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
Official URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Composition-provider-live-birth-report | Version: 2.0.0 | |||
Active as of 2024-10-15 | Computable Name: CompositionProviderLiveBirthReport | |||
Other Identifiers: OID:2.16.840.1.113883.4.642.40.13.42.12 |
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.
Use Case | # | Description | IJE Name | Field | Type | Value Set/Comments |
---|---|---|---|---|---|---|
Natality | 243 | Date of Registration--Year | DOR_YR | date | dateTime | Used for Jurisdiction Report also |
Natality | 244 | Date of Registration--Month | DOR_MO | date | dateTime | Used for Jurisdiction Report also |
Natality | 245 | Date of Registration--Day | DOR_DY | date | dateTime | Used for Jurisdiction Report also |
Item # | Form Field | FHIR Profile Field | Reference |
---|---|---|---|
13 | Date Filed By Registrar | date | Certificate of Live Birth |
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 | |
status | 1..1 | code | In the case of a live birth sent in error, a status of 'entered-in-error' must be set. | |
type | 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 | 1..1 | Reference(Patient - Child Vital Records) | The subject of the composition is the newborn baby | |
encounter | 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) | Encounter Maternity Reference URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-encounter-maternity-reference | |
date | 1..1 | dateTime | Date report completed | |
author | 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 | 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 | 0..1 | BackboneElement | motherPrenatal Section on the Provider Live Birth Report | |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 1..1 | Reference(Patient - Mother Vital Records) | The focus of this section is the mother | |
Slices for entry | 0..* | Reference(Resource) | Entries that are contained in the motherPrenatal Section Slice: Unordered, Open by profile:$this.resolve() | |
entry:firstPrenatalCareVisit | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit | |
entry:numberPrenatalCareVisits | 0..1 | Reference(Observation - Number of Prenatal Visits) | Number of prenatal care visits | |
entry:dateLastNormalMenses | 0..1 | Reference(Observation - Last Menstrual Period) | Date last normal menses began | |
entry:numberNowLiving | 0..1 | Reference(Observation - Number of Births Now Living) | Number of previous live births now living | |
entry:numberNowDead | 0..1 | Reference(Observation - Number of Births Now Dead) | Number of previous live births now dead | |
entry:dateLastLiveBirth | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth | |
entry:numberOtherOutcomes | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes) | Number of other pregnancy outcomes | |
entry:dateLastOtherOutcome | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome | |
entry:principalSourceOfPayment | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery | |
entry:mothersWeightAtDelivery | 0..1 | Reference(Observation - Mother Delivery Weight (reported in pounds)) | Mother's weight at delivery | |
entry:mothersHeight | 0..1 | Reference(Observation - Mother Height) | Mother's height | |
entry:mothersPrepregnancyWeight | 0..1 | Reference(Observation - Mother Prepregnancy Weight) | Mother's prepregnancy weight | |
entry:motherReceivedWICFood | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use | |
entry:cigaretteSmokingBeforeDuringPregnancy | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy | |
section:medicalHealthInformation | 0..1 | BackboneElement | medicalHealthInformation Section on the Provider Live Birth Report | |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 1..1 | Reference(Patient - Mother Vital Records) | The focus of this section is the mother | |
Slices for entry | 0..* | Reference(Resource) | Entries that are contained in the medicalHealthInformation Section Slice: Unordered, Open by profile:$this.resolve() | |
entry:pregnancyRiskFactors | 0..* | Reference(Condition - Prepregnancy Diabetes | Condition - Gestational Diabetes | Condition - Prepregnancy Hypertension | Condition - Gestational Hypertension | Condition - Eclampsia Hypertension | Observation - Previous Preterm Birth | Procedure - Infertility Treatment | Procedure - Fertility Enhancing Drug Therapy, Artificial or Intrauterine Insemination | Procedure - Assisted Reproductive Technology | Observation - Previous Cesarean | Observation - None Of Specified Pregnancy Risk Factors) | Risk factors in this pregnancy | |
entry:numberPreviousCesareans | 0..1 | Reference(Observation - Number of Previous Cesareans) | If mother had a previous cesarean delivery, how many | |
entry:infectionsDuringPregnancy | 0..* | Reference(Condition - Infection Present During Pregnancy | Observation - None Of Specified Infections During Pregnancy) | Infections present and/or treated during this pregnancy | |
entry:obstetricProcedures | 0..1 | Reference(Procedure - Obstetric | Observation - None Of Specified Obstetric Procedures) | Obstetric procedures | |
entry:characteristicsLaborDelivery | 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 | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth | |
entry:finalRouteMethodDelivery | 0..1 | Reference(Procedure - Final Route and Method of Delivery | Observation - Unknown Final Route and Method of Delivery) | Final route and method of delivery | |
