Bundle - Jurisdiction Fetal Death Report - Fetus Not Named - Birth And Fetal Death (BFDR) FHIR Implementation Guide v2.0.0

Birth And Fetal Death (BFDR) FHIR Implementation Guide, published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-bfdr/ and changes regularly. See the Directory of published versions

Example Bundle: Bundle - Jurisdiction Fetal Death Report - Fetus Not Named

Document Details

Generated Narrative: Bundle Jurisdiction fetal death report Document

Document Subject

Unable to resolve subject ''

Document Content

Generated Narrative: Composition composition-jurisdiction-fetal-death-not-named

status: Final

type: Jurisdiction fetal death report Document

encounter: Encounter: extension = mother; identifier = http://hospital.smarthealthit.org#8937015; status = finished; class = inpatient encounter (ActCode#IMP); type = Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.; period = 2019-01-08 10:00:00-0700 --> 2019-01-09 17:00:00-0700

date: 2019-01-09

author: Organization Jurisdictional Vital Records Office

title: Jurisdiction fetal death report Document

Prenatal records

Clinical information

Fetal delivery information Document [US Standard Report of Fetal Death]

Mother's administrative information

Father's administrative information

Additional Resources Included in Document

Entry 1 - fullUrl = http://www.example.org/fhir/Composition/composition-jurisdiction-fetal-death-not-named

Resource Composition:

Generated Narrative: Composition composition-jurisdiction-fetal-death-not-named

status: Final
type: Jurisdiction fetal death report Document
encounter: Encounter: extension = mother; identifier = http://hospital.smarthealthit.org#8937015; status = finished; class = inpatient encounter (ActCode#IMP); type = Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.; period = 2019-01-08 10:00:00-0700 --> 2019-01-09 17:00:00-0700
date: 2019-01-09
author: Organization Jurisdictional Vital Records Office
title: Jurisdiction fetal death report Document

Entry 2 - fullUrl = http://www.example.org/fhir/Patient/patient-decedent-fetus-not-named

Resource Patient:

Generated Narrative: Patient patient-decedent-fetus-not-named

null (official) Female, DoB: 2019-01-09 ( Medical Record Number: 9932702 (use: usual, ))
Deceased: true Multiple Birth: 3
Reported Parent Age At Delivery Vital Records:
reportedAge: 34 a (Details: UCUM codea = 'a')
motherOrFather: mother
Reported Parent Age At Delivery Vital Records:
reportedAge: 35 a (Details: UCUM codea = 'a')
motherOrFather: father
Patient Birth Place Ann Arbor MI 48103
US Core Birth Sex Extension F

Entry 3 - fullUrl = http://www.example.org/fhir/Encounter/encounter-maternity-carmen-teresa-lee

Resource Encounter:

Generated Narrative: Encounter encounter-maternity-carmen-teresa-lee

Extension Parental Role: mother
identifier: http://hospital.smarthealthit.org/8937015
status: Finished
class: ActCode IMP: inpatient encounter
type: Under Observation or Inpatient Care Services (Including Admission and Discharge Services)
subject: Patient - Mother (Carmen Teresa Lee)
Participants
- Type Individual
* Birth attendant [Extended Identifier] Practitioner - Vital Records (Janet Seito, DO)
period: 2019-01-08 10:00:00-0700 --> 2019-01-09 17:00:00-0700
Locations
- Location PhysicalType
* Location - US Core Location (South Hospital) Hospital
serviceProvider: Organization - US Core Organization (South Hospital Organization)

Entry 4 - fullUrl = http://www.example.org/fhir/Organization/organization-jurisdictional-vital-records-office

Resource Organization:

Generated Narrative: Organization organization-jurisdictional-vital-records-office

active: true
name: Jurisdictional Vital Records Office

Entry 5 - fullUrl = http://www.example.org/fhir/Patient/patient-mother-carmen-teresa-lee

Resource Patient:

Generated Narrative: Patient patient-mother-carmen-teresa-lee

Carmen Teresa Lee (official) Female, DoB: 1986-02-15 ( Medical Record Number: 9992702 (use: usual, ))
Alt. Name: Carmen Teresa Santos (Name changed for Marriage)
Contact Detail 3670 Miller Road Ann Arbor MI 48103 US (home)
Links:
Also see: RelatedPerson Carmen Teresa Lee (official)
US Core Ethnicity Extension:
ombCategory: CDC Race and Ethnicity 2135-2: Hispanic or Latino
text: Hispanic or Latino
Patient Birth Place PR
US Core Birth Sex Extension F
US Core Race Extension:
ombCategory: CDC Race and Ethnicity 2054-5: Black or African American
text: Black or African America

Entry 6 - fullUrl = http://www.example.org/fhir/Observation/observation-date-of-first-prenatal-care-visit-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-date-of-first-prenatal-care-visit-carmen-teresa-lee

status: Final
code: Date first prenatal visit
subject: Patient - Mother (Carmen Teresa Lee)
focus: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: 2018-05-18

Entry 7 - fullUrl = http://www.example.org/fhir/Observation/observation-last-menstrual-period-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-last-menstrual-period-carmen-teresa-lee

status: Final
code: Last menstrual period start date
subject: Patient - Mother (Carmen Teresa Lee)
effective: 2018-05-02
performer: Practitioner Janet Seito
value: 2018-04-18

Entry 8 - fullUrl = http://www.example.org/fhir/Observation/observation-number-births-now-living-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-number-births-now-living-carmen-teresa-lee

status: Final
code: [#] Births.still living
subject: Patient - Mother (Carmen Teresa Lee)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: 1

Entry 9 - fullUrl = http://www.example.org/fhir/Observation/observation-number-births-now-dead-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-number-births-now-dead-carmen-teresa-lee

status: Final
code: Previous live births now dead #
subject: Patient - Mother (Carmen Teresa Lee)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: 0

Entry 10 - fullUrl = http://www.example.org/fhir/Observation/observation-date-of-last-live-birth-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-date-of-last-live-birth-carmen-teresa-lee

status: Final
code: Date of last live birth
subject: Patient - Mother (Carmen Teresa Lee)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: 2016-01-28

Entry 11 - fullUrl = http://www.example.org/fhir/Observation/observation-mother-height-carmen-teresa-lee-w-edit

Resource Observation:

Generated Narrative: Observation observation-mother-height-carmen-teresa-lee-w-edit

status: Final
category: Vital Signs
code: Body height
subject: Patient - Mother (Carmen Teresa Lee)
effective: 2019-01-10
performer: Carmen Teresa Lee (official) Female, DoB: 1986-02-15 ( Medical Record Number: 9992702 (use: usual, ))
value: 56 in (Details: UCUM code[in_i] = '[in_i]')

Entry 12 - fullUrl = http://www.example.org/fhir/Observation/observation-mother-prepregnancy-weight-carmen-teresa-lee-w-edit

Resource Observation:

Generated Narrative: Observation observation-mother-prepregnancy-weight-carmen-teresa-lee-w-edit

status: Final
category: Vital Signs
code: Body weight --pre current pregnancy
subject: Patient - Mother (Carmen Teresa Lee)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: 180 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')

Entry 13 - fullUrl = http://www.example.org/fhir/Observation/observation-mother-received-wic-food-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-mother-received-wic-food-carmen-teresa-lee

status: Final
code: Mother WIC food recipient
subject: Patient - Mother (Carmen Teresa Lee)
focus: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Carmen Teresa Lee (official) Female, DoB: 1986-02-15 ( Medical Record Number: 9992702 (use: usual, ))
value: No

Entry 14 - fullUrl = http://www.example.org/fhir/Observation/observation-cig-smoking-pregnancy-1-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-cig-smoking-pregnancy-1-carmen-teresa-lee

status: Final
code: In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day [PhenX]
subject: Patient - Mother (Carmen Teresa Lee)
focus: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Carmen Teresa Lee (official) Female, DoB: 1986-02-15 ( Medical Record Number: 9992702 (use: usual, ))
value: 0

