Electronic Case Reporting (eCR)
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Electronic Case Reporting (eCR), published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 3.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/case-reporting/ and changes regularly. See the Directory of published versions

Example Bundle: US Public Health Reporting Bundle Example: bundle-ecr-message-zika

Bundle bundle-ecr-message-zika of type message

Entry 1 - fullUrl = http://example.org/fhir/MessageHeader/messageheader-ecr-requested-eicr

Resource MessageHeader:

US Public Health Data Encrypted Extension: false

US Public Health Message Processing Category Extension: consequence

event: US Public Health Message Types CodeSystem eicr-case-report-message: Indicates a message containing electronic case report healthcare data sent from clinical care.

Destinations

-NameTarget
*YMCA Acme Message GatewayDevice: identifier = http://acme.com/software/client-ids#goodhealth_id; manufacturer = Acme Devices, Inc; type = ; contact = http://acme.com; url = http://acme.com/ymca/software/

sender: Organization Salem Medical Center

Sources

-NameSoftwareVersionContact
*Acme Central Patient RegistryFooBar Patient Manager3.1.45.AABB+1 (555) 123 4567

reason: Indicates the close of an encounter

focus: Bundle: identifier = UUID:2be4b4e4-6df1-4cb2-a947-c70fa0eda54b; type = document; timestamp = 2021-08-02 22:13:23+0000

Entry 2 - fullUrl = http://example.org/fhir/Bundle/bundle-eicr-document-zika

Resource Bundle:

Document Details

Profile: eICR Document Bundle

Final Document at 2018-01-02 22:13:23+0000 by Henry Seven, MD for Eve Everywoman in encounter Ambulatory Office Visit

Document Subject

Eve L Everywoman Female, DoB: 1974-11-24 ( Medical Record Number: 1032702 (use: usual, ))

Active:trueDeceased:false
Contact Detail
Language:English
US Core Ethnicity Extension:
US Core Birth Sex ExtensionF
US Core Race Extension:
US Core Tribal Affiliation Extension:
  • tribalAffiliation: Fort Mojave Indian Tribe of Arizona, California & Nevada
  • isEnrolled: true

Document Content

Reason for Visit Section

title
Reason for Visit Section
code

Reason for Visit: Bad cough

Chief Complaint

title
Chief complaint Narrative - Reported
code

Chief Complaint: Bad cough

History of Present Illness Section

title
History of Present Illness Section
code
Persistent Cough REPORTED starting on 2018/03/05
Whooping Respiration not reported
Paroxysms Of Coughing REPORTED starting on 2018/03/06
Post-tussive vomiting not reported

Problems Section

title
Problems Section
code
entryCommon cold (disorder)
id
condition-eicr-eve-everywoman-common-cold
meta
versionId
15
lastUpdated
2019-10-10T21:21:49.000-04:00
profile
http://hl7.org/fhir/us/ph-library/StructureDefinition/us-ph-condition
category
code
subject
onsetDateTime
2017-09-23
asserter

Medications Administered Section

title
Medications Administered Section
code
entryAzithromycin 500 MG Oral Tablet
id
medicationadministration-eve-everywoman-azithromycin
meta
versionId
10
lastUpdated
2019-10-05T03:11:22.000-04:00
status
completed
medicationCodeableConcept
subject
effectivePeriod
start
2018-03-07
end
2018-03-07
dosage
route
method
dose
value
2
unit
TAB
system
code
TAB

Admission Medications Section

title
Admission Medications Section
code
entry1 ML naloxone hydrochloride 0.4 MG/ML Injection

Medications Section

title
Medications Section
code
entryAzithromycin 500 MG Oral Tablet

Results Section

title
Results Section
code
entryLymphocytes [#/​volume] in Blood by Automated count - Interpretation: High
id
observation-us-ph-lab-result-eve-everywoman-lymphocytes
meta
versionId
10
lastUpdated
2019-10-05T02:50:13.000-04:00
profile
http://hl7.org/fhir/us/ph-library/StructureDefinition/us-ph-lab-result-observation
status
final
category
code
subject
effectiveDateTime
2018-03-07
valueQuantity
interpretation
referenceRange
low
value
1
system
code
10*3/uL
high
value
4.8
system
code
10*3/uL

Plan of Treatment Section

title
Plan of Treatment Section
code
entry
  • Trigger code
  • Trigger Code:
  • Trigger Code Display:
  • Trigger Code System:
  • Trigger Code Value Set: urn:oid:2.16.840.1.114222.4.11.7508
  • Trigger Code Value Set Version: 19/05/2018
Request for Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method
id
servicerequest-eicr-zika
meta
versionId
9
lastUpdated
2019-10-23T13:56:36.000-04:00
profile
http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-servicerequest
status
completed
intent
order
category
code
  • Zika RT-PCR
    • Zika virus envelope E gene [Presence] in Serum by NAA with probe detection
      (
      80825-3
      )
subject
performer

Immunizations Section

title
Immunizations Section
code
entrypneumococcal polysaccharide vaccine
entryVaccine Credential Patient Assertion Observation Example

Procedures Section

title
Procedures Section
code
entryExtracorporeal membrane oxygenation (procedure)

Vital Signs Section

title
Vital Signs Section
code
entryBlood pressure systolic and diastolic

Social History Section

title
Social History Section
code
entryeICR Travel History: Eve Everywoman 2018-01
id
observation-travel-history-eve-everywoman-201801
meta
versionId
11
lastUpdated
2019-10-05T03:15:42.000-04:00
profile
http://hl7.org/fhir/us/ph-library/StructureDefinition/us-ph-travel-history
status
final
code
subject
effectivePeriod
start
2018-01-15
end
2018-01-30
component
code
valueCodeableConcept
    • Fiji
      (
      FJI
      )
    • urn:iso:std:iso:3166
component
code
valueCodeableConcept
entryODH Usual Work Example
id
observation-odh-usual-work-eve-everywoman
meta
versionId
2
lastUpdated
2019-10-20T10:53:14.000-04:00
profile
http://hl7.org/fhir/us/odh/StructureDefinition/odh-UsualWork
status
final
code
subject
effectivePeriod
start
2015-01-01
end
2018-03-07
valueCodeableConcept
component
code
valueCodeableConcept

Pregnancy Section

title
Pregnancy Section
code
entryeICR Pregnancy Status Example
id
observation-pregnancy-status-eve-everywoman
meta
versionId
13
lastUpdated
2019-10-05T03:15:42.000-04:00
profile
http://hl7.org/fhir/us/ph-library/StructureDefinition/us-ph-pregnancy-status-observation
us-ph-date-recorded-extension
  • 2017-10-01
date-determined-extension
  • 2017-10-01
status
final
code
subject
effectivePeriod
start
2017-08-26
valueCodeableConcept
method
component
date-determined-extension
  • 2017-10-01
code
    • Gestational age Estimated from patient reported estimated date of conception
      (
      53691-2
      )
valueQuantity
  • 143
  • d
component
date-determined-extension
  • 2017-10-01
code
    • Delivery date Estimated from date fundal height reaches umb
      (
      57064-8
      )
valueDateTime
2018-05-01

Emergency Outbreak Information Section

title
Emergency Outbreak Information Section
code
entryUS Public Health Emergency Outbreak Information Example

Past Medical History Section

title
Past Medical History Section
code

Past medical history

Review of Systems Section

title
Review of Systems Section
code

Review of systems

Additional Resources Included in Document

Entry 2 - fullUrl = http://example.org/fhir/MedicationAdministration/medicationadministration-eve-everywoman-azithromycin

Resource MedicationAdministration:

status: completed

subject: Eve Everywoman

Dosages

-TextRouteMethodDose
*Two tablets at onceOral routeSwallow - dosing instruction imperative (qualifier value)2 TAB (Details: Orderable Drug Form codeTAB = 'Tablet')