entry:maternalMorbidity | 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 | 0..1 | BackboneElement | newbornInformation Section on the Provider Live Birth Report | |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 0..* | Reference(Resource) | Entries that are contained in the newbornInformation Section Slice: Unordered, Open by profile:$this.resolve() | |
entry:birthWeight | 0..1 | Reference(Observation - Birth Weight) | Birthweight | |
entry:gestationalAgeAtDelivery | 0..1 | Reference(Observation - Gestational Age at Delivery) | Obstetric estimate of gestation | |
entry:APGARScore | 0..2 | Reference(Observation - APGAR Score) | APGAR Score - while the APGAR timing value set contains 3 possible values, 5 and 10 are the only scores used. | |
entry:numberLiveBirthsThisDelivery | 0..1 | Reference(Observation - Number of Live Births This Delivery) | Number of live births this delivery | |
entry:abnormalConditionsNewborn | 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 | 0..* | Reference(Condition - Congenital Anomaly of Newborn | Observation - None Of Specified Congenital Anomolies Of The Newborn) | Congenital anomolies of the newborn | |
entry:infantLiving | 0..1 | Reference(Observation - Infant Living) | Is infant living at time of report? | |
entry:infantBreastfedAtDischarge | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? | |
section:motherInformation | 0..1 | BackboneElement | motherInformation Section on the Provider Live Birth Report | |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 1..1 | Reference(Patient - Mother Vital Records) | The focus of this section is the mother | |
Slices for entry | 0..* | Reference(Resource) | Entries that are contained in the motherInformation Section Slice: Unordered, Open by profile:$this.resolve() | |
entry:marriedDuringPregnancy | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy | |
entry:ssnRequestedForChild | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child | |
entry:mothersEducation | 0..1 | Reference(Observation - Education Level Vital Records) | Mother's education | |
entry:mothersPresentJob | 0..1 | Reference(Observation - Present Job) | Mother's Usual Work | |
entry:mothersRaceEthnicity | 0..1 | Reference(Observation - Input Race and Ethnicity Vital Records) | Mother's Input Race and Ethnicity | |
section:fatherInformation | 0..1 | BackboneElement | fatherInformation Section on the Provider Live Birth Report | |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 1..1 | Reference(RelatedPerson - Father Natural Vital Records) | The focus of this section is the father | |
Slices for entry | 0..* | Reference(Resource) | Entries that are contained in the fatherInformation Section Slice: Unordered, Open by profile:$this.resolve() | |
entry:paternityAcknowledgementSigned | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father | |
entry:fathersEducation | 0..1 | Reference(Observation - Education Level Vital Records) | Father's education | |
entry:fathersPresentJob | 0..1 | Reference(Observation - Present Job) | Father's Present Job | |
entry:fathersRaceEthnicity | 0..1 | Reference(Observation - Input Race and Ethnicity Vital Records) | Father's Input Race and Ethnicity | |
section:patientsQuestionnaireResponse | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | |
code | 1..1 | CodeableConcept | Questionnaire response Document Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |
entry | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate | |
section:emergingIssues | 0..1 | BackboneElement | emergingIssues Section on the Provider Live Birth Report | |
code | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/vr-common-library/CodeSystem/CodeSystem-local-observation-codes-vr | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: emergingissues | |
Slices for entry | 0..* | Reference(Resource) | Entries that are contained in the emergingIssues Section Slice: Unordered, Open by profile:$this.resolve() | |
entry:EmergingIssues | 0..1 | Reference(Observation - Emerging Issues Vital Records) | Emerging Issues | |
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 |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 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 | Σ | 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 | Σ | 1..1 | Reference(Patient - Child Vital Records) | The subject of the composition is the newborn baby |
encounter | Σ | 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) | Encounter Maternity Reference URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-encounter-maternity-reference Slice: Unordered, Open by value:url | |
date | Σ | 1..1 | dateTime | Date report completed |
author | Σ | 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 | C | 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 cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
section:motherPrenatal | C | 0..1 | BackboneElement | motherPrenatal Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 1..1 | Reference(Patient - Mother Vital Records) | The focus of this section is the mother | |
Slices for entry | C | 0..* | Reference(Resource) | Entries that are contained in the motherPrenatal Section Slice: Unordered, Open by profile:$this.resolve() |
entry:firstPrenatalCareVisit | C | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
entry:numberPrenatalCareVisits | C | 0..1 | Reference(Observation - Number of Prenatal Visits) | Number of prenatal care visits |
entry:dateLastNormalMenses | C | 0..1 | Reference(Observation - Last Menstrual Period) | Date last normal menses began |
