecords address.line
11e Residence of Mother-Apt. No. PatientMotherVitalRecords address.line
11f Residence of Mother-Zip Code PatientMotherVitalRecords address.postalCode
11g Residence of Mother-Inside City Limits? PatientMotherVitalRecords address.extension:withinCityLimitsIndicator
12a Father’s Current Legal Name RelatedPersonFatherNaturalVitalRecords name:currentLegalName
12b Father's Date of Birth RelatedPersonFatherNaturalVitalRecords birthDate
12c Father's Birthplace RelatedPersonFatherNaturalVitalRecords extension:birthPlace
13 Method of Disposition: ObservationMethodOfDisposition value
14 Attendant’s Name PractitionerVitalRecords name
14 Attendant’s Title PractitionerVitalRecords qualification
14 Attendant’s NPI PractitionerVitalRecords identifier
15 Name Of Person Completing Report PractitionerVitalRecords name
15 Title Of Person Completing Report PractitionerVitalRecords qualification
16 Date Report Completed CompositionProviderFetalDeathReport date
17 Date Received By Registrar CompositionProviderFetalDeathReport extension:dateReceivedByRegistrar
18a Initiating Cause/Condition ConditionFetalDeathCauseOrCondition code
18b Other Significant Causes or Conditions ConditionFetalDeathOtherCauseOrCondition code
18c Weight of Fetus ObservationBirthWeight value
18d Obstetric Estimate of Gestation at Delivery ObservationGestationalAgeAtDelivery value
18e Estimated Time of Fetal Death ObservationFetalDeathTimePoint value
18f Was an Autopsy Performed? ObservationAutopsyPerformedIndicatorVitalRecords value
18g Was a Histological Placental Examination Performed? ObservationHistologicalPlacentalExamPerformed value
18h Were Autopsy or Histological Placental Examination Results Used in Determining the Cause of Fetal Death? ObservationAutopsyHistologicalExamResultsUsed value
19 Mother’s Education ObservationEducationLevelVitalRecords code
20 Mother of Hispanic Origin? PatientMotherVitalRecords extension:ethnicity
21 Mother’s Race PatientMotherVitalRecords extension:race
22 Mother Married? ObservationMotherMarriedDuringPregnancy value
23a Date of First Prenatal Care Visit ObservationDateOfFirstPrenatalCareVisit value
24 Total Number of Prenatal Visits For This Pregnancy ObservationNumberPrenatalVisits value
25 Mother’s Height ObservationMotherHeight value
26 Mother’s Prepregnancy Weight ObservationMotherPrepregnancyWeight value
28 Did Mother Get WIC Food For Herself During This Pregnancy? ObservationMotherReceivedWICFood value
29a Number of Previous Live Births: Now Living Number ObservationNumberBirthsNowLiving value
29b Number of Previous Live Births: Now Dead Number ObservationNumberBirthsNowDead value
29c Date of Last Live Birth ObservationDateOfLastLiveBirth value
31 Cigarette Smoking Before and During Pregnancy ObservationCigaretteSmokingBeforeDuringPregnancy value
32 Date Last Normal Menses Began ObservationLastMenstrualPeriod value
33 Plurality PatientChildVitalRecords multipleBirthInteger.extension:multipleBirthTotal
34 If Not Single Birth-Born First, Second, Third, etc. PatientDecedentFetusVitalRecords multipleBirthInteger
36.1 Risk factors in this pregnancy: Diabetes - Prepregnancy ConditionPrepregnancyDiabetes
36.2 Risk factors in this pregnancy: Diabetes - Gestational ConditionGestationalDiabetes
36.3 Risk factors in this pregnancy: Hypertension - Prepregnancy ConditionPrepregnancyHypertension
36.4 Risk factors in this pregnancy: Hypertension - Gestational ConditionGestationalHypertension
36.5 Risk factors in this pregnancy: Eclampsia ConditionEclampsiaHypertension
36.8 Risk factors in this pregnancy: Pregnancy resulted from infertility treatment ProcedureInfertilityTreatment
36.9 Risk factors in this pregnancy: Fertility-enhancing drugs, artificial insemination or intrauterine insemination ProcedureArtificialInsemination
36.10 Risk factors in this pregnancy: Assisted reproductive technology ProcedureAssistedFertilization
36.11 Risk factors in this pregnancy: Previous cesarean delivery ObservationPreviousCesarean
36.11 Risk factors in this pregnancy: Previous cesarean delivery ObservationNumberPreviousCesareans
36.12 Risk factors in this pregnancy: None of the above ObservationNoneOfSpecifiedPregnancyRiskFactors
38.C Method of Delivery: Fetal presentation at delivery ObservationFetalPresentation value
38.D Method of Delivery: Final route and method of delivery ProcedureFinalRouteMethodDelivery code
38.D.1 Method of Delivery: If cesarean, was a trial of labor attempted? ObservationLaborTrialAttempted value
39.3 Maternal Morbidity: Ruptured uterus ConditionRupturedUterus
39.5 Maternal Morbidity: Admission to intensive care unit ObservationICUAdmission
39.7 Maternal Morbidity: None of the above ObservationNoneOfSpecifiedMaternalMorbidities

