HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm
2.1.2 - STU 2 United States of America flag

HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm, published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 2.1.2 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

Resource Profile: eICR Composition

Official URL: http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition Version: 2.1.2
Active as of 2024-10-30 Computable Name: EICRComposition
Other Identifiers: OID:2.16.840.1.113883.4.642.40.46.42.2

This Composition profile represents an electronic initial case report (eICR). It is based on and further constrains the US Public Health Composition.

This profile describes the content requirements for the eICR including:

  • patient demographics
  • patient pregnancy status
  • patient work information
    • current occupation, current industry, current employer name, phone, and address, occupational exposure (Past or Present Job)
      • Note: An Occupational Hazard is a source of potential harm to one’s health that may be encountered at work. An Occupational Exposure is a known interaction with an occupational hazard in a way that increases the risk of harm.
    • usual occupation, usual industry (Usual Work)
  • patient travel history
  • patient exposure/contact information
  • provider and facility information
  • laboratory orders, tests, and results
  • signs, symptoms, and diagnoses
  • medication and immunization information
  • flags for the existence of reportable condition trigger codes in diagnoses, ordered/resulted laboratory tests, medications, immunizations, and procedures
    • flags contain RCTC OID and RCTC version
    • codes indicating whether the eICR was manually or alternately initiated

In the case where a trigger code was previously entered in error and has now been corrected, set verificationStatus or status (depending on profile type) of the profile to 'entered-in-error' and set the eICR Initiation Type extension to PHC1464.

Where a trigger occurs outside of an encounter and Encounter.class is set to “PHC2237”, system=”2.16.840.1.114222.4.5.274” (External Encounter) the responsible provider and facility information is contained in the eICR Composition.author. See table:

Data Element Note
Composition.author In a public health case report, the author may be the provider, software, or a person in the role of a public health reporter, such as an infection control professional (ICP), a medical assistant, an office administrator, or another staff person who assists a provider with public health reporting.
Composition.author[PractitionerRole] [External encounter case] Provider: Provider responsible for the patient's care when the case was triggered.
Composition.author[PractitionerRole].identifier [External encounter case] Provider Id: Identifier of the provider responsible for the patient's care when the case was triggered
Composition.author[PractitionerRole].practitioner[Practitioner].identifier [External encounter case] Provider Address: Address of the provider responsible for the patient's care when the case was triggered.
Composition.author[PractitionerRole].telecom [External encounter case] Provider Telecom: A telecom address (phone, email, fax, etc.) for the provider responsible for the patient's care when the case was triggered.
Composition.author[PractitionerRole].practitioner[Practitioner].name [External encounter case] Provider Name: Name of the provider responsible for the patient's care when the case was triggered
Composition.author[PractitionerRole].organization[Organization] [External encounter case] Facility: The facility in which care was provided when the case was triggered
Composition.author[PractitionerRole].organization[Organization].identifier [External encounter case] Facility Id: Identification code for the facility in which care was provided when the case was triggered
Composition.author[PractitionerRole].organization[Organization].address [External encounter case] Facility Address: The physical location of the facility in which care was provided when the case was triggered

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USPublicHealthComposition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition S 0..* USPublicHealthComposition eICR Composition Profile
... Slices for extension S 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extensionEICRInitiationType S 0..1 CodeableConcept Initial Case Report Initiation Type
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-initiation-type-extension
Binding: eICR Initiation (extensible): Initiation Types

.... extensionEICRInitiationReason S 0..* string, CodeableConcept Initial Case Report Initiation Reason
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-initiation-reason-extension
... type S 1..1 CodeableConcept Public Health Case Report
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: 55751-2
... encounter S 1..1 Reference(eICR Encounter) Encounter related to the public health event
... custodian S 1..1 Reference(US Public Health Organization) Organization which maintains the composition
... Slices for relatesTo S 0..* BackboneElement Relationships to other compositions/documents
Slice: Unordered, Open by value:code
.... relatesTo:sliceTransformed S 0..1 BackboneElement Document or Composition that this Composition is transformed from
..... code 1..1 code replaces | transforms | signs | appends
Fixed Value: transforms
..... target[x] 1..1 Identifier Identifier of the Document or Composition transformed
.... relatesTo:sliceReplaced S 0..1 BackboneElement Document or Composition that this Composition replaces
..... code 1..1 code replaces | transforms | signs | appends
Fixed Value: replaces
..... target[x] 1..1 Identifier, Reference(Composition) Identifier/Reference to the Document or Composition transformed
... Slices for section S 0..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by value:code
.... section:sliceReasonForVisitSection S 1..1 BackboneElement Reason for Visit Section
..... code S 1..1 CodeableConcept Reason for Visit code
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: 29299-5
..... text S 1..1 Narrative Reason for Visit narrative
.... section:sliceChiefComplaintSection S 1..1 BackboneElement Chief Complaint Section
..... code S 1..1 CodeableConcept Chief Complaint code
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: 10154-3
..... text S 1..1 Narrative Chief Complaint narrative
.... section:sliceHistoryOfPresentIllnessSection S 1..1 BackboneElement History of Present Illness Section
..... code S 1..1 CodeableConcept History of Present Illness code
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: 10164-2
..... text S 1..1 Narrative History of Present Illness narrative
.... section:sliceProblemSection S 1..1 BackboneElement Problem Section
..... code S 1..1 CodeableConcept Problem Section code
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: 11450-4
..... text S 1..1 Narrative Problem Section narrative
..... Slices for entry S 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEICRCondition S 0..* Reference(US Public Health Condition) eICR Condition entry
....... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
........ sliceTriggerCondition S 0..1 (Complex) eICR Trigger Code Flag
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-trigger-code-flag-extension
.... section:sliceMedicationsAdministeredSection S 1..1 BackboneElement Medications Administered Section
..... code S 1..1 CodeableConcept Medications Administered Section code
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: 29549-3
..... text S 1..1 Narrative Medications Administered Section narrative
..... Slices for entry S 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceMedicationAdministration S 0..* Reference(US Public Health MedicationAdministration) Medication Administration entry
....... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
........ sliceTriggerMedicationAdministered S 0..1 (Complex) eICR Trigger Code Flag
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-trigger-code-flag-extension
.... section:sliceAdmissionMedicationsSection S 0..1 BackboneElement Admission Medications Section
..... code S 1..1 CodeableConcept Admission Medications Section code
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: 42346-7
..... text S 1..1 Narrative Admission Medications Section narrative
..... Slices for entry S 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceMedication S 0..* Reference(MedicationAdministration) Admission Medication entry
.... section:sliceMedicationsSection S 0..1 BackboneElement Medications Section
..... code S 1..1 CodeableConcept Medications Section code
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: 10160-0
..... text S 1..1 Narrative Medications Section narrative
..... Slices for entry S 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceMedicationAdministration S 0..* Reference(MedicationAdministration) Medication Administration entry
....... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
........ sliceTriggerMedicationAdministered S 0..1 (Complex) eICR Trigger Code Flag
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-trigger-code-flag-extension
.... section:sliceResultsSection S 1..1 BackboneElement Results Section
..... code S 1..1 CodeableConcept Results Section code
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: 30954-2
..... text S 1..1 Narrative Results Section narrative
..... Slices for entry S 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceUSPHLabResultObservation S 0..* Reference(US Public Health Laboratory Result Observation Profile) A reference to data that supports this section
....... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
........ sliceTriggerUSPHLabResultObservation S 0..* (Complex) eICR Trigger Code Flag
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-trigger-code-flag-extension
.... section:slicePlanOfTreatmentSection S 0..1 BackboneElement Plan of Treatment Section
..... code S 1..1 CodeableConcept Plan of Treatment code
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: 18776-5
..... text S 1..1 Narrative Plan of Treatment narrative
..... Slices for entry S 1..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEICRServiceRequest S 0..* Reference(eICR ServiceRequest) eICR Service Request entry
....... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
........ sliceTriggerEICRServiceRequest S 0..1 (Complex) eICR Trigger Code Flag
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-trigger-code-flag-extension
...... entry:sliceUSCoreMedicationRequest S 0..* Reference(US Core MedicationRequest Profile(4.0.0)) US Core Medication Request entry
....... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
........ sliceTriggerUSCoreMedicationRequest S 0..1 (Complex) eICR Trigger Code Flag
