Bundle - Provider Live Birth - Baby G Quinn - UV_Vital Records Birth and Fetal Death Reporting v1.1.0

UV_Vital Records Birth and Fetal Death Reporting, published by IHE International. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/fhir-bfdr/ and changes regularly. See the Directory of published versions

Example Bundle: Bundle - Provider Live Birth - Baby G Quinn

Document Details

Generated Narrative: Bundle Provider supplied live birth report Document

version: versionId: id (PrimitiveType/Bundle.meta.versionId): native = id -> 4; Last updated: 2023-07-07 02:39:35+0000

Profile: Bundle - Document Birth and Fetal Death

Final Document at 2019-02-12 by Practitioner - Vital Records (Dr. Avery Jones, MD) for Patient - Child (Baby G Quinn) in encounter Encounter - Birth (Baby G Quinn)

Document Subject

Document Content

Mother (prenatal) Section on the Live Birth Certificate

Medical Health Information Section

Newborn section on the Live Birth Certificate

Mother's Information Section

Father's Information Section

Mother's QuestionnaireResponse Section

Additional Resources Included in Document

Entry 1 - fullUrl = http://example.org/fhir/Composition/composition-provider-live-birth-babyg-quinn

Resource Composition:

Generated Narrative: Composition composition-provider-live-birth-babyg-quinn

identifier: a03eab8c-11e8-4d0c-ad2a-b385395e27de
status: Final
type: U.S. standard certificate of live birth - 2003 revision
encounter: Encounter - Birth (Baby G Quinn)
date: 2019-02-12
author: Practitioner - Vital Records (Dr. Avery Jones, MD)
title: Provider supplied live birth report Document

Entry 2 - fullUrl = http://example.org/fhir/Patient/patient-child-babyg-quinn

Resource Patient:

Generated Narrative: Patient patient-child-babyg-quinn

Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, ))
US Core Ethnicity Extension:
ombCategory: Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino
text: Not Hispanic or Latino
Patient Birth Place Salt Lake City UT
US Core Birth Sex Extension F
US Core Race Extension:
ombCategory: Race & Ethnicity - CDC 2106-3: White
text: White

Entry 3 - fullUrl = http://example.org/fhir/Encounter/encounter-birth-babyg-quinn

Resource Encounter:

Generated Narrative: Encounter encounter-birth-babyg-quinn
Not done yet

Entry 4 - fullUrl = http://example.org/fhir/Encounter/encounter-maternity-jada-ann-quinn

Resource Encounter:

Generated Narrative: Encounter encounter-maternity-jada-ann-quinn
Not done yet

Entry 5 - fullUrl = http://example.org/fhir/Practitioner/practitioner-vital-records-avery-jones

Resource Practitioner:

Generated Narrative: Practitioner practitioner-vital-records-avery-jones

identifier: NPI/112247003
name: Avery Jones
Qualifications
- Code
* Osteopath (occupation)

Entry 6 - fullUrl = http://example.org/fhir/Patient/patient-mother-jada-ann-quinn

Resource Patient:

Generated Narrative: Patient patient-mother-jada-ann-quinn

Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Social Security number: SSN#132225986 (use: usual, ))
Other Id: Medical Record Number/1032702 (use: usual, )
Alt. Name: Jada Ann King (Name changed for Marriage)
Contact Detail
ph: 1-(404)555-1212(Home)
jadaann.quinn@example.com
1875 West Morton Avenue Salt Lake City UT 84116 US (home)
1848 South 1300 East Salt Lake City UT 84401 US (billing)
Links:
Also see: RelatedPerson Jada Ann Quinn (official)
US Core Ethnicity Extension:
ombCategory: Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino
text: Not Hispanic or Latino
Patient Birth Place UT
US Core Birth Sex Extension F
US Core Race Extension:
ombCategory: Race & Ethnicity - CDC 2106-3: White
ombCategory: Race & Ethnicity - CDC 1002-5: American Indian or Alaska Native
text: White, American Indian or Alaska Native

Entry 7 - fullUrl = http://example.org/fhir/Observation/observation-planned-to-deliver-at-home-babyg-quinn

Resource Observation:

Generated Narrative: Observation observation-planned-to-deliver-at-home-babyg-quinn

status: Final
code: Planned to deliver at home?
subject: BabyG Quinn
focus: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: true

Entry 8 - fullUrl = http://example.org/fhir/Observation/observation-date-of-first-prenatal-care-visit-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-date-of-first-prenatal-care-visit-jada-ann-quinn

status: Final
code: Date of first prenatal care visit
subject: BabyG Quinn
focus: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 2018-07-20

Entry 9 - fullUrl = http://example.org/fhir/Observation/observation-number-prenatal-visits-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-number-prenatal-visits-jada-ann-quinn

status: Final
code: Prenatal visits for this pregnancy #
subject: BabyG Quinn
focus: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 8

Entry 10 - fullUrl = http://example.org/fhir/Observation/observation-last-menstrual-period-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-last-menstrual-period-jada-ann-quinn

status: Final
code: Last menstrual period start date
subject: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 2018-06-05

Entry 11 - fullUrl = http://example.org/fhir/Observation/observation-number-births-now-living-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-number-births-now-living-jada-ann-quinn

status: Final
code: [#] Births.still living
subject: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 1

Entry 12 - fullUrl = http://example.org/fhir/Observation/observation-number-births-now-dead-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-number-births-now-dead-jada-ann-quinn

status: Final
code: Previous live births now dead #
subject: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 0

Entry 13 - fullUrl = http://example.org/fhir/Observation/observation-date-of-last-live-birth-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-date-of-last-live-birth-jada-ann-quinn

status: Final
code: Date of last live birth
subject: BabyG Quinn
focus: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 2014-11-20

Entry 14 - fullUrl = http://example.org/fhir/Observation/observation-number-other-pregnancy-outcomes-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-number-other-pregnancy-outcomes-jada-ann-quinn

status: Final
code: Other pregnancy outcomes #
subject: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 0

Entry 15 - fullUrl = http://example.org/fhir/Observation/observation-date-of-last-other-pregnancy-outcome-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-date-of-last-other-pregnancy-outcome-jada-ann-quinn

status: Final
code: Date of last other pregnancy outcome
subject: BabyG Quinn
focus: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 2015-05

Entry 16 - fullUrl = http://example.org/fhir/Coverage/coverage-principal-payer-for-delivery-jada-ann-quinn

Resource Coverage:

Generated Narrative: Coverage coverage-principal-payer-for-delivery-jada-ann-quinn

status: Active
type: Private Health Insurance
beneficiary: Patient - Mother (Jada Ann Quinn)

Entry 17 - fullUrl = http://example.org/fhir/Observation/observation-mother-delivery-weight-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-mother-delivery-weight-jada-ann-quinn

status: Final
category: Vital Signs
code: Mother's body weight --at delivery
subject: Patient - Mother (Jada Ann Quinn)
effective: 2019-02-12
performer: Practitioner Avery Jones
value: 175 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')

Entry 18 - fullUrl = http://example.org/fhir/Observation/observation-mother-height-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-mother-height-jada-ann-quinn

status: Final
category: Vital Signs
code: Body height Measured
subject: Patient - Mother (Jada Ann Quinn)
effective: 2019-02-10
performer: Practitioner Avery Jones
value: 67 [in_i] (Details: UCUM code[in_i] = '[in_i]')

Entry 19 - fullUrl = http://example.org/fhir/Observation/observation-mother-prepregnancy-weight-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-mother-prepregnancy-weight-jada-ann-quinn

status: Final
category: Vital Signs
code: Body weight --pre current pregnancy
subject: Patient - Mother (Jada Ann Quinn)
effective: 2019-06-20
performer: Practitioner Avery Jones
value: 145 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')

Entry 20 - fullUrl = http://example.org/fhir/Observation/observation-mother-received-wic-food-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-mother-received-wic-food-jada-ann-quinn

status: Final
code: Did mother get WIC food for herself during this pregnancy?
subject: BabyG Quinn
focus: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: Yes

Entry 21 - fullUrl = http://example.org/fhir/Observation/observation-cig-smoking-pregnancy-1-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-cig-smoking-pregnancy-1-jada-ann-quinn

status: Final
code: In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day [PhenX]
subject: Patient - Mother (Jada Ann Quinn)
focus: BabyG Quinn
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: 20