2019 US Standard Facility Worksheet for the Report of Fetal Death Mapping

Item # Form Element FHIR Profile FHIR Field
- Patient’s medical record # PatientMotherVitalRecords identifier:MRN
- Patient’s name PatientMotherVitalRecords name
1 Facility name EncounterMaternity name
1 Facility address EncounterMaternity address
2 Facility I.D. (National Provider Identifier) EncounterMaternity identifier
3 City, Town or Location of delivery PatientDecedentFetusVitalRecords extension:birthPlace
4 County of delivery PatientDecedentFetusVitalRecords extension:birthPlace
5 Place of delivery EncounterMaternity location.physicalType
5.a Planned to deliver at home ObservationPlannedToDeliverAtHome value
6 Date of first prenatal care visit ObservationDateOfFirstPrenatalCareVisit value
7 Date last normal menses began: ObservationLastMenstrualPeriod value
8 Number of previous live births now living ObservationNumberBirthsNowLiving value
9 Number of previous live births now dead ObservationNumberBirthsNowDead value
10 Date of last live birth ObservationDateOfLastLiveBirth value
11.1 Risk factors in this pregnancy: Diabetes - Prepregnancy ConditionPrepregnancyDiabetes
11.2 Risk factors in this pregnancy: Diabetes - Gestational ConditionGestationalDiabetes
11.3 Risk factors in this pregnancy: Hypertension - Prepregnancy ConditionPrepregnancyHypertension
11.4 Risk factors in this pregnancy: Hypertension - Gestational ConditionGestationalHypertension
11.5 Risk factors in this pregnancy: Eclampsia ConditionEclampsiaHypertension
11.6 Risk factors in this pregnancy: Pregnancy resulted from infertility treatment ProcedureInfertilityTreatment
11.7 Risk factors in this pregnancy: Fertility-enhancing drugs, artificial insemination or intrauterine insemination ProcedureArtificialInsemination
11.8 Risk factors in this pregnancy: Assisted reproductive technology ProcedureAssistedFertilization
11.9 Risk factors in this pregnancy: previous cesarean delivery ObservationPreviousCesarean
11.9 Risk factors in this pregnancy: previous cesarean delivery ObservationNumberPreviousCesareans
11.10 Risk factors in this pregnancy: None of the above ObservationNoneOfSpecifiedPregnancyRiskFactors
12 Date of delivery PatientDecedentFetusVitalRecords birthDate
13 Time of delivery PatientDecedentFetusVitalRecords extension:birthTime
14 Name of person completing report PractitionerVitalRecords name
14 Title of person completing report PractitionerVitalRecords qualification
15 Date report completed CompositionProviderFetalDeathReport date
16 Attendant’s name PractitionerVitalRecords name
16 Attendant’s title PractitionerVitalRecords qualification
16 Attendant’s N.P.I. PractitionerVitalRecords identifier
17.A Method of Delivery: Fetal presentation at delivery ObservationFetalPresentation value
17.B Method of Delivery: Final route and method of delivery ProcedureFinalRouteMethodDelivery code
18.1 Maternal Morbidity: Ruptured uterus ConditionRupturedUterus
18.2 Maternal Morbidity: Admission to intensive care unit ObservationICUAdmission
18.3 Maternal Morbidity: None of the above ObservationNoneOfSpecifiedMaternalMorbidities
19 Weight of fetus ObservationBirthWeight value
20 Obstetric estimate of gestation at delivery ObservationGestationalAgeAtDelivery value
21 Sex PatientDecedentFetusVitalRecords extension:birthsex
22 Plurality PatientDecedentFetusVitalRecords multipleBirth[x].extension:multipleBirthTotal
23 If not single delivery, order delivered in the pregnancy PatientDecedentFetusVitalRecords multipleBirthInteger
24 If not single delivery, specify number of fetal losses in this delivery ObservationNumberFetalDeathsThisDelivery value
25 Method of Disposition ObservationMethodOfDisposition
26 Initiating Cause/Condition ConditionFetalDeathCauseOrCondition code
27 Other Significant Causes or Conditions ConditionFetalDeathOtherCauseOrCondition code
28 Was an autopsy performed? ObservationAutopsyPerformedIndicatorVitalRecords
29 Was a histological placental examination performed? ObservationHistologicalPlacentalExamPerformed value
30 Were autopsy or histological placental examination results used in determining the cause of fetal death? ObservationAutopsyHistologicalExamResultsUsed value
31 Estimated time of fetal death ObservationFetalDeathTimePoint value

