This page is part of the Vital Records Death Reporting FHIR Implementation Guide (v2.2.0: STU 2) 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/vrdr/StructureDefinition/vrdr-death-certification | Version: 2.2.0 | |||
Active as of 2023-10-17 | Computable Name: DeathCertification |
Death Certification Procedure (USCoreProcedure). The procedure where the certification of death was performed by the certifier (USCoreProcedure).
Note:
The Death Certification profile includes:
# | Description | IJE Name | IJE only | Field | Type | Value Set |
---|---|---|---|---|---|---|
119 | Title of Certifier | CERTL | performer.function (note that if value is “OTH” then performed.function.text should contain ‘Full Text for Other Individual Legally Allowed to Certify’) | codeable | CertifierTypesVS | |
235 | Certifier Date Signed | CERTDATE | x | performed | dateTime | - |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreProcedureProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | USCoreProcedureProfile | |||
status | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Fixed Value: completed | |
category | 1..1 | CodeableConcept | Classification of the procedure Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 103693007 | |
code | 1..1 | CodeableConcept | Identification of the procedure Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 308646001 | |
performed[x] | 0..1 | dateTime | certification Datetime | |
performer | ||||
function | 1..1 | CodeableConcept | Type of performance Binding: Certifier Types VS (required) | |
actor | 1..1 | Reference(Certifier) | The reference to the practitioner | |
Documentation for this format |
Path | Conformance | ValueSet |
Procedure.performer.function | required | CertifierTypesVS |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) Fixed Value: completed |
category | Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 103693007 | |
code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 308646001 | |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on |
performed[x] | SΣC | 0..1 | dateTime | certification Datetime |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Procedure.status | required | Fixed Value: completed |
Procedure.category | example | Pattern: SNOMED CT code 103693007 |
Procedure.code | extensible | Pattern: SNOMED CT code 308646001 |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient | ||||
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 | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||
partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
status | ?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) Fixed Value: completed | ||||
statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
category | Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 103693007 | |||||
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 | |||||
code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 308646001 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
performed[x] | SΣC | 0..1 | dateTime S | certification Datetime | ||||
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
function | Σ | 1..1 | CodeableConcept | Type of performance Binding: Certifier Types VS (required) | ||||
actor | Σ | 1..1 | Reference(Certifier) | The reference to the practitioner | ||||
onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||
bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
note | 0..* | Annotation | Additional information about the procedure | |||||
focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Procedure.language | preferred | CommonLanguages
| ||||
Procedure.status | required | Fixed Value: completed | ||||
Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) | ||||
Procedure.category | example | Pattern: SNOMED CT code 103693007 | ||||
Procedure.code | extensible | Pattern: SNOMED CT code 308646001 | ||||
Procedure.performer.function | required | CertifierTypesVS | ||||
Procedure.reasonCode | example | ProcedureReasonCodes | ||||
Procedure.bodySite | example | SNOMEDCTBodyStructures | ||||
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | ||||
Procedure.complication | example | Condition/Problem/DiagnosisCodes | ||||
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | ||||
Procedure.usedCode | example | FHIRDeviceTypes |
This structure is derived from USCoreProcedureProfile
Differential View
This structure is derived from USCoreProcedureProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | USCoreProcedureProfile | |||
status | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Fixed Value: completed | |
category | 1..1 | CodeableConcept | Classification of the procedure Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 103693007 | |
code | 1..1 | CodeableConcept | Identification of the procedure Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 308646001 | |
performed[x] | 0..1 | dateTime | certification Datetime | |
performer | ||||
function | 1..1 | CodeableConcept | Type of performance Binding: Certifier Types VS (required) | |
actor | 1..1 | Reference(Certifier) | The reference to the practitioner | |
Documentation for this format |
Path | Conformance | ValueSet |
Procedure.performer.function | required | CertifierTypesVS |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) Fixed Value: completed |
category | Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 103693007 | |
code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 308646001 | |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on |
performed[x] | SΣC | 0..1 | dateTime | certification Datetime |
Documentation for this format |
Path | Conformance | ValueSet / Code |
Procedure.status | required | Fixed Value: completed |
Procedure.category | example | Pattern: SNOMED CT code 103693007 |
Procedure.code | extensible | Pattern: SNOMED CT code 308646001 |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient | ||||
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 | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||
partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
status | ?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) Fixed Value: completed | ||||
statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
category | Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 103693007 | |||||
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 | |||||
code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 308646001 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
performed[x] | SΣC | 0..1 | dateTime S | certification Datetime | ||||
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
function | Σ | 1..1 | CodeableConcept | Type of performance Binding: Certifier Types VS (required) | ||||
actor | Σ | 1..1 | Reference(Certifier) | The reference to the practitioner | ||||
onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||
bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
note | 0..* | Annotation | Additional information about the procedure | |||||
focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
Procedure.language | preferred | CommonLanguages
| ||||
Procedure.status | required | Fixed Value: completed | ||||
Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) | ||||
Procedure.category | example | Pattern: SNOMED CT code 103693007 | ||||
Procedure.code | extensible | Pattern: SNOMED CT code 308646001 | ||||
Procedure.performer.function | required | CertifierTypesVS | ||||
Procedure.reasonCode | example | ProcedureReasonCodes | ||||
Procedure.bodySite | example | SNOMEDCTBodyStructures | ||||
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | ||||
Procedure.complication | example | Condition/Problem/DiagnosisCodes | ||||
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | ||||
Procedure.usedCode | example | FHIRDeviceTypes |
This structure is derived from USCoreProcedureProfile
Other representations of profile: CSV, Excel, Schematron