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-trigger-code-flag-extension
.... section:sliceImmunizationsSection S 0..1 BackboneElement Immunizations Section
..... code S 1..1 CodeableConcept Immunizations code
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: 11369-6
..... text S 1..1 Narrative Immunizations narrative
..... Slices for entry S 1..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceUSCoreImmunization S 1..* Reference(US Core Immunization Profile(4.0.0)) Immunization entry
....... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
........ sliceTriggerImmunization S 0..1 (Complex) eICR Trigger Code Flag
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-trigger-code-flag-extension
...... entry:sliceVaccineCredentialsPatientAssertion S 0..* Reference(eICR Vaccine Credential Patient Assertion) A reference to data that supports this section
.... section:sliceProceduresSection S 0..1 BackboneElement This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated.
..... code S 1..1 CodeableConcept Procedures Section code
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: 47519-4
..... text S 1..1 Narrative Procedures Section narrative
..... Slices for entry S 1..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceEICRProcedure S 1..* Reference(eICR Procedure) EICR Procedure entry
....... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
........ sliceTriggerProcedure S 0..1 (Complex) eICR Trigger Code Flag
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-trigger-code-flag-extension
.... section:sliceVitalSignsSection S 0..1 BackboneElement Vital Signs Section
..... code S 1..1 CodeableConcept Vital Signs code
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: 8716-3
..... text S 1..1 Narrative Vital Signs narrative
..... Slices for entry S 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceVitalSigns S 0..* Reference(US Core Vital Signs Profile) A reference to data that supports this section
.... section:sliceSocialHistorySection S 1..1 BackboneElement Social History Section
..... code S 1..1 CodeableConcept Social History Section code
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: 29762-2
..... text S 1..1 Narrative Social History Section narrative
..... Slices for entry S 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceCharacteristicsOfHomeEnvironment S 0..* Reference(US Public Health Characteristics of Home Environment) Characteristics of Home Environment
...... entry:sliceODHPastOrPresentJob S 0..* Reference(Past Or Present Job) ODH Past or Present Job entry
...... entry:sliceODHUsualWork S 0..* Reference(Usual Work) ODH Usual Work entry
...... entry:sliceODHEmploymentStatus S 0..* Reference(Employment Status) ODH Employment Status entry
...... entry:sliceTravelHistory S 0..* Reference(US Public Health Travel History) Travel History entry
...... entry:sliceDisabilityStatus S 0..* Reference(US Public Health Disability Status) Disability Status entry
...... entry:sliceExposureContactInformation S 0..* Reference(US Public Health Exposure Contact Information) Exposure Information entry
...... entry:sliceCountryOfResidence S 0..* Reference(eICR Country of Residence) Country of residence entry
...... entry:sliceCountryOfNationality S 0..* Reference(eICR Country of Nationality) Country of nationality entry
.... section:slicePregnancySection S 0..1 BackboneElement Pregnancy Section
..... code S 1..1 CodeableConcept Pregnancy summary Document code
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: 90767-5
..... text S 1..1 Narrative Pregnancy summary Document narrative
..... Slices for entry S 1..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:slicePregnancyStatusObservation S 1..* Reference(US Public Health Pregnancy Status Observation) Pregnancy Status Observation entry
...... entry:slicePregnancyOutcome S 0..* Reference(US Public Health Pregnancy Outcome Observation) Pregnancy Outcome entry
...... entry:sliceLastMenstrualPeriod S 0..* Reference(Observation - Last Menstrual Period) Last Menstrual Period entry
...... entry:slicePostpartumStatus S 0..* Reference(US Public Health Postpartum Status) Postpartum Status entry
.... section:sliceEmergencyOutbreakInformationSection S 0..1 BackboneElement Emergency Outbreak Information Section
..... code S 1..1 CodeableConcept Emergency Outbreak Information Section code
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: 83910-0
..... text S 1..1 Narrative Emergency Outbreak Information Section narrative
..... Slices for entry S 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceObservationEmergencyOutbreakInformation S 0..* Reference(US Public Health Emergency Outbreak Information) A reference to data that supports this section
.... section:slicePastMedicalHistorySection S 0..1 BackboneElement Past Medical History Section
..... code S 1..1 CodeableConcept Past Medical History Section code
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: 11348-0
..... text S 1..1 Narrative Past Medical History Section narrative
..... Slices for entry S 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceUSCoreCondition S 0..* Reference(US Core Condition Profile(4.0.0)) US Core Condition entry
.... section:sliceReviewOfSystemsSection S 0..1 BackboneElement Review of Systems Section
..... code S 1..1 CodeableConcept Review of Systems code
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: 10187-3
..... text S 1..1 Narrative Review of Systems narrative
.... section:sliceReportabilityResponseInformationSection S 0..1 BackboneElement Reportability Response Information Section (for post-processing only)
..... code S 1..1 CodeableConcept Reportability response report Document Public health
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: 88085-6
..... text S 1..1 Narrative Reportability Response Information Section narrative
..... Slices for entry 0..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
...... entry:sliceReportabilityResponseRelevantCondition S 0..* Reference(RR Relevant Reportable Condition Observation) A reference to data that supports this section

doco Documentation for this format

 

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