2019 US Standard Patient’s Worksheet for the Report of Fetal Death Mapping

Item # Form Element FHIR Profile FHIR Field
- Patient’s Medical Record # PatientMotherVitalRecords identifier:MRN
- Patient’s Name PatientMotherVitalRecords name
1 Would you like to name the child? PatientDecedentFetusVitalRecords name
2 What is your current legal name? PatientMotherVitalRecords name
3 Where do you usually live (household/residence location)? PatientMotherVitalRecords address
4 Is this household inside city limits? PatientMotherVitalRecords address.extension:withinCityLimitsIndicator
5 What is your mailing address? PatientMotherVitalRecords address
6 What is your date of birth? PatientMotherVitalRecords birthDate
7 In what State, U.S. territory, or foreign country were you born? PatientMotherVitalRecords extension:birthPlace
8 What is the highest level of schooling that you have completed at the time of delivery? ObservationEducationLevelVitalRecords code
9 Are you Spanish/Hispanic/Latina? PatientMotherVitalRecords extension:ethnicity
10 What is your race? PatientMotherVitalRecords extension:race
11 What is the current legal name of your baby’s father? RelatedPersonFatherNaturalVitalRecords name:currentLegalName
12 What is the father’s date of birth? RelatedPersonFatherNaturalVitalRecords birthDate
13 In what State, U.S. territory, or foreign country was the father born? RelatedPersonFatherNaturalVitalRecords extension:birthPlace
14 Did you receive WIC (Women, Infants & Children) food for yourself during this pregnancy? ObservationMotherReceivedWICFood value
15 What is your height? ObservationMotherHeight value
16 What was your prepregnancy weight? ObservationMotherPrepregnancyWeight value
17 How many cigarettes OR packs of cigarettes did you smoke on an average day during each time period? ObservationCigaretteSmokingBeforeDuringPregnancy value

2016 US Standard Mothers Worksheet for Child’s Birth Certificate Questionnaire Mapping

Item # Form Element Questionnaire FHIR Field
1 What is your current legal name? Questionnaire-mothers-live-birth.item.linkId=mother-current-legal-name item.linkId=mother-current-legal-name
2 What will be your baby’s legal name? Questionnaire-mothers-live-birth.item.linkId=child-name item.linkId=child-name
3 Where do you usually live--that is--where is your household/residence located? Questionnaire-mothers-live-birth.item.linkId=mother-address item.linkId=mother-address
4 Is this household inside city limits? Questionnaire-mothers-live-birth.item.linkId=inside-city-limits item.linkId=inside-city-limits
5 What is your mailing address? Questionnaire-mothers-live-birth.item.linkId=mother-mail item.linkId=mother-mail
6 What is your date of birth? Questionnaire-mothers-live-birth.item.linkId=mother-dob item.linkId=mother-dob
7 In what State, U.S. territory, or foreign country were you born? Questionnaire-mothers-live-birth.item.linkId=mother-birthplace item.linkId=mother-birthplace
8 What is the highest level of schooling that you will have completed at the time of delivery? Questionnaire-mothers-live-birth.item.linkId=mother-education item.linkId=mother-education
9 Are you Spanish/Hispanic/Latina? Questionnaire-mothers-live-birth.item.linkId=mother-ethnicity item.linkId=mother-ethnicity
10 What is your race? Questionnaire-mothers-live-birth.item.linkId=mother-race item.linkId=mother-race
11 Did you receive WIC food for yourself because you were pregnant with this child? Questionnaire-mothers-live-birth.item.linkId=receive-wic item.linkId=receive-wic
12 Did this pregnancy result from infertility treatment? Questionnaire-mothers-live-birth.item.linkId=infertility-treatment item.linkId=infertility-treatment
13 What is your height? Questionnaire-mothers-live-birth.item.linkId=mothers-height item.linkId=mothers-height
14 What was your prepregnancy weight, that is, your weight immediately before you became pregnant with this child? Questionnaire-mothers-live-birth.item.linkId=mothers-prepregnancy-weight item.linkId=mothers-prepregnancy-weight
15 How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? Questionnaire-mothers-live-birth.item.linkId=mothers-smoking item.linkId=mothers-smoking
17 What name did you use prior to your first marriage? Questionnaire-mothers-live-birth.item.linkId=mother-prior-name item.linkId=mother-prior-name
18 Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? Questionnaire-mothers-live-birth.item.linkId=married-conception item.linkId=married-conception
18 If not married, has a paternity acknowledgment been completed? Questionnaire-mothers-live-birth.item.linkId=married-conception.linkId=paternity-ack item.linkId=married-conception.linkId=paternity-ack
19 What is the current legal name of your baby’s father? Questionnaire-mothers-live-birth.item.linkId=father-current-legal-name item.linkId=father-current-legal-name
20 What is the father’s date of birth? Questionnaire-mothers-live-birth.item.linkId=father-dob item.linkId=father-dob
21 In what State, U.S. territory, or foreign country was the father born? Questionnaire-mothers-live-birth.item.linkId=father-birthplace item.linkId=father-birthplace
22 What is the highest level of schooling that the father will have completed at the time of delivery? Questionnaire-mothers-live-birth.item.linkId=father-education item.linkId=father-education
23 Is the father Spanish/Hispanic/Latino? Questionnaire-mothers-live-birth.item.linkId=father-ethnicity item.linkId=father-ethnicity
24 What is the father’s race? Questionnaire-mothers-live-birth.item.linkId=father-race item.linkId=father-race
25a What is your Social Security Number? Questionnaire-mothers-live-birth.item.linkId=mother-ssn item.linkId=mother-ssn
25b What is the father’s Social Security Number? Questionnaire-mothers-live-birth.item.linkId=father-ssn item.linkId=father-ssn
26a Do you want a Social Security Number issued for your baby? Questionnaire-mothers-live-birth.item.linkId=baby-ssn item.linkId=baby-ssn
26b I request that the Social Security Administration assign a Social Security number to the child named on this form and authorize the State to provide the Social Security Administration with the information from this form which is needed to assign a number. Questionnaire-mothers-live-birth.item.linkId=baby-ssn-sig item.linkId=baby-ssn-sig
27a If other than the mother, what is the name of the person providing information for this worksheet? Questionnaire-mothers-live-birth.item.linkId=informant-name item.linkId=informant-name
27b What is your relationship to the baby’s mother? Questionnaire-mothers-live-birth.item.linkId=informant-relationship item.linkId=informant-relationship

2019 US Standard Patient’s Worksheet for the Report of Fetal Death Questionnaire Mapping

Item # Form Element Questionnaire FHIR Field
- Patient’s Medical Record # Questionnaire-patients-fetal-death.source source
- Patient’s Name Questionnaire-patients-fetal-death.source source
1 Would you like to name the child? Questionnaire-patients-fetal-death.item.linkId=child-name item.linkId=child-name
2 What is your current legal name? Questionnaire-patients-fetal-death.item.linkId=mother-current-legal-name item.linkId=mother-current-legal-name
3 Where do you usually live (household/residence location)? Questionnaire-patients-fetal-death.item.linkId=mother-address item.linkId=mother-address
4 Is this household inside city limits? Questionnaire-patients-fetal-death.item.linkId=inside-city-limits item.linkId=inside-city-limits
5 What is your mailing address? Questionnaire-patients-fetal-death.item.linkId=mother-mail item.linkId=mother-mail
6 What is your date of birth? Questionnaire-patients-fetal-death.item.linkId=mother-dob item.linkId=mother-dob
7 In what State, U.S. territory, or foreign country were you born? Questionnaire-patients-fetal-death.item.linkId=mother-birthplace item.linkId=mother-birthplace
8 What is the highest level of schooling that you have completed at the time of delivery? Questionnaire-patients-fetal-death.item.linkId=mother-education item.linkId=mother-education
9 Are you Spanish/Hispanic/Latina? Questionnaire-patients-fetal-death.item.linkId=mother-ethnicity item.linkId=mother-ethnicity
10 What is your race? Questionnaire-patients-fetal-death.item.linkId=mother-race item.linkId=mother-race
11 What is the current legal name of your baby’s father? Questionnaire-patients-fetal-death.item.linkId=father-current-legal-name item.linkId=father-current-legal-name
12 What is the father’s date of birth? Questionnaire-patients-fetal-death.item.linkId=father-dob item.linkId=father-dob
13 In what State, U.S. territory, or foreign country was the father born? Questionnaire-patients-fetal-death.item.linkId=father-birthplace item.linkId=father-birthplace
14 Did you receive WIC (Women, Infants & Children) food for yourself during this pregnancy? Questionnaire-patients-fetal-death.item.linkId=receive-wic item.linkId=receive-wic
15 What is your height? Questionnaire-patients-fetal-death.item.linkId=mothers-height item.linkId=mothers-height
16 What was your prepregnancy weight? Questionnaire-patients-fetal-death.item.linkId=mothers-prepregnancy-weight item.linkId=mothers-prepregnancy-weight
17 How many cigarettes OR packs of cigarettes did you smoke on an average day during each time period? Questionnaire-patients-fetal-death.item.linkId=mothers-smoking item.linkId=mothers-smoking