entry:numberNowLiving | C | 0..1 | Reference(Observation - Number of Births Now Living) | Number of previous live births now living |
entry:numberNowDead | C | 0..1 | Reference(Observation - Number of Births Now Dead) | Number of previous live births now dead |
entry:dateLastLiveBirth | C | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
entry:numberOtherOutcomes | C | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes) | Number of other pregnancy outcomes |
entry:dateLastOtherOutcome | C | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
entry:principalSourceOfPayment | C | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
entry:mothersWeightAtDelivery | C | 0..1 | Reference(Observation - Mother Delivery Weight (reported in pounds)) | Mother's weight at delivery |
entry:mothersHeight | C | 0..1 | Reference(Observation - Mother Height) | Mother's height |
entry:mothersPrepregnancyWeight | C | 0..1 | Reference(Observation - Mother Prepregnancy Weight) | Mother's prepregnancy weight |
entry:motherReceivedWICFood | C | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use |
entry:cigaretteSmokingBeforeDuringPregnancy | C | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy |
section:medicalHealthInformation | C | 0..1 | BackboneElement | medicalHealthInformation Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 1..1 | Reference(Patient - Mother Vital Records) | The focus of this section is the mother | |
Slices for entry | C | 0..* | Reference(Resource) | Entries that are contained in the medicalHealthInformation Section Slice: Unordered, Open by profile:$this.resolve() |
entry:pregnancyRiskFactors | C | 0..* | Reference(Condition - Prepregnancy Diabetes | Condition - Gestational Diabetes | Condition - Prepregnancy Hypertension | Condition - Gestational Hypertension | Condition - Eclampsia Hypertension | Observation - Previous Preterm Birth | Procedure - Infertility Treatment | Procedure - Fertility Enhancing Drug Therapy, Artificial or Intrauterine Insemination | Procedure - Assisted Reproductive Technology | Observation - Previous Cesarean | Observation - None Of Specified Pregnancy Risk Factors) | Risk factors in this pregnancy |
entry:numberPreviousCesareans | C | 0..1 | Reference(Observation - Number of Previous Cesareans) | If mother had a previous cesarean delivery, how many |
entry:infectionsDuringPregnancy | C | 0..* | Reference(Condition - Infection Present During Pregnancy | Observation - None Of Specified Infections During Pregnancy) | Infections present and/or treated during this pregnancy |
entry:obstetricProcedures | C | 0..1 | Reference(Procedure - Obstetric | Observation - None Of Specified Obstetric Procedures) | Obstetric procedures |
entry:characteristicsLaborDelivery | C | 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 | C | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
entry:finalRouteMethodDelivery | C | 0..1 | Reference(Procedure - Final Route and Method of Delivery | Observation - Unknown Final Route and Method of Delivery) | Final route and method of delivery |
entry:maternalMorbidity | C | 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 | C | 0..1 | BackboneElement | newbornInformation Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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 | C | 0..* | Reference(Resource) | Entries that are contained in the newbornInformation Section Slice: Unordered, Open by profile:$this.resolve() |
entry:birthWeight | C | 0..1 | Reference(Observation - Birth Weight) | Birthweight |
entry:gestationalAgeAtDelivery | C | 0..1 | Reference(Observation - Gestational Age at Delivery) | Obstetric estimate of gestation |
entry:APGARScore | C | 0..2 | Reference(Observation - APGAR Score) | APGAR Score - while the APGAR timing value set contains 3 possible values, 5 and 10 are the only scores used. |
entry:numberLiveBirthsThisDelivery | C | 0..1 | Reference(Observation - Number of Live Births This Delivery) | Number of live births this delivery |
entry:abnormalConditionsNewborn | C | 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 | C | 0..* | Reference(Condition - Congenital Anomaly of Newborn | Observation - None Of Specified Congenital Anomolies Of The Newborn) | Congenital anomolies of the newborn |
entry:infantLiving | C | 0..1 | Reference(Observation - Infant Living) | Is infant living at time of report? |
entry:infantBreastfedAtDischarge | C | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
section:motherInformation | C | 0..1 | BackboneElement | motherInformation Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 1..1 | Reference(Patient - Mother Vital Records) | The focus of this section is the mother | |
Slices for entry | C | 0..* | Reference(Resource) | Entries that are contained in the motherInformation Section Slice: Unordered, Open by profile:$this.resolve() |
entry:marriedDuringPregnancy | C | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy |
entry:ssnRequestedForChild | C | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child |
entry:mothersEducation | C | 0..1 | Reference(Observation - Education Level Vital Records) | Mother's education |
entry:mothersPresentJob | C | 0..1 | Reference(Observation - Present Job) | Mother's Usual Work |
entry:mothersRaceEthnicity | C | 0..1 | Reference(Observation - Input Race and Ethnicity Vital Records) | Mother's Input Race and Ethnicity |