Entry 3 - fullUrl = http://example.org/fhir/Procedure/us-ph-procedure-ecmo

Resource Procedure:

identifier: Uniform Resource Identifier (URI)/urn:uuid:b2a737f2-2fdb-49c1-b097-dac173d07afd

status: Completed

code: Extracorporeal membrane oxygenation (procedure)

subject: Eve L Everywoman Female, DoB: 1974-11-24 ( Medical Record Number: 1032702 (use: usual, ))

FocalDevices

-Manipulated
*Device: status = active; manufacturer = ACME Biomedical; expirationDate = 2022-01-01; lotNumber = M320; serialNumber = AC222; modelNumber = 4.0; type = Extracorporeal membrane oxygenator (physical object)

Entry 4 - fullUrl = http://example.org/fhir/MedicationAdministration/medicationadministration-eve-everywoman-naloxone-response

Resource MedicationAdministration:

US Public Health Therapeutic Medication Response Extension: Patient's condition improved (finding)

status: completed

subject: Eve Everywoman

Dosages

-RouteMethodDose
*Gluteus maximus muscleInject - dosing instruction imperative (qualifier value)1 mL (Details: UCUM codemL = 'mL')

Entry 5 - fullUrl = http://example.org/fhir/ServiceRequest/servicerequest-eicr-zika

Resource ServiceRequest:

identifier: http://lab.smarthealthit.org/061ef612-344f-4e7b-81a8-1059ae7bbe11

status: Completed

intent: Order

category: Diagnostics Procedure

code: No display for ServiceRequest.code (concept: Zika virus envelope E gene [Presence] in Serum by NAA with probe detection)

subject: Eve Everywoman

performer: Acme Labs

Entry 6 - fullUrl = http://example.org/fhir/Condition/condition-eicr-eve-everywoman-common-cold

Resource Condition:

category: Problem List Item

code: Common cold (disorder)

subject: Eve Everywoman

onset: 2017-09-23

Entry 7 - fullUrl = http://example.org/fhir/Encounter/encounter-eicr-eve-everywoman-outpatient

Resource Encounter:

identifier: http://hospital.smarthealthit.org/9937012

status: completed

class: ambulatory

type: Office Visit

subject: Eve Everywoman

serviceProvider: Salem Medical Center, 22222 Health Authority Drive, Ann Arbor MI, 99999

Participants

-Type
*attender

diagnosis

eICR Trigger Code Flag Extension

  • triggerCodeValueSet: urn:oid:2.16.840.1.114222.4.11.7508
  • triggerCodeValueSetVersion: 12/12/2018
  • triggerCode: SNOMED CT 3928002: Zika virus disease (disorder)

condition: No display for Encounter.diagnosis.condition (reference: ->Condition Zika virus disease (disorder))

diagnosis

condition: No display for Encounter.diagnosis.condition (reference: ->Condition Common cold (disorder))

Locations

-Location
*Clinic Bldg A, Salem Medical Center, 4646 Brown Rd, Salem, MA 02368

Entry 8 - fullUrl = http://example.org/fhir/Observation/observation-pregnancy-status-eve-everywoman

Resource Observation:

org/fhir/us/ph-library/StructureDefinition/us-ph-date-recorded-extension: 2017-10-01

US Public Health Date Determined Extension: 2017-10-01

status: Final

code: Pregnancy status

subject: Eve Everywoman

effective: 2017-08-26

value: Pregnancy (finding)

method: Ultrasonography (procedure)

component

US Public Health Date Determined Extension: 2017-10-01

code: Gestational age Estimated from patient reported estimated date of conception

value: 143 d

component

US Public Health Date Determined Extension: 2017-10-01

code: Delivery date Estimated from date fundal height reaches umb

value: 2018-05-01

Entry 9 - fullUrl = http://example.org/fhir/Observation/observation-vaccine-credential-assertion-eve-everywoman

Resource Observation:

status: Final

code: Immunization status - Reported

subject: Eve Everywoman

effective: 2020-11-10 22:33:22+0000

value: Yes

Entry 10 - fullUrl = http://example.org/fhir/Observation/observation-us-ph-emergency-outbreak-info-eve-everywoman

Resource Observation:

status: Final

category: Social History

code: Employee desk distance from mail sorter

subject: Eve Everywoman

effective: 2020-11-18 22:33:22+0000

performer: PractitionerRole Primary Care Clinic/Center

value: 2 m

Entry 11 - fullUrl = http://example.org/fhir/Observation/observation-country-of-nationality-eve-everywoman

Resource Observation:

status: Final

code: Ethnicity / related nationality data (observable entity)

subject: Eve Everywoman

effective: 2020-11-10 22:33:22+0000

value: Australia

Entry 12 - fullUrl = http://example.org/fhir/Patient/patient-ecr-eve-everywoman

Resource Patient:

Eve L Everywoman Female, DoB: 1974-11-24 ( Medical Record Number: 1032702 (use: usual, ))

Active:trueDeceased:false
Contact Detail
Language:English
US Core Ethnicity Extension:
US Core Birth Sex ExtensionF
US Core Race Extension:
US Core Tribal Affiliation Extension:
  • tribalAffiliation: Fort Mojave Indian Tribe of Arizona, California & Nevada
  • isEnrolled: true

Entry 13 - fullUrl = http://example.org/fhir/Immunization/immunization-ecr-pneumo

Resource Immunization:

status: Completed

vaccineCode: pneumococcal polysaccharide PPV23

patient: Eve Everywoman

occurrence: 2018-09-01

primarySource: true

Entry 14 - fullUrl = http://example.org/fhir/Observation/observation-country-of-residence-eve-everywoman

Resource Observation:

status: Final

code: Country of usual residence

subject: Eve Everywoman

effective: 2020-11-10 22:33:22+0000

value: United Kingdom of Great Britain and Northern Ireland (the)

Entry 15 - fullUrl = http://example.org/fhir/PractitionerRole/practitionerrole-henry-seven

Resource PractitionerRole:

identifier: United States National Provider Identifier/9941339108

practitioner: Henry Seven, MD

organization: Salem Medical Center

code: Primary Care Clinic/Center

specialty: Family practice

location: Salem Medical Center

Entry 16 - fullUrl = http://example.org/fhir/Observation/observation-blood-pressure-eve-everywoman

Resource Observation:

status: Final

category: Vital Signs

code: Blood pressure systolic and diastolic

subject: Eve Everywoman

encounter: GP Visit

effective: 2020-07-02

performer: Health Authority West Rules Authoring Agency

component

code: Systolic blood pressure

value: 109 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

component

code: Diastolic blood pressure

value: 44 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

Entry 17 - fullUrl = http://example.org/fhir/Observation/observation-us-ph-exposure-contact-info-football-game

Resource Observation:

status: Final

category: An interaction between entities that provides opportunity for transmission of a physical, chemical, or biological agent from an exposure source entity to an exposure target entity.

code: Mass gathering (football game)

subject: Eve Everywoman

focus: City Football Stadium

effective: 2020-01-11 18:00:00+0000 --> 2020-01-11 21:30:00+0000

value: City Football Stadium

Components

-CodeValue[x]
*ExposureAgentSevere acute respiratory syndrome coronavirus 2 (organism)

Entry 18 - fullUrl = http://example.org/fhir/Observation/observation-travel-history-eve-everywoman-201801

Resource Observation:

status: Final

category: Social History

code: Travel History

subject: Eve Everywoman

effective: 2018-01-15 --> 2018-01-30

component

code: Location

value: Vanuatu

component

code: Type of activity (attribute)

value: Active duty military (occupation)

Entry 19 - fullUrl = http://example.org/fhir/Observation/observation-disability-status-eve-everywoman

Resource Observation:

status: Final

category: Disability Status

code: Are you deaf, or do you have serious difficulty hearing

subject: Eve Everywoman

effective: 2020-11-10 22:33:22+0000

performer: PractitionerRole Primary Care Clinic/Center

value: Yes

Entry 20 - fullUrl = http://example.org/fhir/Observation/observation-us-ph-lab-result-eve-everywoman-lymphocytes

Resource Observation:

status: Final

category: Laboratory

code: Lymphocytes [#/volume] in Blood by Automated count

subject: Eve Everywoman

effective: 2018-03-07

value: 5.2 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')

interpretation: High

ReferenceRanges

-LowHigh
*1 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')4.8 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')

Entry 21 - fullUrl = http://example.org/fhir/Organization/organization-ecr-acme-laboratory

Resource Organization:

identifier: http://hl7.org.fhir/sid/us-npi/1144221999

active: true

type: outpatient laboratory

name: Acme_Labs

contact

telecom: +1-555-555-4444, mail@acme-labs.com

address: 7777 Laboratory Drive Ann Arbor MI 99999

Entry 22 - fullUrl = http://example.org/fhir/Location/location-ecr-salem-medical-center

Resource Location:

identifier: http://hl7.org.fhir/sid/us-npi/1144221995

status: Active

name: Clinic Bldg A, Salem Medical Center

type: Hospital

address: Clinic Bldg A 4444 Healthcare Drive Ann Arbor MI 99999

managingOrganization: Organization Salem Medical Center

Entry 23 - fullUrl = http://example.org/fhir/Location/location-ecr-city-football-stadium

Resource Location:

status: Active

name: City Football Stadium

type: City Football Stadium

address: 99 Football Stadium Road My City AZ 8562

Entry 24 - fullUrl = http://example.org/fhir/Organization/organization-ecr-salem-medical-center

Resource Organization:

identifier: http://hl7.org.fhir/sid/us-npi/55555555

active: true

type: Outpatient facility

name: Salem Medical Center

contact

telecom: +1-555-555-1111, mail@salemmedicalcenter.com

address: 22222 Health Authority Drive Ann Arbor MI 99999

Entry 25 - fullUrl = http://example.org/fhir/Condition/condition-eicr-eve-everywoman-zika

Resource Condition:

category: Encounter Diagnosis

code: Zika virus disease (disorder)

subject: Eve Everywoman

onset: 2017-08-23

Entry 26 - fullUrl = http://example.org/fhir/Practitioner/practitioner-us-core-henry-seven

Resource Practitioner:

identifier: United States National Provider Identifier/9941339108

name: Seven Henry

telecom: henry.seven@example.com

address: BMass Doctors 2100 North Ave Burlington MA 02368 US

Entry 27 - fullUrl = http://example.org/fhir/Device/device-ecmo

Resource Device:

UdiCarriers

-DeviceIdentifierCarrierHRFEntryType
*99863313444316(01)99863313444316(17)220101(10)M320(21)AC222RFID

status: Active

manufacturer: ACME Biomedical

expirationDate: 2022-01-01

lotNumber: M320

serialNumber: AC222

modelNumber: 4.0

type: Extracorporeal membrane oxygenator (physical object)

Entry 3 - fullUrl = http://example.org/fhir/Device/device-ecr-software-ymca

Resource Device:

identifier: http://acme.com/software/client-ids/goodhealth_id

manufacturer: Acme Devices, Inc

type: EHR

Versions

-Value
*10.23-23423

contact: http://acme.com

url: http://acme.com/ymca/software/

Entry 4 - fullUrl = http://example.org/fhir/Organization/organization-ecr-salem-medical-center

Resource Organization:

identifier: http://hl7.org.fhir/sid/us-npi/55555555

active: true

type: Outpatient facility

name: Salem Medical Center

contact

telecom: +1-555-555-1111, mail@salemmedicalcenter.com

address: 22222 Health Authority Drive Ann Arbor MI 99999