Birth And Fetal Death (BFDR) FHIR Implementation Guide
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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

Resource Profile: Procedure - Final Route and Method of Delivery

Official URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Procedure-final-route-method-delivery Version: 2.0.0
Active as of 2024-10-11 Computable Name: ProcedureFinalRouteMethodDelivery
Other Identifiers: OID:2.16.840.1.113883.4.642.40.13.42.94

This profile represents the final route and method of delivery.

IJE Mapping

Natality
Use Case # Description IJE Name Field Type Value Set/Comments
Natality 193 Method of Delivery--Route and Method of Delivery ROUT code codeable DeliveryRoutesVS unless unknown,
See note on missing method of delivery data

Fetal Death
Use Case # Description IJE Name Field Type Value Set/Comments
Fetal Death 134 Method of Delivery--Route and Method of Delivery ROUT code codeable DeliveryRoutesVS unless unknown,
See note on missing method of delivery data

Form Mapping

Form Mapping
Item # Form Field FHIR Profile Field Reference
46.D Final route and method of delivery code Certificate of Live Birth
27.D Method of delivery: Final route and method of delivery code Facility Worksheet for the Live Birth Certificate
27.D Method of delivery: Final route and method of delivery code Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births
38.D Method of Delivery: Final route and method of delivery code Report of Fetal Death
17.B Method of Delivery: Final route and method of delivery code Facility Worksheet for the Report of Fetal Death

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreProcedureProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure USCoreProcedureProfile
... category 1..1 CodeableConcept Final route and method of delivery [US Standard Certificate of Live Birth]
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: 73762-7
... code 1..1 CodeableConcept The value set contains the list of the possible routes by which the infant or fetus may be delivered.
Binding: Delivery Routes (required): Delivery Routes (NCHS)

... subject 1..1 Reference(Patient - Mother Vital Records) Who the procedure was performed on

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.coderequiredDeliveryRoutesVS
http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
.... 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: 73762-7
... code SΣ 1..1 CodeableConcept The value set contains the list of the possible routes by which the infant or fetus may be delivered.
Binding: Delivery Routes (required): Delivery Routes (NCHS)

... subject SΣ 1..1 Reference(Patient - Mother Vital Records) Who the procedure was performed on
... performed[x] SΣC 0..1 When the procedure was performed
.... performedDateTime dateTime
... reasonReference Σ 0..* Reference(Observation - Labor Trial Attempted) If cesarean, was a trial of labor attempted?

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.categoryexamplePattern: LOINC Code 73762-7
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.coderequiredDeliveryRoutesVS
http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
... 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Identifiers for this procedure
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest) A request for this procedure
... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) Part of referenced event
... status ?!SΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
... statusReason Σ 0..1 CodeableConcept Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category Σ 1..1 CodeableConcept Final route and method of delivery [US Standard Certificate of Live Birth]
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.


Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://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: 73762-7
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept The value set contains the list of the possible routes by which the infant or fetus may be delivered.
Binding: Delivery Routes (required): Delivery Routes (NCHS)

... subject SΣ 1..1 Reference(Patient - Mother Vital Records) Who the procedure was performed on
... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
... performed[x] SΣC 0..1 When the procedure was performed
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this procedure
... performer Σ 0..* BackboneElement The people who performed the procedure
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... function Σ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) The reference to the practitioner
.... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
... location Σ 0..1 Reference(Location) Where the procedure happened
... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ 0..* Reference(Observation - Labor Trial Attempted) If cesarean, was a trial of labor attempted?
... bodySite Σ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ 0..1 CodeableConcept The result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

... report 0..* Reference(DiagnosticReport | DocumentReference | Composition) Any report resulting from the procedure
... complication 0..* CodeableConcept Complication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


... complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure
... followUp 0..* CodeableConcept Instructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..* Annotation Additional information about the procedure
... focalDevice 0..* BackboneElement Manipulated, implanted, or removed device
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... action 0..1 CodeableConcept Kind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1 Reference(Device) Device that was changed
... usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure
... usedCode 0..* CodeableConcept Coded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.categoryexamplePattern: LOINC Code 73762-7
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.coderequiredDeliveryRoutesVS
http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes
from this IG
Procedure.performer.functionexampleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeexampleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeexampleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Differential View

This structure is derived from USCoreProcedureProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure USCoreProcedureProfile
... category 1..1 CodeableConcept Final route and method of delivery [US Standard Certificate of Live Birth]
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: 73762-7
... code 1..1 CodeableConcept The value set contains the list of the possible routes by which the infant or fetus may be delivered.
Binding: Delivery Routes (required): Delivery Routes (NCHS)

... subject 1..1 Reference(Patient - Mother Vital Records) Who the procedure was performed on

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.coderequiredDeliveryRoutesVS
http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
.... 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: 73762-7
... code SΣ 1..1 CodeableConcept The value set contains the list of the possible routes by which the infant or fetus may be delivered.
Binding: Delivery Routes (required): Delivery Routes (NCHS)

... subject SΣ 1..1 Reference(Patient - Mother Vital Records) Who the procedure was performed on
... performed[x] SΣC 0..1 When the procedure was performed
.... performedDateTime dateTime
... reasonReference Σ 0..* Reference(Observation - Labor Trial Attempted) If cesarean, was a trial of labor attempted?

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.categoryexamplePattern: LOINC Code 73762-7
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.coderequiredDeliveryRoutesVS
http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
... 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Identifiers for this procedure
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest) A request for this procedure
... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) Part of referenced event
... status ?!SΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
... statusReason Σ 0..1 CodeableConcept Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category Σ 1..1 CodeableConcept Final route and method of delivery [US Standard Certificate of Live Birth]
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.


Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://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: 73762-7
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept The value set contains the list of the possible routes by which the infant or fetus may be delivered.
Binding: Delivery Routes (required): Delivery Routes (NCHS)

... subject SΣ 1..1 Reference(Patient - Mother Vital Records) Who the procedure was performed on
... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
... performed[x] SΣC 0..1 When the procedure was performed
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this procedure
... performer Σ 0..* BackboneElement The people who performed the procedure
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... function Σ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) The reference to the practitioner
.... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
... location Σ 0..1 Reference(Location) Where the procedure happened
... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ 0..* Reference(Observation - Labor Trial Attempted) If cesarean, was a trial of labor attempted?
... bodySite Σ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ 0..1 CodeableConcept The result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

... report 0..* Reference(DiagnosticReport | DocumentReference | Composition) Any report resulting from the procedure
... complication 0..* CodeableConcept Complication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


... complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure
... followUp 0..* CodeableConcept Instructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..* Annotation Additional information about the procedure
... focalDevice 0..* BackboneElement Manipulated, implanted, or removed device
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... action 0..1 CodeableConcept Kind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1 Reference(Device) Device that was changed
... usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure
... usedCode 0..* CodeableConcept Coded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.categoryexamplePattern: LOINC Code 73762-7
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.coderequiredDeliveryRoutesVS
http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes
from this IG
Procedure.performer.functionexampleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeexampleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeexampleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron