Vital Records Birth and Fetal Death Reporting
1.1.0 - STU 1.1
Vital Records Birth and Fetal Death Reporting
1.1.0 - STU 1.1
This page is part of the Vital Records Birth and Fetal Death Reporting (v1.1.0: STU 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Composition-provider-live-birth-report | Version: 1.1.0 | |||
| Active as of 2023-10-10 | Computable Name: CompositionProviderLiveBirthReport | |||
This Composition profile defines constraints to address the use case in which information for live birth information is recorded and communicated to the jurisdictional Vital Records Office.
For the most part, labor and delivery takes place at a healthcare provider site. When a baby is delivered at home, or on the way to the hospital, the mother and baby are typically taken to the hospital for evaluation and possible treatment. Personal and pregnancy information is collected from the mother or an informant, while information regarding labor and delivery and the condition of the newborn is collected from the responsible party at the healthcare facility.
The data requirements for provider supplied live birth information are based on the
The jurisdiction may have additional data requirements and edit specifications that will be addressed at the jurisdictional level.
See Patient Worksheet Questionnaires for information about including a QuestionnaireResponse in this Composition.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Composition | Provider Live Birth Report | |
  Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url |
 liveBirthCertificateNumber | S | 0..1 | Identifier | Birth Number URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-certificate-number |
| liveBirthLocalFileNumber | S | 0..1 | Identifier | Local File No. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-local-file-number |
| dateFiledByRegistrar | S | 1..1 | dateTime | Date filed by registrar URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-date-filed-by-registrar |
| replacementStatus | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) |
 status | S | 1..1 | code | In the case of a live birth sent in error, a status of 'entered-in-error' must be set. |
 type | S | 1..1 | CodeableConcept | U.S. standard certificate of live birth - 2003 revision 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://loinc.org | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 68998-4 | |
 subject | S | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the baby's name. |
| encounter | S | 0..1 | Reference(Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. |
| Extension-encounter-maternity-reference | 0..1 | Reference(Encounter - Maternity) | The Encounter is the maternity encounter. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-encounter-maternity-reference | |
| date | S | 1..1 | dateTime | Date report completed |
| author | S | 1..1 | Reference(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. |
 Slices for section | S | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Slice: Unordered, Open by pattern:code |
 section:motherPrenatal | S | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate |
  code | S | 1..1 | CodeableConcept | Prenatal records 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57073-9 | |
 focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. |
 Slices for entry | S | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() |
 entry:plannedToDeliverAtHome | S | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit | S | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits | S | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits |
| entry:dateLastNormalMenses | S | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began |
| entry:numberNowLiving | S | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living |
| entry:numberNowDead | S | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead |
| entry:dateLastLiveBirth | S | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes | S | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome | S | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment | S | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery | S | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery |
| entry:mothersHeight | S | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:mothersPrepregnancyWeight | S | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:motherReceivedWICFood | S | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
 entry:cigaretteSmokingBeforeDuringPregnancy | S | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| section:medicalHealthInformation | S | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate |
| code | S | 1..1 | CodeableConcept | Clinical information 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55752-0 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry | S | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() |
| entry:pregnancyRiskFactors | S | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements. |
| entry:numberPreviousCesareans | S | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many |
| entry:infectionsDuringPregnancy | S | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| entry:obstetricProcedures | S | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures |
| entry:characteristicsLaborDelivery | S | 0..* | Reference(Procedure - Induction of Labor | Procedure - Augmentation of Labor | Observation - Administration of Steroids for Fetal Lung Maturation | Observation - Antibiotics Administered During Labor | Condition - Chorioamnionitis | Procedure - Epidural or Spinal Anesthesia | Observation - None Of Specified Characteristics of Labor and Delivery) | Characteristics of labor and delivery |
| entry:fetalPresentation | S | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| entry:finalRouteMethodDelivery | S | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| entry:maternalMorbidity | S | 0..* | Reference(Procedure - Blood Transfusion | Condition - Perineal Laceration | Condition - Ruptured Uterus | Procedure - Unplanned Hysterectomy | Observation - ICU Admission | Observation - None Of Specified Maternal Morbidities) | Maternal morbidity (complications associated with labor and delivery) |
| section:newbornInformation | S | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate |
| code | S | 1..1 | CodeableConcept | Newborn delivery information 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57075-4 | |
| Slices for entry | S | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() |
| entry:birthWeight | S | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight |
| entry:gestationalAgeAtDelivery | S | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation |
| entry:ApgarScore | S | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. |
| entry:numberLiveBirthsThisDelivery | S | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery |
| entry:abnormalConditionsNewborn | S | 0..* | Reference(Procedure - Assisted Ventilation Following Delivery | Procedure - Assisted Ventilation More Than Six Hours | Observation - NICU Admission | Procedure - Surfactant Replacement Therapy | Procedure - Antibiotic for Suspected Neonatal Sepsis | Condition - Seizure | Observation - None Of Specified Abnormal Conditions of Newborn) | Abnormal conditions of the newborn |
| entry:congenitalAnomaliesNewborn | S | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| entry:infantLiving | S | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? |
| entry:infantBreastfedAtDischarge | S | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| section:motherInformation | S | 0..1 | BackboneElement | Composition is broken into sections |
| code | S | 1..1 | CodeableConcept | Mother's administrative information 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92014-0 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | Who/what the section is about, when it is not about the subject of composition |
| Slices for entry | S | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:marriedDuringPregnancy | S | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:ssnRequestedForChild | S | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:mothersEducation | S | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the US Standard Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element. |
| section:fatherInformation | S | 0..1 | BackboneElement | Father section on the Live Birth Certificate |
| code | S | 1..1 | CodeableConcept | Father's administrative information 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92013-2 | |
| focus | S | 1..1 | Reference(RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity. |
| Slices for entry | S | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| entry:paternityAcknowledgementSigned | S | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:fathersEducation | S | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
 section:patientsQuestionnaireResponse | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate | |
| code | 1..1 | CodeableConcept | Questionnaire response Document 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |
 entry | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | Provider Live Birth Report | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url |
| liveBirthCertificateNumber | S | 0..1 | Identifier | Birth Number URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-certificate-number |
| liveBirthLocalFileNumber | S | 0..1 | Identifier | Local File No. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-local-file-number |
| dateFiledByRegistrar | S | 1..1 | dateTime | Date filed by registrar URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-date-filed-by-registrar |
| replacementStatus | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣ | 1..1 | code | In the case of a live birth sent in error, a status of 'entered-in-error' must be set. Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
 type | SΣ | 1..1 | CodeableConcept | U.S. standard certificate of live birth - 2003 revision Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 68998-4 | |
| subject | SΣ | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the baby's name. |
| encounter | SΣ | 0..1 | Reference(Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. |
| Extension-encounter-maternity-reference | 0..1 | Reference(Encounter - Maternity) | The Encounter is the maternity encounter. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-encounter-maternity-reference Slice: Unordered, Open by value:url | |
| date | SΣ | 1..1 | dateTime | Date report completed |
| author | SΣ | 1..1 | Reference(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. |
| title | Σ | 1..1 | string | Human Readable name/title |
| Slices for section | SC | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| section:motherPrenatal | SC | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Prenatal records Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57073-9 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. |
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() |
| entry:plannedToDeliverAtHome | SC | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit | SC | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits | SC | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits |
| entry:dateLastNormalMenses | SC | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began |
| entry:numberNowLiving | SC | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living |
| entry:numberNowDead | SC | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead |
| entry:dateLastLiveBirth | SC | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes | SC | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome | SC | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment | SC | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery | SC | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery |
| entry:mothersHeight | SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:mothersPrepregnancyWeight | SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:motherReceivedWICFood | SC | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:cigaretteSmokingBeforeDuringPregnancy | SC | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| section:medicalHealthInformation | SC | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Clinical information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55752-0 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() |
| entry:pregnancyRiskFactors | SC | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements. |
| entry:numberPreviousCesareans | SC | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many |
| entry:infectionsDuringPregnancy | SC | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| entry:obstetricProcedures | SC | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures |
| entry:characteristicsLaborDelivery | SC | 0..* | Reference(Procedure - Induction of Labor | Procedure - Augmentation of Labor | Observation - Administration of Steroids for Fetal Lung Maturation | Observation - Antibiotics Administered During Labor | Condition - Chorioamnionitis | Procedure - Epidural or Spinal Anesthesia | Observation - None Of Specified Characteristics of Labor and Delivery) | Characteristics of labor and delivery |
| entry:fetalPresentation | SC | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| entry:finalRouteMethodDelivery | SC | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| entry:maternalMorbidity | SC | 0..* | Reference(Procedure - Blood Transfusion | Condition - Perineal Laceration | Condition - Ruptured Uterus | Procedure - Unplanned Hysterectomy | Observation - ICU Admission | Observation - None Of Specified Maternal Morbidities) | Maternal morbidity (complications associated with labor and delivery) |
| section:newbornInformation | SC | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Newborn delivery information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57075-4 | |
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() |
| entry:birthWeight | SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight |
| entry:gestationalAgeAtDelivery | SC | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation |
| entry:ApgarScore | SC | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. |
| entry:numberLiveBirthsThisDelivery | SC | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery |
| entry:abnormalConditionsNewborn | SC | 0..* | Reference(Procedure - Assisted Ventilation Following Delivery | Procedure - Assisted Ventilation More Than Six Hours | Observation - NICU Admission | Procedure - Surfactant Replacement Therapy | Procedure - Antibiotic for Suspected Neonatal Sepsis | Condition - Seizure | Observation - None Of Specified Abnormal Conditions of Newborn) | Abnormal conditions of the newborn |
| entry:congenitalAnomaliesNewborn | SC | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| entry:infantLiving | SC | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? |
| entry:infantBreastfedAtDischarge | SC | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| section:motherInformation | SC | 0..1 | BackboneElement | Composition is broken into sections |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Mother's administrative information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92014-0 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | Who/what the section is about, when it is not about the subject of composition |
| Slices for entry | SC | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:marriedDuringPregnancy | SC | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:ssnRequestedForChild | SC | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:mothersEducation | SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the US Standard Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element. |
| section:fatherInformation | SC | 0..1 | BackboneElement | Father section on the Live Birth Certificate |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Father's administrative information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92013-2 | |
| focus | S | 1..1 | Reference(RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity. |
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| entry:paternityAcknowledgementSigned | SC | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:fathersEducation | SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| section:patientsQuestionnaireResponse | C | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | CodeableConcept | Questionnaire response Document Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |
| entry | C | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: LOINC code 68998-4 |
| Composition.section:motherPrenatal.code | example | Pattern: LOINC code 57073-9 |
| Composition.section:medicalHealthInformation.code | example | Pattern: LOINC code 55752-0 |
| Composition.section:newbornInformation.code | example | Pattern: LOINC code 57075-4 |
| Composition.section:motherInformation.code | example | Pattern: LOINC code 92014-0 |
| Composition.section:fatherInformation.code | example | Pattern: LOINC code 92013-2 |
| Composition.section:patientsQuestionnaireResponse.code | example | Pattern: LOINC code 74465-6 |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Composition | Provider Live Birth Report | |||||
| 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.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| liveBirthCertificateNumber | S | 0..1 | Identifier | Birth Number URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-certificate-number | ||||
| liveBirthLocalFileNumber | S | 0..1 | Identifier | Local File No. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-local-file-number | ||||
| dateFiledByRegistrar | S | 1..1 | dateTime | Date filed by registrar URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-date-filed-by-registrar | ||||
| replacementStatus | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!SΣ | 1..1 | code | In the case of a live birth sent in error, a status of 'entered-in-error' must be set. Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | U.S. standard certificate of live birth - 2003 revision Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 68998-4 | |||||
| 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 | |||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the baby's name. | ||||
| encounter | SΣ | 0..1 | Reference(Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Extension-encounter-maternity-reference | 0..1 | Reference(Encounter - Maternity) | The Encounter is the maternity encounter. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-encounter-maternity-reference Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| date | SΣ | 1..1 | dateTime | Date report completed | ||||
| author | SΣ | 1..1 | Reference(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. | ||||
| title | Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
| 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 | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| 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 | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| 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 | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | SC | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Slice: Unordered, Open by pattern:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:motherPrenatal | SC | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Prenatal records Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57073-9 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. | ||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:plannedToDeliverAtHome | SC | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home | ||||
| entry:firstPrenatalCareVisit | SC | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit | ||||
| entry:numberPrenatalCareVisits | SC | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits | ||||
| entry:dateLastNormalMenses | SC | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began | ||||
| entry:numberNowLiving | SC | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living | ||||
| entry:numberNowDead | SC | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead | ||||
| entry:dateLastLiveBirth | SC | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth | ||||
| entry:numberOtherOutcomes | SC | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes | ||||