Entry 22 - fullUrl = http://example.org/fhir/Observation/observation-cig-smoking-pregnancy-2-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-cig-smoking-pregnancy-2-jada-ann-quinn

status: Final
code: Cigarettes smoked per day by Mother--1st trimester
subject: Patient - Mother (Jada Ann Quinn)
focus: BabyG Quinn
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: 3

Entry 23 - fullUrl = http://example.org/fhir/Observation/observation-cig-smoking-pregnancy-3-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-cig-smoking-pregnancy-3-jada-ann-quinn

status: Final
code: Cigarettes smoked per day by Mother--2nd trimester
subject: Patient - Mother (Jada Ann Quinn)
focus: BabyG Quinn
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: 1

Entry 24 - fullUrl = http://example.org/fhir/Observation/observation-cig-smoking-pregnancy-4-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-cig-smoking-pregnancy-4-jada-ann-quinn

status: Final
code: In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day [PhenX]
subject: Patient - Mother (Jada Ann Quinn)
focus: BabyG Quinn
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: 0

Entry 25 - fullUrl = http://example.org/fhir/Condition/condition-prepregnancy-diabetes-jada-ann-quinn

Resource Condition:

Generated Narrative: Condition condition-prepregnancy-diabetes-jada-ann-quinn

clinicalStatus: Active
category: Problem List Item
code: Diabetes mellitus (disorder)
subject: Patient - Mother (Jada Ann Quinn)
onset: 2015-02-12

Entry 26 - fullUrl = http://example.org/fhir/Condition/condition-gestational-hypertension-jada-ann-quinn

Resource Condition:

Generated Narrative: Condition condition-gestational-hypertension-jada-ann-quinn

clinicalStatus: Active
category: Problem List Item
code: Pregnancy-induced hypertension (disorder)
subject: Patient - Mother (Jada Ann Quinn)

Entry 27 - fullUrl = http://example.org/fhir/Observation/observation-number-previous-cesareans-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-number-previous-cesareans-jada-ann-quinn

status: Final
code: Previous cesarean deliveries #
subject: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 1

Entry 28 - fullUrl = http://example.org/fhir/Condition/condition-infection-present-during-pregnancy-jada-ann-quinn

Resource Condition:

Generated Narrative: Condition condition-infection-present-during-pregnancy-jada-ann-quinn

clinicalStatus: Active
category: Problem List Item, Infections present AndOr treated during this pregnancy for live birth [US Standard Certificate of Live Birth]
code: Chlamydial infection (disorder)
subject: Patient - Mother (Jada Ann Quinn)

Entry 29 - fullUrl = http://example.org/fhir/Procedure/procedure-obstetric-procedure-jada-ann-quinn

Resource Procedure:

Generated Narrative: Procedure procedure-obstetric-procedure-jada-ann-quinn

status: Completed
code: External cephalic version: Failed
subject: Patient - Mother (Jada Ann Quinn)
outcome: External cephalic version: Unsuccessful

Entry 30 - fullUrl = http://example.org/fhir/Condition/condition-chorioamnionitis-jada-ann-quinn

Resource Condition:

Generated Narrative: Condition condition-chorioamnionitis-jada-ann-quinn

clinicalStatus: Active
category: Problem List Item
code: Chorioamnionitis (disorder)
subject: Patient - Mother (Jada Ann Quinn)

Entry 31 - fullUrl = http://example.org/fhir/Procedure/procedure-induction-of-labor-jada-ann-quinn

Resource Procedure:

Generated Narrative: Procedure procedure-induction-of-labor-jada-ann-quinn

status: Completed
code: Induction of labor (procedure)
subject: Patient - Mother (Jada Ann Quinn)

Entry 32 - fullUrl = http://example.org/fhir/Observation/observation-fetal-presentation-babyg-quinn

Resource Observation:

Generated Narrative: Observation observation-fetal-presentation-babyg-quinn

status: Final
code: Fetal presentation--at birth [US Standard Certificate of Live Birth]
subject: Patient - Child (Baby G Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: Breech presentation (finding)

Entry 33 - fullUrl = http://example.org/fhir/Procedure/procedure-final-route-method-delivery-babyg-quinn

Resource Procedure:

Generated Narrative: Procedure procedure-final-route-method-delivery-babyg-quinn

status: Completed
code: Cesarean section
subject: Patient - Mother (Jada Ann Quinn)

