This page is part of the Vital Records Birth and Fetal Death Reporting (v2.0.0: STU2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Mapping Electronic Health Record Data to the Birth and Fetal Death Record Data Elements

Data elements that are included in a birth or fetal death report are based on data that are part of the mother, child or fetus' electronic health record (EHR). The following PHINVADs-hosted valuesets were published as part of the IHE Quality, Research and Public Health Technical Framework Supplement Birth and Fetal Death Reporting-Enhanced (BFDR-E) to support query of data elements from an EHR. Implementers can use these valuesets as a supplement to the Guide to Completing the Facility Worksheets for the Certificate of Live Birth and Report of Fetal Death.

The table shows the name of the data element, the IJE element that corresponds to the data element, the FHIR profile in this IG used to represent the data element, the type of element, and the valueset that can be used as part of a query. Please note that the referenced value sets have not been updated since the publication of the IHE document in 2021. Therefore, implementers should consider these value sets as an informative guide rather than a definitive resource.

This content is provided in support of implementers of this IG, but is not formally a part of the FHIR specification for exchange of birth and fetal death records.

Note: In some cases, there is not a direct mapping between data element and IJE element, and the IJE element that is most closely associated with the the data element is denoted with an asterisk.

Observations

Name	IJE Name	Purpose	Profile	Codesystem
10 Min Apgar Score	APGAR10	10 Min Apgar Score	ObservationApgarScore	LOINC
5 Min Apgar Score	APGAR5	5 Min Apgar Score	ObservationApgarScore	LOINC
Augmentation of Labor Finding	AUGL*	Labor was augmented	ProcedureAugmentationOfLabor	SNOMED-CT
Birth Plurality of Delivery	PLUR	Plurality, which is the number of fetuses delivered live or dead at any time in the pregnancy regardless of gestational age or if the fetuses were delivered at different dates in the pregnancy. (“Reabsorbed” fetuses, those which are not “delivered” (expulsed or extracted from the mother) should not be counted.)	PatientChildVitalRecords	LOINC
Birth Weight	BWG	Birth Weight	ObservationBirthWeight	LOINC
Birth Place Home Intended		Birth occurred in the at home as intended	ObservationPlannedToDeliverAtHome	SNOMED-CT
Birth Place Home Unintended		Birth occurred in the at home as unintended	ObservationPlannedToDeliverAtHome	SNOMED-CT
Birthplace Setting		Birthplace of the newborn (setting)		LOINC
Body Weight		Body weight of the patient		LOINC
Breastfed Infant	BFED	Breastfed Infant at discharge	ObservationInfantBreastfedAtDischarge	SNOMED-CT
Conception Date		Conception Date		LOINC
Date of Last Live Birth	YLLB, MLLB	Date of Last Live Birth	ObservationDateOfLastLiveBirth	LOINC
Date of Last Menses	DLMP_YR, DLMP_MO, DLMP_DY	Date of Last Menses	ObservationLastMenstrualPeriod	LOINC
Date of Last Other Pregnancy Outcome	YOPO, MOPO	Date of Last Other Pregnancy Outcome such as spontaneous or induced losses or ectopic pregnancy	ObservationDateOfLastOtherPregnancyOutcome	LOINC
Estimated Time Of Fetal Death	ETIME	Question as to the estimated time of fetal death	ObservationFetalDeathTimePoint	LOINC
Fetal Presentation at Birth- Breech	PRES*	Fetal Presentation at Birth- Breech method of delivery	ObservationFetalPresentation	SNOMED-CT
Fetal Presentation at Birth- Cephalic	PRES*	Fetal Presentation at Birth- Cephalic method of delivery	ObservationFetalPresentation	SNOMED-CT
Fetal Presentation at Birth- Other	PRES*	Fetal Presentation at Birth- Other	ObservationFetalPresentation	SNOMED-CT
Fever Greater Than 100.4		Fever Greater Than 100.4 During Labor		SNOMED-CT
First Prenatal Care Visit	DOFP_YR, DOFP_MO, DOFP_DY	Date of the First Prenatal Care Visit	ObservationDateOfFirstPrenatalCareVisit	LOINC
Height	HFT, HIN	Mother’s height	ObservationMotherHeight	LOINC
Induction of Labor Finding	INDL*	Labor was induced	ProcedureInductionOfLabor	SNOMED-CT
Institution Referred to		Institution to which the patient was referred		LOINC
Karyotype Confirmed		Karyotype Confirmed as an anomaly of the newborn		SNOMED-CT
Karyotype Result		Karyotyping to determine that the result is pending		LOINC
Method of Delivery Cesarean Finding		Delivery of the entire fetus through the vaginal wall (cesarean)	ProcedureFinalRouteMethodDelivery	SNOMED-CT
Method of Delivery Vaginal Forceps Finding	ATTF - NOT IMPLEMENTED	Delivery of the fetus using vaginal forceps	ProcedureFinalRouteMethodDelivery	SNOMED-CT
Method of Delivery Vaginal-Spon Finding		Delivery of the entire fetus through the vagina by the natural force of labor with or without manual assistance from the delivery attendant.	ProcedureFinalRouteMethodDelivery	SNOMED-CT
Method of Delivery Vaginal Vacuum Finding	ATTV - NOT IMPLEMENTED	Delivery of the fetus using vaginal vacuum	ProcedureFinalRouteMethodDelivery	SNOMED-CT
Mothers Delivery Weight	DWGT	Mother’s Delivery Weight	ObservationMotherDeliveryWeight	LOINC
Number of Fetal Deaths This Delivery	FDTH	Number of Fetal Deaths This Delivery	ObservationNumberFetalDeathsThisDelivery	LOINC
Number of Live Births	LIVEB	Number of Live Births for the current pregnancy	ObservationNumberLiveBirthsThisDelivery	LOINC
Number of Preterm Births		Number of preterm births in prior pregnancies		LOINC
Number of Previous Cesareans	NPCES	Number of Previous Cesareans as a Risk Factor in Pregnancy	ObservationNumberPreviousCesareans	LOINC
Number of Previous Live Births Now Dead	PLBD	Number of Previous Live Births Now Dead	ObservationNumberBirthsNowDead	LOINC
Number of Previous Live Births Now Living	PLBL	Number of Live Births Now Living	ObservationNumberBirthsNowLiving	LOINC
Number of Prior Pregnancies		Number of Prior Pregnancies		LOINC
Number Prenatal Care Visits	NPREV	Number Prenatal Care Visits	ObservationNumberPrenatalVisits	LOINC
Obstetric Estimate of Gestation	OWGEST	Obstetric Estimate of Gestation of the newborn	ObservationGestationalAgeAtDelivery	LOINC
Pre-Pregnancy Weight	PWGT	Mother’s Pre-Pregnancy Weight	ObservationMotherPrepregnancyWeight	LOINC
Previous Cesarean	PCES	Risk Factors of Pregnancy Previous Cesarean	ObservationPreviousCesarean	SNOMED-CT
Previous Other Pregnancy Outcomes	POPO	Previous Other Pregnancy Outcomes	ObservationNumberOtherPregnancyOutcomes	LOINC
Scheduled Cesarean Finding		Cesarean Section was scheduled		SNOMED-CT
Seizure or Serious Neurologic Dysfunction	SEIZ	Newborn suffered a Seizure or Serious Neurologic Dysfunction reflecting an abnormal condition of the newborn	ConditionSeizure	SNOMED-CT
Spontaneous Onset of Labor		Spontaneous Onset of Labor		SNOMED-CT

Conditions

Name	IJE Name	Purpose	Profile	Codesystem
Anencephaly of the Newborn	ANEN	Anencephaly of the Newborn as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Chlamydia	CHAM	Chlamydia as Infections present and treated during this pregnancy	ConditionInfectionPresentDuringPregnancy	SNOMED-CT
Chorioamnionitis During Labor	CHOR	Chorioamnionitis During Labor	ConditionChorioamnionitis	SNOMED-CT
Cleft Lip with or without Cleft Palate	CL	Cleft Lip with/without Cleft Palate as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Cleft Palate Alone	CP	Cleft Palate alone as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Congenital Diaphragmatic Hernia	CDH	Congenital Diaphragmatic Hernia as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Cyanotic Congenital Heart Disease	CCHD	Cyanotic Congenital Heart Disease as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Cytomegalovirus		Infection with Cytomegalovirus		SNOMED-CT
Downs Syndrome	DOWT	Downs Syndrome as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Eclampsia	EHYPE	Risk Factors of Eclampsia	ConditionEclampsiaHypertension	SNOMED-CT
Fourth Degree Perineal Laceration	PLAC	Fourth Degree Perineal Laceration as a maternal morbidity	ConditionPerinealLaceration	SNOMED-CT
Gastroschisis of the Newborn	GAST	Gastroschisis of the Newborn as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Gestational Diabetes	GDIAB	Risk Factors of Gestational Diabetes	ConditionGestationalDiabetes	SNOMED-CT
Gestational Hypertension	GHYPE	Risk Factors of Gestational Hypertension	ConditionGestationalHypertension	SNOMED-CT
Gonorrhea	GON	Gonorrhea as Infections present and treated during this pregnancy	ConditionInfectionPresentDuringPregnancy	SNOMED-CT
Group B Streptococcus	GBS - NOT IMPLEMENTED	Infection with Group B Streptococcus	ConditionInfectionPresentDuringPregnancy	SNOMED-CT
Hepatitis B	HEPB	Hepatitis B as Infections present and treated during this pregnancy	ConditionInfectionPresentDuringPregnancy	SNOMED-CT
Hepatitis C	HEPC	Hepatitis C as Infections present and treated during this pregnancy	ConditionInfectionPresentDuringPregnancy	SNOMED-CT
Hypospadias	HYPO	Hypospadias as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Limb Reduction Defect	LIMB	Limb Reduction Defect as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Listeria		Listeria as Infections present and treated during this pregnancy	ConditionInfectionPresentDuringPregnancy	SNOMED-CT
Meningomyelocele/Spina Bifida - Newborn	MNSB	Meningomyelocele/Spina Bifida of the Newborn as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Neonatal Sepsis		Newborn had suspected neonatal sepsis reflecting an abnormal condition of the newborn		SNOMED-CT
Omphalocele of the Newborn	OMPH	Omphalocele of the Newborn as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Parvovirus		Infection with Parvovirus	ConditionInfectionPresentDuringPregnancy	SNOMED-CT
Precipitous Labor	PRIC - NOT IMPLEMENTED	Onset of labor with Precipitous Labor		SNOMED-CT
Premature Rupture	PROM - NOT IMPLEMENTED	Onset of labor with Premature Rupture		SNOMED-CT
Prepregnancy Diabetes	PDIAB	Risk Factors of Prepregnancy Diabetes	ConditionPrepregnancyDiabetes	SNOMED-CT
Prepregnancy Hypertension	PHYPE	Risk Factors of Prepregnancy Hypertension	ConditionPrepregnancyHypertension	SNOMED-CT
Prolonged Labor	PROL - NOT IMPLEMENTED	Onset of labor with Prolonged Labor		SNOMED-CT
Ruptured Uterus	RUT	Ruptured Uterus as a maternal morbidity	ConditionRupturedUterus	SNOMED-CT
Significant Birth Injury	BINJ - NOT IMPLEMENTED	Newborn suffered a Significant Birth Injury (skeletal fracture(s), peripheral nerve injury, and/ or soft tissue/solid organ hemorrhage which requires intervention) reflecting an abnormal condition of the newborn		SNOMED-CT
Suspected Chromosomal Disorder	CDIT	Suspected Chromosomal Disorder as an anomaly of the newborn	ConditionCongenitalAnomalyOfNewborn	SNOMED-CT
Syphilis	SYPH	Syphilis as Infections present and treated during this pregnancy	ConditionInfectionPresentDuringPregnancy	SNOMED-CT
Third Degree Perineal Laceration	PLAC	Third Degree Perineal Laceration as a maternal morbidity	ConditionPerinealLaceration	SNOMED-CT
Toxoplasmosis		Infection with Toxoplasmosis	ConditionInfectionPresentDuringPregnancy	SNOMED-CT

Procedures

Name	IJE Name	Purpose	Profile	Codesystem
Antibiotic Administration Procedure	ANTI*	Antibiotic Administration Procedure during labor and delivery	ObservationAntibioticsAdministeredDuringLabor	SNOMED-CT
Artificial or Intrauterine Insemination	INFT_DRG	Artificial or Intrauterine Insemination as a Risk Factor in Pregnancy	[ProcedureArtificialInsemination]	SNOMED-CT
Assisted Ventilation	AVEN1*, AVEN6*	Newborn was provided assisted ventilation reflecting an abnormal condition of the newborn	ProcedureAssistedVentilationFollowingDelivery, ProcedureAssistedVentilationMoreThanSixHours	SNOMED-CT
Assistive Reproductive Technology	INFT_ART	Assistive Reproductive Technology as a Risk Factor in Pregnancy	[ProcedureAssistedFertilization]	SNOMED-CT
Augmentation of Labor - Procedure	AUGL	Procedure of Augmentation of Labor	ProcedureAugmentationOfLabor	SNOMED-CT
Cervical Cerclage	CERV - NOT IMPLEMENTED	Obstetric Procedures as Cervical Cerclage		SNOMED-CT
Delivery	ROUT	Delivery Procedure	ProcedureFinalRouteMethodDelivery	SNOMED-CT
Epidural Anesthesia - Procedure	ESAN	Epidural Anesthesia Procedure	ProcedureEpiduralOrSpinalAnesthesia	SNOMED-CT
External Cephalic Version	ECVS	Obstetric Procedures as External Cephalic Version	ProcedureObstetric	SNOMED-CT
Autopsy Performed	AUTOP	Autopsy was performed	ObservationAutopsyPerformedIndicator	SNOMED-CT
Hysterotomy Hysterectomy	UHYS	hysterotomy/hysterectomy as the method of delivery in fetal death	ProcedureFinalRouteMethodDelivery	SNOMED-CT
ICU Care	AINT	Mother was transferred to ICU following the birth	ObservationICUAdmission	SNOMED-CT
Induction of Labor	INDL	Induction of Labor	ProcedureInductionOfLabor	SNOMED-CT
Infertility Treatment	INFT	Risk Factors of Pregnancy Infertility Treatment	ProcedureInfertilityTreatment	SNOMED-CT
Karyotype Determination		Karyotype determination as an anomaly of the newborn		SNOMED-CT
Pregnancy Resulting From Fertility Enhancing Drugs	INFT_DRG*	Indicate whether a pregnancy resulted from fertility enhancing drugs	[ProcedureArtificialInsemination]	SNOMED-CT
Surfactant Replacement Therapy	SURF	Surfactant Replacement Therapy	ProcedureSurfactantReplacementTherapy	SNOMED-CT
NICU Care	NICU	Baby was transferred to NICU following the birth	ObservationNICUAdmission	SNOMED-CT
Route and Method of Delivery - Cesarean	ROUT*	Route and Method of Delivery as Cesarean Delivery	ProcedureFinalRouteMethodDelivery	SNOMED-CT
Route and Method of Delivery - Forceps	ROUT*	Route and Method of Delivery as Forceps Delivery	ProcedureFinalRouteMethodDelivery	SNOMED-CT
Route and Method of Delivery - Scheduled C	ROUT*	Route and Method of Delivery as Scheduled Cesarean	ProcedureFinalRouteMethodDelivery	SNOMED-CT
Route and Method of Delivery - Spontaneous	ROUT*	Route and Method of Delivery as Spontaneous Delivery	ProcedureFinalRouteMethodDelivery	SNOMED-CT
Route Method of Delivery - Trial of Labor	TLAB	Route and Method of Delivery if Cesarean was as Trial of Labor Attempted	ObservationLaborTrialAttempted	SNOMED-CT
Route and Method of Delivery - Vacuum	ROUT*	Route and Method of Delivery as Vacuum Delivery	ProcedureFinalRouteMethodDelivery	SNOMED-CT
Spinal Anesthesia - Procedure	ESAN*	Spinal Anesthesia Procedure	ProcedureEpiduralOrSpinalAnesthesia	SNOMED-CT
Steroids For Fetal Lung Maturation	STER	Indicate whether steroids (glucocorticoids) for fetal lung maturation was received by the mother before delivery	ObservationSteroidsFetalLungMaturation	SNOMED-CT
Tocolysis	TOC - NOT IMPLEMENTED	Obstetric Procedures as Tocolysis		SNOMED-CT
Transfer to	HOSPTO	If the infant was transferred within 24 hours of delivery to another facility	LocationBFDR	SNOMED-CT
Transferred for Maternal Medical or Fetal Indications for Delivery	TRAN	Transferred for Maternal Medical or Fetal Indications for Delivery	EncounterMaternity	SNOMED-CT
Transfusion Whole Blood or Packed Red Bld	MTR	Transfusion Whole Blood or Packed Red Blood as a maternal morbidity	ProcedureBloodTransfusion	SNOMED-CT
Unplanned Hysterectomy	UHYS	Unplanned hysterectomy as a maternal morbidity	ProcedureUnplannedHysterectomy	SNOMED-CT
Unplanned Operation	UOPR - NOT IMPLEMENTED	Unplanned operation as a maternal morbidity		SNOMED-CT

Medications

Name	IJE Name	Purpose	Profile	Codesystem
Antibiotics	ANTI	Antibiotics were received by the mother during delivery and by the newborn for suspected neonatal sepsis	ProcedureAntibioticSuspectedNeonatalSepsis	RxNorm
Augmentation of Labor - Medication	AUGL*	Medication used for the of Augmentation of Labor	ProcedureAugmentationOfLabor	RxNorm
Epidural/Spinal Anesthesia - Medication	ESAN*	Epidural and Spinal Anesthesia Medication	ProcedureEpiduralOrSpinalAnesthesia	RxNorm
Fertility Enhancing Drugs Medications	INFT_DRG	Fertility Enhancing Drugs were administered as a risk factor for pregnancy	[ProcedureArtificialInsemination]	RxNorm
Newborn Receiving Surfactant Replacement Therapy	SURF*	Newborn received Surfactant Replacement Therapy reflecting an abnormal condition of the newborn	ProcedureSurfactantReplacementTherapy	RxNorm

Locations

Name	IJE Name	Purpose	Profile	Codesystem
Facility Location ICU	AINT	Patient (mother) was treated in the ICU for complications associated with labor and delivery reflecting a maternal morbidity.	ObservationICUAdmission	HL7 Service Delivery Location
Facility Location NICU	NICU	Newborn was admitted to the NICU reflecting an abnormal condition of the newborn	ObservationNICUAdmission	HL7 Service Delivery Location
Facility Location OR		Patient (mother) was treated in the OR for an unplanned operation for complications associated with labor and delivery reflecting unplanned operation		HL7 Service Delivery Location

Miscellaneous

Name	IJE Name	Purpose	Profile	Codesystem
Autopsy Planned	AUTOP*	Autopsy was planned		SNOMED-CT
Birth Place Clinic Office		Birth occurred in the at clinic or office	EncounterBirth	SNOMED-CT
Birth Place Freestanding Birthing Center		Birth occurred at a freestanding birthing center	EncounterBirth	SNOMED-CT
Birthplace Hospital		Birth occurred in the hospital	EncounterBirth	SNOMED-CT
Certified Midwife	ATTEND*	Title of the Attendant responsible for the delivery Procedure as a Certified Midwife	PractitionerBirthAttendant	SNOMED-CT
Doctor of Osteopathic Medicine	ATTEND*	Title of the Attendant responsible for the delivery Procedure as a Doctor of Osteopathic Medicine	PractitionerBirthAttendant	SNOMED-CT
Fetal Death Time Point	ETIME	A list of time points during the delivery process at which the fetal death is thought to have occurred. Note, SNOMED is being used as the primary source for codes within the value set.	ObservationFetalDeathTimePoint	SNOMED-CT
Histological Placental Examination	HISTOP	Histological Placental Examination for fetal death	ObservationHistologicalPlacentalExamPerformed	SNOMED-CT
IM Medication Administration Route		Intramuscular Medication Administration Route was used to administer a medication		HL7 Route of Administration
IV Medication Administration Route		IV Medication Administration Route was used to administer a medication		HL7 Route of Administration
Midwife	ATTEND*	Title of the Attendant responsible for the delivery Procedure as a Midwife excluding registered midwife which is reflected in the ‘certified midwife’ value set	PractitionerBirthAttendant	SNOMED-CT
Neonatal Death		Newborn died		SNOMED-CT
Physician	ATTEND*	Title of the Attendant responsible for the delivery Procedure as a Physician	PractitionerBirthAttendant	SNOMED-CT
Preterm Birth	PPB	Risk Factors of Preterm Birth (history)	ObservationPreviousPretermBirth	SNOMED-CT
Problem Status Active		Problem Status Active		SNOMED-CT
Transfer In	HOSPFROM	If the mother was transferred to this facility	LocationBFDR	Admit source (HL7)