section:fatherInformation | C | 0..1 | BackboneElement | fatherInformation Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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 | 1..1 | Reference(RelatedPerson - Father Natural Vital Records) | The focus of this section is the father | |
Slices for entry | C | 0..* | Reference(Resource) | Entries that are contained in the fatherInformation Section Slice: Unordered, Open by profile:$this.resolve() |
entry:paternityAcknowledgementSigned | C | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father |
entry:fathersEducation | C | 0..1 | Reference(Observation - Education Level Vital Records) | Father's education |
entry:fathersPresentJob | C | 0..1 | Reference(Observation - Present Job) | Father's Present Job |
entry:fathersRaceEthnicity | C | 0..1 | Reference(Observation - Input Race and Ethnicity Vital Records) | Father's Input Race and Ethnicity |
section:patientsQuestionnaireResponse | C | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
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 - Mother's Worksheet for Child's Birth Certificate |
section:emergingIssues | C | 0..1 | BackboneElement | emergingIssues Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | 1..1 | CodeableConcept | Classification of section (recommended) 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://hl7.org/fhir/us/vr-common-library/CodeSystem/CodeSystem-local-observation-codes-vr | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: emergingissues | |
Slices for entry | C | 0..* | Reference(Resource) | Entries that are contained in the emergingIssues Section Slice: Unordered, Open by profile:$this.resolve() |
entry:EmergingIssues | C | 0..1 | Reference(Observation - Emerging Issues Vital Records) | Emerging Issues |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | Pattern: LOINC Code 68998-4http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.section:motherPrenatal.code | example | Pattern: LOINC Code 57073-9http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:medicalHealthInformation.code | example | Pattern: LOINC Code 55752-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:newbornInformation.code | example | Pattern: LOINC Code 57075-4http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:motherInformation.code | example | Pattern: LOINC Code 92014-0http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:fatherInformation.code | example | Pattern: LOINC Code 92013-2http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:patientsQuestionnaireResponse.code | example | Pattern: LOINC Code 74465-6http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section:emergingIssues.code | example | Pattern: emergingissueshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
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 | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
status | ?!Σ | 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 | Σ | 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 | Σ | 1..1 | Reference(Patient - Child Vital Records) | The subject of the composition is the newborn baby | ||||
encounter | Σ | 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) | Encounter Maternity Reference 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 | Σ | 1..1 | dateTime | Date report completed | ||||
author | Σ | 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 | C | 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 cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | C | 0..1 | BackboneElement | motherPrenatal Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | Classification of section (recommended) 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 | 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 | C | 0..* | Reference(Resource) | Entries that are contained in the motherPrenatal Section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:firstPrenatalCareVisit | C | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit | ||||
entry:numberPrenatalCareVisits | C | 0..1 | Reference(Observation - Number of Prenatal Visits) | Number of prenatal care visits | ||||
entry:dateLastNormalMenses | C | 0..1 | Reference(Observation - Last Menstrual Period) | Date last normal menses began | ||||
entry:numberNowLiving | C | 0..1 | Reference(Observation - Number of Births Now Living) | Number of previous live births now living | ||||
entry:numberNowDead | C | 0..1 | Reference(Observation - Number of Births Now Dead) | Number of previous live births now dead | ||||
entry:dateLastLiveBirth | C | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth | ||||
entry:numberOtherOutcomes | C | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes) | Number of other pregnancy outcomes | ||||
entry:dateLastOtherOutcome | C | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome | ||||
entry:principalSourceOfPayment | C | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery | ||||
entry:mothersWeightAtDelivery | C | 0..1 | Reference(Observation - Mother Delivery Weight (reported in pounds)) | Mother's weight at delivery | ||||
entry:mothersHeight | C | 0..1 | Reference(Observation - Mother Height) | Mother's height | ||||
entry:mothersPrepregnancyWeight | C | 0..1 | Reference(Observation - Mother Prepregnancy Weight) | Mother's prepregnancy weight | ||||
entry:motherReceivedWICFood | C | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use | ||||
entry:cigaretteSmokingBeforeDuringPregnancy | C | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy | ||||