Entry 34 - fullUrl = http://example.org/fhir/Condition/condition-ruptured-uterus-jada-ann-quinn

Resource Condition:

Generated Narrative: Condition condition-ruptured-uterus-jada-ann-quinn

clinicalStatus: Active
category: Problem List Item
code: Rupture of uterus (disorder)
subject: Patient - Mother (Jada Ann Quinn)

Entry 35 - fullUrl = http://example.org/fhir/Observation/observation-birth-weight-babyg-quinn

Resource Observation:

Generated Narrative: Observation observation-birth-weight-babyg-quinn

status: Final
category: Vital Signs
code: Birth weight Measured
subject: BabyG Quinn
effective: 2019-02-10
performer: Practitioner Avery Jones
value: 2500 g (Details: UCUM codeg = 'g')

Entry 36 - fullUrl = http://example.org/fhir/Observation/observation-gestational-age-at-delivery-babyg-quinn

Resource Observation:

Generated Narrative: Observation observation-gestational-age-at-delivery-babyg-quinn

status: Final
code: Gestational age Estimated
subject: BabyG Quinn
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 36 wk (Details: UCUM codewk = 'wk')

Entry 37 - fullUrl = http://example.org/fhir/Observation/observation-apgar-score-babyg-quinn-1-min

Resource Observation:

Generated Narrative: Observation observation-apgar-score-babyg-quinn-1-min

status: Final
category: Survey
code: 1 minute Apgar Score
subject: BabyG Quinn
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 5

Entry 38 - fullUrl = http://example.org/fhir/Observation/observation-apgar-score-babyg-quinn-5-min

Resource Observation:

Generated Narrative: Observation observation-apgar-score-babyg-quinn-5-min

status: Final
category: Survey
code: 5 minute Apgar Score
subject: BabyG Quinn
effective: 2019-12-02
performer: Practitioner Avery Jones
value: 7

Entry 39 - fullUrl = http://example.org/fhir/Condition/condition-congenital-anomaly-of-newborn-babyg-quinn

Resource Condition:

Generated Narrative: Condition condition-congenital-anomaly-of-newborn-babyg-quinn

clinicalStatus: Active
category: Problem List Item, Congenital anomalies of the newborn [US Standard Certificate of Live Birth]
code: Cyanotic congenital heart disease (disorder)
subject: BabyG Quinn

Entry 40 - fullUrl = http://example.org/fhir/Condition/condition-congenital-anomaly-of-newborn-babyg-quinn-2

Resource Condition:

Generated Narrative: Condition condition-congenital-anomaly-of-newborn-babyg-quinn-2

clinicalStatus: Active
category: Problem List Item, Congenital anomalies of the newborn [US Standard Certificate of Live Birth]
code: Anomaly of chromosome pair 21 (disorder)
subject: Patient - Child (Baby G Quinn)
evidence

Entry 41 - fullUrl = http://example.org/fhir/Observation/observation-infant-living-babyg-quinn

Resource Observation:

Generated Narrative: Observation observation-infant-living-babyg-quinn

status: Final
code: Infant living at time of report [US Standard Certificate of Live Birth]
subject: BabyG Quinn
effective: 2019-12-02
performer: Practitioner Avery Jones
value: true

Entry 42 - fullUrl = http://example.org/fhir/Observation/observation-infant-breastfed-at-discharge-babyg-quinn

Resource Observation:

Generated Narrative: Observation observation-infant-breastfed-at-discharge-babyg-quinn

status: Final
code: Infant is being breastfed at discharge [US Standard Certificate of Live Birth]
subject: BabyG Quinn
effective: 2019-12-02
performer: Practitioner Avery Jones
value: true

Entry 43 - fullUrl = http://example.org/fhir/Observation/observation-mother-married-during-pregnancy-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-mother-married-during-pregnancy-jada-ann-quinn

status: Final
code: Was mother married at conception, at the time of birth, or at any time between conception and giving birth?
subject: BabyG Quinn
focus: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: Yes

Entry 44 - fullUrl = http://example.org/fhir/Observation/observation-parent-education-level-jada-ann-quinn

Resource Observation:

Generated Narrative: Observation observation-parent-education-level-jada-ann-quinn

status: Final
code: Highest level of education Mother
subject: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, ))
focus: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: Doctorate Degree or Professional Degree

Entry 45 - fullUrl = http://example.org/fhir/Observation/observation-ssn-requested-for-child-babyg-quinn

Resource Observation:

Generated Narrative: Observation observation-ssn-requested-for-child-babyg-quinn

status: Final
code: Social security number requested for child
subject: BabyG Quinn
focus: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: true

Entry 46 - fullUrl = http://example.org/fhir/RelatedPerson/relatedperson-father-natural-james-brandon-quinn

Resource RelatedPerson:

Generated Narrative: RelatedPerson relatedperson-father-natural-james-brandon-quinn

identifier: Social Security number/132225987
active: true
patient: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, ))
relationship: Natural Father
name: James Brandon Quinn (Official)
gender: Male
birthDate: 1972-11-24

Entry 47 - fullUrl = http://example.org/fhir/Observation/observation-paternity-acknowledgement-signed-james-quinn

Resource Observation:

Generated Narrative: Observation observation-paternity-acknowledgement-signed-james-quinn

status: Final
code: Paternity acknowledgment form signed Father
subject: Patient - Child (Baby G Quinn)
focus: RelatedPerson - Father (James Brandon Quinn)
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: Yes

Entry 48 - fullUrl = http://example.org/fhir/Observation/observation-parent-education-level-james-quinn

Resource Observation:

Generated Narrative: Observation observation-parent-education-level-james-quinn

status: Final
code: Highest level of education Father
subject: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, ))
focus: RelatedPerson James Brandon Quinn (official)
effective: 2019-12-02
performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))
value: Doctorate Degree or Professional Degree

Entry 49 - fullUrl = http://example.org/fhir/QuestionnaireResponse/QuestionnaireResponse-mothers-live-birth-jada-quinn

Resource QuestionnaireResponse:

Generated Narrative: QuestionnaireResponse QuestionnaireResponse-mothers-live-birth-jada-quinn

LinkID Text Definition Answer
QuestionnaireResponse-mothers-live-birth-jada-quinn Questionnaire:Questionnaire - Mother's Worksheet for Child's Birth Certificate

mother-current-legal-name What is your current legal name?

mother-first-name First Jada

mother-middle-name Middle Ann

mother-last-name Last Quinn

child-name What will be your baby's legal name (as it should appear on the birth certificate)?

child-first-name First Baby

child-middle-name Middle G

child-last-name Last Quinn

mother-address Where do you usually live - that is - where is your household/residence located?

mother-nbr-street Complete number and street (do not enter rural route numbers) 1875 West Morton Avenue

mother-city City, Town, or Location Salt Lake City

mother-county County Salt Lake

mother-state State (or U.S. Territory, Canadian Province) UT

mother-zip Zip Code 84116

inside-city-limits Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? expandedYes-NoIndicator Y: Yes

mother-mail What is your mailing address

mother-mail-same Same as residence [Go to next question] false

mother-mail-nbr-street Complete number and street 1848 South 1300 East

mother-mail-city City, Town, or Location Salt Lake City

mother-mail-state State (or U.S. Territory, Canadian Province) UT

mother-mail-zip Zip Code 84401

mother-dob What is your date of birth? 1985-01-15

mother-birthplace In what State, U.S. territory, or foreign country were you born? Please specify one of the following:

mother-birthplace-state State UT

mother-education What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received). unknown PHC1455: Doctorate Degree or Professional Degree

mother-ethnicity Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.

mother-shl Are you Spanish/Hispanic/Latina Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino

mother-race What is your race? (Please check one or more races to indicate what you consider yourself to be).

mother-race-category Race categories Race & Ethnicity - CDC 2106-3: White

mother-detailed-race Extended race codes Race & Ethnicity - CDC 1004-1: American Indian

receive-wic Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy? expandedYes-NoIndicator Y: Yes

infertility-treatment Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b) true

drugs-ai-ii If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination? false

art-ivf-gift If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))? true

mothers-height What is your height?

mothers-height-feet Feet 5 ft (Details: UCUM codeft = 'ft')

mothers-height-inches Inches 7 [in_i] (Details: UCUM code[in_i] = '[in_i]')

mothers-prepregnancy-weight lbs 145 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')

mothers-smoking How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.