Entry 15 - fullUrl = http://www.example.org/fhir/Observation/observation-cig-smoking-pregnancy-2-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-cig-smoking-pregnancy-2-carmen-teresa-lee

status: Final
code: Cigarettes smoked per day by Mother--1st trimester
subject: Patient - Mother (Carmen Teresa Lee)
focus: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Carmen Teresa Lee (official) Female, DoB: 1986-02-15 ( Medical Record Number: 9992702 (use: usual, ))
value: 0

Entry 16 - fullUrl = http://www.example.org/fhir/Observation/observation-cig-smoking-pregnancy-3-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-cig-smoking-pregnancy-3-carmen-teresa-lee

status: Final
code: Cigarettes smoked per day by Mother--2nd trimester
subject: Patient - Mother (Carmen Teresa Lee)
focus: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Carmen Teresa Lee (official) Female, DoB: 1986-02-15 ( Medical Record Number: 9992702 (use: usual, ))
value: 1

Entry 17 - fullUrl = http://www.example.org/fhir/Observation/observation-cig-smoking-pregnancy-4-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-cig-smoking-pregnancy-4-carmen-teresa-lee

status: Final
code: In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day [PhenX]
subject: Patient - Mother (Carmen Teresa Lee)
focus: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Carmen Teresa Lee (official) Female, DoB: 1986-02-15 ( Medical Record Number: 9992702 (use: usual, ))
value: 0

Entry 18 - fullUrl = http://www.example.org/fhir/Observation/observation-number-previous-cesareans-carmen-teresa-lee-w-edit

Resource Observation:

Generated Narrative: Observation observation-number-previous-cesareans-carmen-teresa-lee-w-edit

status: Final
code: Previous cesarean deliveries #
subject: Patient - Mother (Carmen Teresa Lee)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: 1

Entry 19 - fullUrl = http://www.example.org/fhir/Condition/condition-gestational-diabetes-carmen-teresa-lee

Resource Condition:

Generated Narrative: Condition condition-gestational-diabetes-carmen-teresa-lee

clinicalStatus: Active
category: Problem List Item, Mothers Risk factors in this pregnancy [US Standard Certificate of Live Birth]
code: Gestational diabetes mellitus (disorder)
subject: Patient - Mother (Carmen Teresa Lee)
onset: 2018-12-12

Entry 20 - fullUrl = http://www.example.org/fhir/Observation/observation-fetal-presentation-not-named

Resource Observation:

Generated Narrative: Observation observation-fetal-presentation-not-named

status: Final
code: Fetal presentation--at birth [US Standard Certificate of Live Birth]
subject: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: Breech presentation (finding)

Entry 21 - fullUrl = http://www.example.org/fhir/Procedure/procedure-final-route-method-delivery-not-named

Resource Procedure:

Generated Narrative: Procedure procedure-final-route-method-delivery-not-named

status: Completed
category: Final route and method of delivery [US Standard Certificate of Live Birth]
code: Spontaneous vaginal delivery
subject: Patient - Mother (Carmen Teresa Lee)
performed: 2019-01-19 18:00:00-0700 --> 2019-01-19 18:23:00-0700

Entry 22 - fullUrl = http://www.example.org/fhir/Observation/observation-birth-weight-not-named-w-edit

Resource Observation:

Generated Narrative: Observation observation-birth-weight-not-named-w-edit

status: Final
category: Vital Signs
code: Birth weight Measured
subject: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-02-10
performer: Organization Jurisdictional Vital Records Office
value: 1530 g (Details: UCUM codeg = 'g')

Entry 23 - fullUrl = http://www.example.org/fhir/Observation/observation-gestational-age-at-delivery-not-named-w-edit

Resource Observation:

Generated Narrative: Observation observation-gestational-age-at-delivery-not-named-w-edit

status: Final
code: Gestational age Estimated
subject: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: 20 wk (Details: UCUM codewk = 'wk')

Entry 24 - fullUrl = http://www.example.org/fhir/Condition/condition-fetal-death-cause-or-condition-not-named

Resource Condition:

Generated Narrative: Condition condition-fetal-death-cause-or-condition-not-named

category: Encounter Diagnosis, Initiating cause or condition of fetal death [US Standard Report of Fetal Death]
code: Premature rupture of membranes (disorder)
subject: Patient - Decedent Fetus (Fetus Not Named)

Entry 25 - fullUrl = http://www.example.org/fhir/Condition/condition-fetal-death-other-significant-cause-not-named

Resource Condition:

Generated Narrative: Condition condition-fetal-death-other-significant-cause-not-named

category: Encounter Diagnosis, Other significant causes or conditions of fetal death [US Standard Report of Fetal Death]
code: Placental insufficiency (disorder)
subject: Patient - Decedent Fetus (Fetus Not Named)

Entry 26 - fullUrl = http://www.example.org/fhir/Observation/observation-fetal-death-time-point-not-named

Resource Observation:

Generated Narrative: Observation observation-fetal-death-time-point-not-named

status: Final
code: Estimated timing of fetal death [US Standard Report of Fetal Death]
subject: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: Fetal intrapartum death after first assessment (event)

Entry 27 - fullUrl = http://www.example.org/fhir/Observation/observation-autopsy-performed-not-named

Resource Observation:

Generated Narrative: Observation observation-autopsy-performed-not-named

status: Final
code: Autopsy was performed
subject: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: Performed

Entry 28 - fullUrl = http://www.example.org/fhir/Observation/observation-histological-placental-exam-performed-not-named

Resource Observation:

Generated Narrative: Observation observation-histological-placental-exam-performed-not-named

status: Final
code: Histological placental examination was performed [US Standard Report of Fetal Death]
subject: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: Performed

Entry 29 - fullUrl = http://www.example.org/fhir/Observation/observation-autopsy-histological-exam-results-used-not-named

Resource Observation:

Generated Narrative: Observation observation-autopsy-histological-exam-results-used-not-named

status: Final
code: Autopsy or histological placental examination results were used [US Standard Report of Fetal Death]
subject: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: Yes

Entry 30 - fullUrl = http://www.example.org/fhir/Observation/observation-number-deaths-this-delivery-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-number-deaths-this-delivery-carmen-teresa-lee

status: Final
code: Number of fetal deaths delivered
subject: Patient - Mother (Carmen Teresa Lee)
focus: Patient - Decedent Fetus (Fetus Not Named)
effective: 2019-12-02
performer: Practitioner Janet Seito
value: 1

Entry 31 - fullUrl = http://www.example.org/fhir/Observation/observation-parent-education-level-carmen-teresa-lee-w-edit

Resource Observation:

Generated Narrative: Observation observation-parent-education-level-carmen-teresa-lee-w-edit

status: Final
code: Highest level of education Mother
subject: Patient - Decedent Fetus (Fetus Not Named)
focus: Patient - Mother (Carmen Teresa Lee)
effective: 2019-12-02
performer: Carmen Teresa Lee (official) Female, DoB: 1986-02-15 ( Medical Record Number: 9992702 (use: usual, ))
value: 9th through 12th grade; no diploma

Entry 32 - fullUrl = http://www.example.org/fhir/Observation/observation-present-job-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-present-job-carmen-teresa-lee

Extension Parental Role: mother
status: Final
code: History of Occupation
subject: null (official) Female, DoB: 2019-01-09 ( Medical Record Number: 9932702 (use: usual, ))
focus: RelatedPerson Carmen Teresa Lee (official)
effective: 2019-01-09 --> (ongoing)
value: Secretary
Components
- Code Value[x]
* History of Occupation industry State Agency

Entry 33 - fullUrl = http://www.example.org/fhir/Observation/observation-present-job-tom-yan-lee