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 | C | 0..1 | BackboneElement | medicalHealthInformation Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | Classification of section (recommended) 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 | 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 | C | 0..* | Reference(Resource) | Entries that are contained in the medicalHealthInformation Section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:pregnancyRiskFactors | C | 0..* | Reference(Condition - Prepregnancy Diabetes | Condition - Gestational Diabetes | Condition - Prepregnancy Hypertension | Condition - Gestational Hypertension | Condition - Eclampsia Hypertension | Observation - Previous Preterm Birth | Procedure - Infertility Treatment | Procedure - Fertility Enhancing Drug Therapy, Artificial or Intrauterine Insemination | Procedure - Assisted Reproductive Technology | Observation - Previous Cesarean | Observation - None Of Specified Pregnancy Risk Factors) | Risk factors in this pregnancy | ||||
entry:numberPreviousCesareans | C | 0..1 | Reference(Observation - Number of Previous Cesareans) | If mother had a previous cesarean delivery, how many | ||||
entry:infectionsDuringPregnancy | C | 0..* | Reference(Condition - Infection Present During Pregnancy | Observation - None Of Specified Infections During Pregnancy) | Infections present and/or treated during this pregnancy | ||||
entry:obstetricProcedures | C | 0..1 | Reference(Procedure - Obstetric | Observation - None Of Specified Obstetric Procedures) | Obstetric procedures | ||||
entry:characteristicsLaborDelivery | C | 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 | C | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth | ||||
entry:finalRouteMethodDelivery | C | 0..1 | Reference(Procedure - Final Route and Method of Delivery | Observation - Unknown Final Route and Method of Delivery) | Final route and method of delivery | ||||
entry:maternalMorbidity | C | 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 | C | 0..1 | BackboneElement | newbornInformation Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | Classification of section (recommended) 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 | C | 0..* | Reference(Resource) | Entries that are contained in the newbornInformation Section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:birthWeight | C | 0..1 | Reference(Observation - Birth Weight) | Birthweight | ||||
entry:gestationalAgeAtDelivery | C | 0..1 | Reference(Observation - Gestational Age at Delivery) | Obstetric estimate of gestation | ||||
entry:APGARScore | C | 0..2 | Reference(Observation - APGAR Score) | APGAR Score - while the APGAR timing value set contains 3 possible values, 5 and 10 are the only scores used. | ||||
entry:numberLiveBirthsThisDelivery | C | 0..1 | Reference(Observation - Number of Live Births This Delivery) | Number of live births this delivery | ||||
entry:abnormalConditionsNewborn | C | 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 | C | 0..* | Reference(Condition - Congenital Anomaly of Newborn | Observation - None Of Specified Congenital Anomolies Of The Newborn) | Congenital anomolies of the newborn | ||||
entry:infantLiving | C | 0..1 | Reference(Observation - Infant Living) | Is infant living at time of report? | ||||
entry:infantBreastfedAtDischarge | C | 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 | C | 0..1 | BackboneElement | motherInformation Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | Classification of section (recommended) 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 | 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 | C | 0..* | Reference(Resource) | Entries that are contained in the motherInformation Section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:marriedDuringPregnancy | C | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy | ||||
entry:ssnRequestedForChild | C | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child | ||||
entry:mothersEducation | C | 0..1 | Reference(Observation - Education Level Vital Records) | Mother's education | ||||
entry:mothersPresentJob | C | 0..1 | Reference(Observation - Present Job) | Mother's Usual Work | ||||
entry:mothersRaceEthnicity | C | 0..1 | Reference(Observation - Input Race and Ethnicity Vital Records) | Mother's Input Race and Ethnicity | ||||
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 | C | 0..1 | BackboneElement | fatherInformation Section on the Provider Live Birth Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | Classification of section (recommended) 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 | 1..1 | Reference(RelatedPerson - Father Natural Vital Records) | The focus of this section is the father | |||||
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 | C | 0..* | Reference(Resource) | Entries that are contained in the fatherInformation Section Slice: Unordered, Open by profile:$this.resolve() | ||||
entry:paternityAcknowledgementSigned | C | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father | ||||
entry:fathersEducation | C | 0..1 | Reference(Observation - Education Level Vital Records) | Father's education | ||||
entry:fathersPresentJob | C | 0..1 | Reference(Observation - Present Job) | Father's Present Job | ||||
entry:fathersRaceEthnicity | C | 0..1 | Reference(Observation - Input Race and Ethnicity Vital Records) | Father's Input Race and Ethnicity | ||||
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 - Patient's Worksheet for Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 |