mothers-smoking-3-months-prior Three months before pregnancy

mothers-smoking-3-months-prior-cig # of cigarettes* 0

mothers-smoking-3-months-prior-pck # of packs 1

mothers-smoking-trimester-1 First three months of pregnancy

mothers-smoking-trimester-1-cig # of cigarettes* 3

mothers-smoking-trimester-1-pck # of packs 0

mothers-smoking-trimester-2 Second three months of pregnancy

mothers-smoking-trimester-2-cig # of cigarettes* 1

mothers-smoking-trimester-2-pck # of packs 0

mothers-smoking-trimester-3 Third trimester of pregnancy

mothers-smoking-trimester-3-cig # of cigarettes* 0

mothers-smoking-trimester-3-pck # of packs 0

mother-prior-name What name did you use prior to your first marriage?

mother-prior-first-name First Jada

mother-prior-middle-name Middle Ann

mother-prior-last-name Last King

married-conception Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below] true

father-current-legal-name What is the current legal name of your baby's father?

father-first-name First James

father-middle-name Middle Brandon

father-last-name Last Quinn

father-dob What the father's date of birth? 1983-09-27

father-birthplace In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:

father-birthplace-state State NY

father-education What is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received). unknown PHC1455: Doctorate Degree or Professional Degree

father-ethnicity Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.

father-shl Is the father Spanish/Hispanic/Latina Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino

father-race What is the father's race? (Please check one or more races to indicate what he considers himself to be).

father-race-category Race categories Race & Ethnicity - CDC 2106-3: White

parents-ssn Furnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.

mother-ssn What is your Social Security Number? 132-22-5986

father-ssn What is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank. 132-22-5987

baby-ssn Do you want a Social Security Number issued for your baby? [If yes, please sign request below false

informant-name If other than the mother, what is the name of the person providing information for this worksheet?

informant-first-name First Jane

informant-last-name Last King

informant-relationship What is your relationship to the baby's mother? unknown PHC1497: Other relative