| entry:dateLastOtherOutcome | SC | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome | ||||
| entry:principalSourceOfPayment | SC | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery | ||||
| entry:mothersWeightAtDelivery | SC | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery | ||||
| entry:mothersHeight | SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:mothersPrepregnancyWeight | SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:motherReceivedWICFood | SC | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:cigaretteSmokingBeforeDuringPregnancy | SC | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:medicalHealthInformation | SC | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Clinical information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55752-0 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother | ||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:pregnancyRiskFactors | SC | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements. | ||||
| entry:numberPreviousCesareans | SC | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many | ||||
| entry:infectionsDuringPregnancy | SC | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy | ||||
| entry:obstetricProcedures | SC | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures | ||||
| entry:characteristicsLaborDelivery | SC | 0..* | Reference(Procedure - Induction of Labor | Procedure - Augmentation of Labor | Observation - Administration of Steroids for Fetal Lung Maturation | Observation - Antibiotics Administered During Labor | Condition - Chorioamnionitis | Procedure - Epidural or Spinal Anesthesia | Observation - None Of Specified Characteristics of Labor and Delivery) | Characteristics of labor and delivery | ||||
| entry:fetalPresentation | SC | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth | ||||
| entry:finalRouteMethodDelivery | SC | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery | ||||
| entry:maternalMorbidity | SC | 0..* | Reference(Procedure - Blood Transfusion | Condition - Perineal Laceration | Condition - Ruptured Uterus | Procedure - Unplanned Hysterectomy | Observation - ICU Admission | Observation - None Of Specified Maternal Morbidities) | Maternal morbidity (complications associated with labor and delivery) | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:newbornInformation | SC | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Newborn delivery information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57075-4 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:birthWeight | SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight | ||||
| entry:gestationalAgeAtDelivery | SC | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation | ||||
| entry:ApgarScore | SC | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. | ||||
| entry:numberLiveBirthsThisDelivery | SC | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery | ||||
| entry:abnormalConditionsNewborn | SC | 0..* | Reference(Procedure - Assisted Ventilation Following Delivery | Procedure - Assisted Ventilation More Than Six Hours | Observation - NICU Admission | Procedure - Surfactant Replacement Therapy | Procedure - Antibiotic for Suspected Neonatal Sepsis | Condition - Seizure | Observation - None Of Specified Abnormal Conditions of Newborn) | Abnormal conditions of the newborn | ||||
| entry:congenitalAnomaliesNewborn | SC | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn | ||||
| entry:infantLiving | SC | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? | ||||
| entry:infantBreastfedAtDischarge | SC | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:motherInformation | SC | 0..1 | BackboneElement | Composition is broken into sections | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Mother's administrative information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92014-0 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | Who/what the section is about, when it is not about the subject of composition | ||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
| entry:marriedDuringPregnancy | SC | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:ssnRequestedForChild | SC | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:mothersEducation | SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the US Standard Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:fatherInformation | SC | 0..1 | BackboneElement | Father section on the Live Birth Certificate | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Father's administrative information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92013-2 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | S | 1..1 | Reference(RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity. | ||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:paternityAcknowledgementSigned | SC | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:fathersEducation | SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:patientsQuestionnaireResponse | C | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Questionnaire response Document Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | Pattern: LOINC code 68998-4 | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.encounter.type | extensible | ResourceType | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:motherPrenatal.code | example | Pattern: LOINC code 57073-9 | ||||
| Composition.section:motherPrenatal.mode | required | ListMode | ||||
| Composition.section:motherPrenatal.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:motherPrenatal.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:medicalHealthInformation.code | example | Pattern: LOINC code 55752-0 | ||||
| Composition.section:medicalHealthInformation.mode | required | ListMode | ||||
| Composition.section:medicalHealthInformation.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:medicalHealthInformation.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:newbornInformation.code | example | Pattern: LOINC code 57075-4 | ||||
| Composition.section:newbornInformation.mode | required | ListMode | ||||
| Composition.section:newbornInformation.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:newbornInformation.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:motherInformation.code | example | Pattern: LOINC code 92014-0 | ||||
| Composition.section:motherInformation.mode | required | ListMode | ||||
| Composition.section:motherInformation.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:motherInformation.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:fatherInformation.code | example | Pattern: LOINC code 92013-2 | ||||
| Composition.section:fatherInformation.mode | required | ListMode | ||||
| Composition.section:fatherInformation.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:fatherInformation.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:patientsQuestionnaireResponse.code | example | Pattern: LOINC code 74465-6 | ||||
| Composition.section:patientsQuestionnaireResponse.mode | required | ListMode | ||||
| Composition.section:patientsQuestionnaireResponse.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:patientsQuestionnaireResponse.emptyReason | preferred | ListEmptyReasons |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 4 elements (17 nested mandatory elements)
Must-Support: 67 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | Provider Live Birth Report | |
| Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url |
| liveBirthCertificateNumber | S | 0..1 | Identifier | Birth Number URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-certificate-number |
| liveBirthLocalFileNumber | S | 0..1 | Identifier | Local File No. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-local-file-number |
| dateFiledByRegistrar | S | 1..1 | dateTime | Date filed by registrar URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-date-filed-by-registrar |
| replacementStatus | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) |
| status | S | 1..1 | code | In the case of a live birth sent in error, a status of 'entered-in-error' must be set. |
| type | S | 1..1 | CodeableConcept | U.S. standard certificate of live birth - 2003 revision 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 68998-4 | |
| subject | S | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the baby's name. |
| encounter | S | 0..1 | Reference(Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. |
| Extension-encounter-maternity-reference | 0..1 | Reference(Encounter - Maternity) | The Encounter is the maternity encounter. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-encounter-maternity-reference | |
| date | S | 1..1 | dateTime | Date report completed |
| author | S | 1..1 | Reference(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. |
| Slices for section | S | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Slice: Unordered, Open by pattern:code |
| section:motherPrenatal | S | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate |
| code | S | 1..1 | CodeableConcept | Prenatal records 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57073-9 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. |
| Slices for entry | S | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() |
| entry:plannedToDeliverAtHome | S | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit | S | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits | S | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits |
| entry:dateLastNormalMenses | S | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began |
| entry:numberNowLiving | S | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living |
| entry:numberNowDead | S | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead |
| entry:dateLastLiveBirth | S | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes | S | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome | S | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment | S | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery | S | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery |
| entry:mothersHeight | S | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:mothersPrepregnancyWeight | S | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:motherReceivedWICFood | S | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:cigaretteSmokingBeforeDuringPregnancy | S | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| section:medicalHealthInformation | S | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate |
| code | S | 1..1 | CodeableConcept | Clinical information 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55752-0 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry | S | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() |
| entry:pregnancyRiskFactors | S | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements. |
| entry:numberPreviousCesareans | S | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many |
| entry:infectionsDuringPregnancy | S | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| entry:obstetricProcedures | S | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures |
| entry:characteristicsLaborDelivery | S | 0..* | Reference(Procedure - Induction of Labor | Procedure - Augmentation of Labor | Observation - Administration of Steroids for Fetal Lung Maturation | Observation - Antibiotics Administered During Labor | Condition - Chorioamnionitis | Procedure - Epidural or Spinal Anesthesia | Observation - None Of Specified Characteristics of Labor and Delivery) | Characteristics of labor and delivery |
| entry:fetalPresentation | S | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| entry:finalRouteMethodDelivery | S | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| entry:maternalMorbidity | S | 0..* | Reference(Procedure - Blood Transfusion | Condition - Perineal Laceration | Condition - Ruptured Uterus | Procedure - Unplanned Hysterectomy | Observation - ICU Admission | Observation - None Of Specified Maternal Morbidities) | Maternal morbidity (complications associated with labor and delivery) |
| section:newbornInformation | S | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate |
| code | S | 1..1 | CodeableConcept | Newborn delivery information 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57075-4 | |
| Slices for entry | S | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() |
| entry:birthWeight | S | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight |
| entry:gestationalAgeAtDelivery | S | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation |
| entry:ApgarScore | S | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. |
| entry:numberLiveBirthsThisDelivery | S | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery |
| entry:abnormalConditionsNewborn | S | 0..* | Reference(Procedure - Assisted Ventilation Following Delivery | Procedure - Assisted Ventilation More Than Six Hours | Observation - NICU Admission | Procedure - Surfactant Replacement Therapy | Procedure - Antibiotic for Suspected Neonatal Sepsis | Condition - Seizure | Observation - None Of Specified Abnormal Conditions of Newborn) | Abnormal conditions of the newborn |
| entry:congenitalAnomaliesNewborn | S | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| entry:infantLiving | S | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? |
| entry:infantBreastfedAtDischarge | S | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| section:motherInformation | S | 0..1 | BackboneElement | Composition is broken into sections |
| code | S | 1..1 | CodeableConcept | Mother's administrative information 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92014-0 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | Who/what the section is about, when it is not about the subject of composition |