Resource Observation:

Generated Narrative: Observation observation-present-job-tom-yan-lee

Extension Parental Role: father
status: Final
code: History of Occupation
subject: null (official) Female, DoB: 2019-01-09 ( Medical Record Number: 9932702 (use: usual, ))
focus: RelatedPerson Tom Yan Lee (official)
effective: 2019-01-09 --> (ongoing)
value: Teaching Assistant
Components
- Code Value[x]
* History of Occupation industry Elementary and Secondary Schools

Entry 34 - fullUrl = http://www.example.org/fhir/Observation/observation-input-race-and-ethnicity-carmen-teresa-lee

Resource Observation:

Generated Narrative: Observation observation-input-race-and-ethnicity-carmen-teresa-lee

status: Final
code: Mother Input Race and Ethnicity
subject: Patient - Mother (Carmen Teresa Lee)
component
code: White
value: true
component
code: Black Or African American
value: true
component
code: American Indian Or Alaska Native
value: true
component
code: Asian Indian
value: false
component
code: Chinese
value: false
component
code: Filipino
value: false
component
code: Japanese
value: false
component
code: Korean
value: false
component
code: Vietnamese
value: false
component
code: Other Asian
value: false
component
code: Native Hawaiian
value: false
component
code: Guamanian Or Chamorro
value: false
component
code: Samoan
value: false
component
code: Other Pacific Islander
value: false
component
code: Other Race
value: false
component
code: First Other Asian Literal
value: Malaysian
component
code: First American Indian Or Alaska Native Literal
value: Arikara
component
code: Hispanic Mexican
value: Yes
component
code: Hispanic Cuban
value: Yes
component
code: Hispanic Puerto Rican
value: Yes
component
code: Hispanic Other
value: No

Entry 35 - fullUrl = http://www.example.org/fhir/Practitioner/practitioner-vital-records-janet-seito

Resource Practitioner:

Generated Narrative: Practitioner practitioner-vital-records-janet-seito

Practitioner Role - Birth Attendant: attendant
Practitioner Role - Certifier: certifier
identifier: NPI/223347044
name: Janet Seito
Qualifications
- Code
* Osteopath (occupation)

Entry 36 - fullUrl = http://www.example.org/fhir/Location/location-south-hospital

Resource Location:

Generated Narrative: Location location-south-hospital

identifier: NPI/116441967701
status: Active
name: South Hospital
type: Hospital, Birth Location
address: 2100 North Ave Salt Lake City UT 84116 US
Positions
- Longitude Latitude
* 40.8 111.9
managingOrganization: Organization - South Hospital

Entry 37 - fullUrl = http://www.example.org/fhir/Organization/organization-south-hospital

Resource Organization:

Generated Narrative: Organization organization-south-hospital

identifier: NPI/5555512
active: true
type: Hospital
name: South Hospital
telecom: +1-555-555-1111, mail@southhospital.com
address: 2100 North Ave Salt Lake City UT 84116 US

Entry 38 - fullUrl = http://www.example.org/fhir/RelatedPerson/relatedperson-mother-carmen-teresa-lee

Resource RelatedPerson:

Generated Narrative: RelatedPerson relatedperson-mother-carmen-teresa-lee

active: true
patient: Patient - Decedent Fetus (Fetus Not Named)
relationship: Gestational Mother
name: Carmen Teresa Lee (Official)
gender: Female
birthDate: 1986-02-15

Entry 39 - fullUrl = http://www.example.org/fhir/RelatedPerson/relatedperson-father-natural-tom-yan-lee

Resource RelatedPerson:

Generated Narrative: RelatedPerson relatedperson-father-natural-tom-yan-lee

RelatedPerson Birth Place Vital Records: NY
active: true
patient: Patient - Decedent Fetus (Fetus Not Named)
relationship: Natural Father
name: Tom Yan Lee (Official)
gender: Male
birthDate: 1984-02-27