Documentation for this format

LinkID	Text	Answer
QuestionnaireResponse-mothers-live-birth-jada-quinn		Questionnaire:Questionnaire - Mother's Worksheet for Child's Birth Certificate
mother-current-legal-name	What is your current legal name?
mother-first-name	First	Jada
mother-middle-name	Middle	Ann
mother-last-name	Last	Quinn
child-name	What will be your baby's legal name (as it should appear on the birth certificate)?
child-first-name	First	Baby
child-middle-name	Middle	G
child-last-name	Last	Quinn
mother-address	Where do you usually live - that is - where is your household/residence located?
mother-nbr-street	Complete number and street (do not enter rural route numbers)	1875 West Morton Avenue
mother-city	City, Town, or Location	Salt Lake City
mother-county	County	Salt Lake
mother-state	State (or U.S. Territory, Canadian Province)	UT
mother-zip	Zip Code	84116
inside-city-limits	Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?	expandedYes-NoIndicator Y: Yes
mother-mail	What is your mailing address
mother-mail-same	Same as residence [Go to next question]	false
mother-mail-nbr-street	Complete number and street	1848 South 1300 East
mother-mail-city	City, Town, or Location	Salt Lake City
mother-mail-state	State (or U.S. Territory, Canadian Province)	UT
mother-mail-zip	Zip Code	84401
mother-dob	What is your date of birth?	1985-01-15
mother-birthplace	In what State, U.S. territory, or foreign country were you born? Please specify one of the following:
mother-birthplace-state	State	UT
mother-education	What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).	unknown PHC1455: Doctorate Degree or Professional Degree
mother-ethnicity	Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
mother-shl	Are you Spanish/Hispanic/Latina	Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino
mother-race	What is your race? (Please check one or more races to indicate what you consider yourself to be).
mother-race-category	Race categories	Race & Ethnicity - CDC 2106-3: White
mother-detailed-race	Extended race codes	Race & Ethnicity - CDC 1004-1: American Indian
receive-wic	Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?	expandedYes-NoIndicator Y: Yes
infertility-treatment	Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)	true
drugs-ai-ii	If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?	false
art-ivf-gift	If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?	true
mothers-height	What is your height?
mothers-height-feet	Feet	5 ft (Details: UCUM codeft = 'ft')
mothers-height-inches	Inches	7 [in_i] (Details: UCUM code[in_i] = '[in_i]')
mothers-prepregnancy-weight	lbs	145 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')
mothers-smoking	How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.
mothers-smoking-3-months-prior	Three months before pregnancy
mothers-smoking-3-months-prior-cig	# of cigarettes*	0
mothers-smoking-3-months-prior-pck	# of packs	1
mothers-smoking-trimester-1	First three months of pregnancy
mothers-smoking-trimester-1-cig	# of cigarettes*	3
mothers-smoking-trimester-1-pck	# of packs	0
mothers-smoking-trimester-2	Second three months of pregnancy
mothers-smoking-trimester-2-cig	# of cigarettes*	1
mothers-smoking-trimester-2-pck	# of packs	0
mothers-smoking-trimester-3	Third trimester of pregnancy
mothers-smoking-trimester-3-cig	# of cigarettes*	0
mothers-smoking-trimester-3-pck	# of packs	0
mother-prior-name	What name did you use prior to your first marriage?
mother-prior-first-name	First	Jada
mother-prior-middle-name	Middle	Ann
mother-prior-last-name	Last	King
married-conception	Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below]	true
father-current-legal-name	What is the current legal name of your baby's father?
father-first-name	First	James
father-middle-name	Middle	Brandon
father-last-name	Last	Quinn
father-dob	What the father's date of birth?	1983-09-27
father-birthplace	In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
father-birthplace-state	State	NY
father-education	What is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received).	unknown PHC1455: Doctorate Degree or Professional Degree
father-ethnicity	Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
father-shl	Is the father Spanish/Hispanic/Latina	Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino
father-race	What is the father's race? (Please check one or more races to indicate what he considers himself to be).
father-race-category	Race categories	Race & Ethnicity - CDC 2106-3: White
parents-ssn	Furnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.
mother-ssn	What is your Social Security Number?	132-22-5986
father-ssn	What is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank.	132-22-5987
baby-ssn	Do you want a Social Security Number issued for your baby? [If yes, please sign request below	false
informant-name	If other than the mother, what is the name of the person providing information for this worksheet?
informant-first-name	First	Jane
informant-last-name	Last	King
informant-relationship	What is your relationship to the baby's mother?	unknown PHC1497: Other relative
Documentation for this format

Entry 50 - fullUrl = http://example.org/fhir/Location/location-east-hospital

Resource Location:

Generated Narrative: Location location-east-hospital

status: Active
name: East Hospital
type: Hospital

Entry 51 - fullUrl = http://example.org/fhir/Location/location-south-hospital

Resource Location:

Generated Narrative: Location location-south-hospital

status: Active
name: South Hospital
type: Hospital

Entry 52 - fullUrl = http://example.org/fhir/Location/location-north-hospital

Resource Location:

Generated Narrative: Location location-north-hospital

status: Active
name: North Hospital
type: Hospital

Entry 53 - fullUrl = http://example.org/fhir/Organization/organization-south-hospital

Resource Organization:

Generated Narrative: Organization organization-south-hospital

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

Entry 54 - fullUrl = http://example.org/fhir/Observation/observation-labor-trial-attempted-babyg-quinn

Resource Observation:

Generated Narrative: Observation observation-labor-trial-attempted-babyg-quinn

status: Final
code: If cesarean, a trial of labor was attempted [US Standard Certificate of Live Birth]
subject: BabyG Quinn
focus: Patient - Mother (Jada Ann Quinn)
effective: 2019-12-02
performer: Practitioner Avery Jones
value: true

Entry 55 - fullUrl = http://example.org/fhir/RelatedPerson/relatedperson-mother-jada-ann-quinn

Resource RelatedPerson:

Generated Narrative: RelatedPerson relatedperson-mother-jada-ann-quinn

identifier: Social Security number/132225986 (use: usual, )
active: true
patient: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, ))
relationship: Gestational Mother
name: Jada Ann Quinn (Official)
telecom: ph: 1-(404)555-1212(Home), jadaann.quinn@example.com
gender: Female
birthDate: 1985-01-15
address: 1875 West Morton Avenue Salt Lake City UT 84116 US (home)