| Slices for entry | S | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:marriedDuringPregnancy | S | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:ssnRequestedForChild | S | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:mothersEducation | S | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the US Standard Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element. |
| section:fatherInformation | S | 0..1 | BackboneElement | Father section on the Live Birth Certificate |
| code | S | 1..1 | CodeableConcept | Father's administrative information 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92013-2 | |
| focus | S | 1..1 | Reference(RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity. |
| Slices for entry | S | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| entry:paternityAcknowledgementSigned | S | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:fathersEducation | S | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| section:patientsQuestionnaireResponse | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate | |
| code | 1..1 | CodeableConcept | Questionnaire response Document 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |
| entry | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | Provider Live Birth Report | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url |
| liveBirthCertificateNumber | S | 0..1 | Identifier | Birth Number URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-certificate-number |
| liveBirthLocalFileNumber | S | 0..1 | Identifier | Local File No. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-local-file-number |
| dateFiledByRegistrar | S | 1..1 | dateTime | Date filed by registrar URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-date-filed-by-registrar |
| replacementStatus | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣ | 1..1 | code | In the case of a live birth sent in error, a status of 'entered-in-error' must be set. Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | SΣ | 1..1 | CodeableConcept | U.S. standard certificate of live birth - 2003 revision Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 68998-4 | |
| subject | SΣ | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the baby's name. |
| encounter | SΣ | 0..1 | Reference(Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. |
| Extension-encounter-maternity-reference | 0..1 | Reference(Encounter - Maternity) | The Encounter is the maternity encounter. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-encounter-maternity-reference Slice: Unordered, Open by value:url | |
| date | SΣ | 1..1 | dateTime | Date report completed |
| author | SΣ | 1..1 | Reference(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. |
| title | Σ | 1..1 | string | Human Readable name/title |
| Slices for section | SC | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| section:motherPrenatal | SC | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Prenatal records Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57073-9 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. |
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() |
| entry:plannedToDeliverAtHome | SC | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit | SC | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits | SC | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits |
| entry:dateLastNormalMenses | SC | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began |
| entry:numberNowLiving | SC | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living |
| entry:numberNowDead | SC | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead |
| entry:dateLastLiveBirth | SC | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes | SC | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome | SC | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment | SC | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery | SC | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery |
| entry:mothersHeight | SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:mothersPrepregnancyWeight | SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:motherReceivedWICFood | SC | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:cigaretteSmokingBeforeDuringPregnancy | SC | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| section:medicalHealthInformation | SC | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Clinical information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55752-0 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() |
| entry:pregnancyRiskFactors | SC | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements. |
| entry:numberPreviousCesareans | SC | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many |
| entry:infectionsDuringPregnancy | SC | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| entry:obstetricProcedures | SC | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures |
| entry:characteristicsLaborDelivery | SC | 0..* | Reference(Procedure - Induction of Labor | Procedure - Augmentation of Labor | Observation - Administration of Steroids for Fetal Lung Maturation | Observation - Antibiotics Administered During Labor | Condition - Chorioamnionitis | Procedure - Epidural or Spinal Anesthesia | Observation - None Of Specified Characteristics of Labor and Delivery) | Characteristics of labor and delivery |
| entry:fetalPresentation | SC | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| entry:finalRouteMethodDelivery | SC | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| entry:maternalMorbidity | SC | 0..* | Reference(Procedure - Blood Transfusion | Condition - Perineal Laceration | Condition - Ruptured Uterus | Procedure - Unplanned Hysterectomy | Observation - ICU Admission | Observation - None Of Specified Maternal Morbidities) | Maternal morbidity (complications associated with labor and delivery) |
| section:newbornInformation | SC | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Newborn delivery information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57075-4 | |
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() |
| entry:birthWeight | SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight |
| entry:gestationalAgeAtDelivery | SC | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation |
| entry:ApgarScore | SC | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. |
| entry:numberLiveBirthsThisDelivery | SC | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery |
| entry:abnormalConditionsNewborn | SC | 0..* | Reference(Procedure - Assisted Ventilation Following Delivery | Procedure - Assisted Ventilation More Than Six Hours | Observation - NICU Admission | Procedure - Surfactant Replacement Therapy | Procedure - Antibiotic for Suspected Neonatal Sepsis | Condition - Seizure | Observation - None Of Specified Abnormal Conditions of Newborn) | Abnormal conditions of the newborn |
| entry:congenitalAnomaliesNewborn | SC | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| entry:infantLiving | SC | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? |
| entry:infantBreastfedAtDischarge | SC | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| section:motherInformation | SC | 0..1 | BackboneElement | Composition is broken into sections |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Mother's administrative information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92014-0 | |
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | Who/what the section is about, when it is not about the subject of composition |
| Slices for entry | SC | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:marriedDuringPregnancy | SC | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:ssnRequestedForChild | SC | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:mothersEducation | SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the US Standard Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element. |
| section:fatherInformation | SC | 0..1 | BackboneElement | Father section on the Live Birth Certificate |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Father's administrative information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92013-2 | |
| focus | S | 1..1 | Reference(RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity. |
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| entry:paternityAcknowledgementSigned | SC | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| entry:fathersEducation | SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
| section:patientsQuestionnaireResponse | C | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | CodeableConcept | Questionnaire response Document Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |
| entry | C | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: LOINC code 68998-4 |
| Composition.section:motherPrenatal.code | example | Pattern: LOINC code 57073-9 |
| Composition.section:medicalHealthInformation.code | example | Pattern: LOINC code 55752-0 |
| Composition.section:newbornInformation.code | example | Pattern: LOINC code 57075-4 |
| Composition.section:motherInformation.code | example | Pattern: LOINC code 92014-0 |
| Composition.section:fatherInformation.code | example | Pattern: LOINC code 92013-2 |
| Composition.section:patientsQuestionnaireResponse.code | example | Pattern: LOINC code 74465-6 |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Composition | Provider Live Birth Report | |||||
| 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.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| liveBirthCertificateNumber | S | 0..1 | Identifier | Birth Number URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-certificate-number | ||||
| liveBirthLocalFileNumber | S | 0..1 | Identifier | Local File No. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-local-file-number | ||||
| dateFiledByRegistrar | S | 1..1 | dateTime | Date filed by registrar URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-date-filed-by-registrar | ||||
| replacementStatus | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!SΣ | 1..1 | code | In the case of a live birth sent in error, a status of 'entered-in-error' must be set. Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | U.S. standard certificate of live birth - 2003 revision Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 68998-4 | |||||
| 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 | |||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the baby's name. | ||||
| encounter | SΣ | 0..1 | Reference(Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Extension-encounter-maternity-reference | 0..1 | Reference(Encounter - Maternity) | The Encounter is the maternity encounter. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-encounter-maternity-reference Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| date | SΣ | 1..1 | dateTime | Date report completed | ||||
| author | SΣ | 1..1 | Reference(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. | ||||
| title | Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
| 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 | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| 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 | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| 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 | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | SC | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Live Birth Certificate. Slice: Unordered, Open by pattern:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:motherPrenatal | SC | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Prenatal records Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57073-9 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. | ||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:plannedToDeliverAtHome | SC | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home | ||||
| entry:firstPrenatalCareVisit | SC | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit | ||||
| entry:numberPrenatalCareVisits | SC | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits | ||||
| entry:dateLastNormalMenses | SC | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began | ||||
| entry:numberNowLiving | SC | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living | ||||
| entry:numberNowDead | SC | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead | ||||
| entry:dateLastLiveBirth | SC | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth | ||||
| entry:numberOtherOutcomes | SC | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes | ||||
| entry:dateLastOtherOutcome | SC | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome | ||||
| entry:principalSourceOfPayment | SC | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery | ||||
| entry:mothersWeightAtDelivery | SC | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery | ||||
| entry:mothersHeight | SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:mothersPrepregnancyWeight | SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:motherReceivedWICFood | SC | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:cigaretteSmokingBeforeDuringPregnancy | SC | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:medicalHealthInformation | SC | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Clinical information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55752-0 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother | ||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:pregnancyRiskFactors | SC | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements. | ||||
| entry:numberPreviousCesareans | SC | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many | ||||
| entry:infectionsDuringPregnancy | SC | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy | ||||
| entry:obstetricProcedures | SC | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures | ||||
| entry:characteristicsLaborDelivery | SC | 0..* | Reference(Procedure - Induction of Labor | Procedure - Augmentation of Labor | Observation - Administration of Steroids for Fetal Lung Maturation | Observation - Antibiotics Administered During Labor | Condition - Chorioamnionitis | Procedure - Epidural or Spinal Anesthesia | Observation - None Of Specified Characteristics of Labor and Delivery) | Characteristics of labor and delivery | ||||
| entry:fetalPresentation | SC | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth | ||||
| entry:finalRouteMethodDelivery | SC | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery | ||||
| entry:maternalMorbidity | SC | 0..* | Reference(Procedure - Blood Transfusion | Condition - Perineal Laceration | Condition - Ruptured Uterus | Procedure - Unplanned Hysterectomy | Observation - ICU Admission | Observation - None Of Specified Maternal Morbidities) | Maternal morbidity (complications associated with labor and delivery) | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:newbornInformation | SC | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Newborn delivery information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57075-4 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:birthWeight | SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight | ||||
| entry:gestationalAgeAtDelivery | SC | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation | ||||
| entry:ApgarScore | SC | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. | ||||
| entry:numberLiveBirthsThisDelivery | SC | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery | ||||
| entry:abnormalConditionsNewborn | SC | 0..* | Reference(Procedure - Assisted Ventilation Following Delivery | Procedure - Assisted Ventilation More Than Six Hours | Observation - NICU Admission | Procedure - Surfactant Replacement Therapy | Procedure - Antibiotic for Suspected Neonatal Sepsis | Condition - Seizure | Observation - None Of Specified Abnormal Conditions of Newborn) | Abnormal conditions of the newborn | ||||
| entry:congenitalAnomaliesNewborn | SC | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn | ||||
| entry:infantLiving | SC | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? | ||||
| entry:infantBreastfedAtDischarge | SC | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:motherInformation | SC | 0..1 | BackboneElement | Composition is broken into sections | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Mother's administrative information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92014-0 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | S | 1..1 | Reference(Patient - Mother - Vital Records) | Who/what the section is about, when it is not about the subject of composition | ||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | ||||
| entry:marriedDuringPregnancy | SC | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:ssnRequestedForChild | SC | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:mothersEducation | SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the US Standard Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:fatherInformation | SC | 0..1 | BackboneElement | Father section on the Live Birth Certificate | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Father's administrative information Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 92013-2 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | S | 1..1 | Reference(RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity. | ||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() | ||||
| entry:paternityAcknowledgementSigned | SC | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| entry:fathersEducation | SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:patientsQuestionnaireResponse | C | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate | ||||
| 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 | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | Questionnaire response Document Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |||||
| 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 | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | Pattern: LOINC code 68998-4 | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.encounter.type | extensible | ResourceType | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:motherPrenatal.code | example | Pattern: LOINC code 57073-9 | ||||
| Composition.section:motherPrenatal.mode | required | ListMode | ||||
| Composition.section:motherPrenatal.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:motherPrenatal.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:medicalHealthInformation.code | example | Pattern: LOINC code 55752-0 | ||||
| Composition.section:medicalHealthInformation.mode | required | ListMode | ||||
| Composition.section:medicalHealthInformation.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:medicalHealthInformation.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:newbornInformation.code | example | Pattern: LOINC code 57075-4 | ||||
| Composition.section:newbornInformation.mode | required | ListMode | ||||
| Composition.section:newbornInformation.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:newbornInformation.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:motherInformation.code | example | Pattern: LOINC code 92014-0 | ||||
| Composition.section:motherInformation.mode | required | ListMode | ||||
| Composition.section:motherInformation.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:motherInformation.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:fatherInformation.code | example | Pattern: LOINC code 92013-2 | ||||
| Composition.section:fatherInformation.mode | required | ListMode | ||||
| Composition.section:fatherInformation.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:fatherInformation.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:patientsQuestionnaireResponse.code | example | Pattern: LOINC code 74465-6 | ||||
| Composition.section:patientsQuestionnaireResponse.mode | required | ListMode | ||||
| Composition.section:patientsQuestionnaireResponse.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:patientsQuestionnaireResponse.emptyReason | preferred | ListEmptyReasons |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 4 elements (17 nested mandatory elements)
Must-Support: 67 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ HL7 International / Public Health. Package hl7.fhir.us.bfdr#1.1.0 based on FHIR 4.0.1. Generated 2023-10-10
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