UV_Vital Records Birth and Fetal Death Reporting
1.1.0 - STU 1.1
UV_Vital Records Birth and Fetal Death Reporting
1.1.0 - STU 1.1
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
| Official URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Composition-jurisdiction-live-birth-report | Version: 1.1.0 | |||
| Active as of 2024-07-09 | Computable Name: CompositionJurisdictionLiveBirthReport | |||
This Composition profile contains information of a live birth and the issuance of a Birth Certificate to be recorded and communicated to the national statistics agency.
The data requirements for jurisdictional reporting of live births are based on the Edit Specifications for the 2003 Revision of the U.S. Standard Certificate of 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 | Jurisdiction Live Birth Report | |
  Slices for extension |
S | 2..* | Extension | Extension Slice: Unordered, Open by value:url |
   liveBirthCertificateNumber |
S | 1..1 | Identifier | Birth Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-certificate-number |
| liveBirthLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-local-file-number |
| dateFiledByRegistrar |
S | 1..1 | dateTime | Date filed by registrar URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-filed-by-registrar |
 replacementStatus |
S | 0..1 | CodeableConcept | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) |
  status |
S | 1..1 | code | In the case of a live birth sent in error, a status of 'entered-in-error' must be set. |
| type |
S | 1..1 | CodeableConcept | Jurisdiction live birth report 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: 92011-6 | |
 subject |
S | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby |
| encounter |
S | 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) | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-encounter-maternity-reference | |
| date |
S | 1..1 | dateTime | Date report completed |
| author |
S | 1..1 | Reference(US Core Organization Profile(5.0.1)) | The author is the jurisdictional Vital Records Office. |
 Slices for section |
S | 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 |
S | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate |
  code |
S | 1..1 | CodeableConcept | Prenatal records 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
 Slices for entry |
S | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() |
| entry:plannedToDeliverAtHome |
S | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit |
S | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits |
S | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits |
| entry:dateLastNormalMenses |
S | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began |
| entry:numberNowLiving |
S | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living |
| entry:numberNowDead |
S | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead |
| entry:dateLastLiveBirth |
S | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes |
S | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome |
S | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment |
S | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery |
S | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery |
| entry:mothersHeight |
S | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height |
| entry:mothersPrepregnancyWeight |
S | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight |
| entry:motherReceivedWICFood |
S | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother |
| entry:cigaretteSmokingBeforeDuringPregnancy |
S | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy |
| section:medicalHealthInformation |
S | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate |
| code |
S | 1..1 | CodeableConcept | Clinical information 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
S | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:pregnancyRiskFactors |
S | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:numberPreviousCesareans |
S | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infectionsDuringPregnancy |
S | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:obstetricProcedures |
S | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures |
| Slices for entry |
Content/Rules for all slices | |||
| entry:characteristicsLaborDelivery |
S | 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 |
| Slices for entry |
Content/Rules for all slices | |||
| entry:fetalPresentation |
S | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| Slices for entry |
Content/Rules for all slices | |||
| entry:finalRouteMethodDelivery |
S | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| Slices for entry |
Content/Rules for all slices | |||
| entry:maternalMorbidity |
S | 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 |
S | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate |
| code |
S | 1..1 | CodeableConcept | Newborn delivery information 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 |
S | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:birthWeight |
S | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight |
| Slices for entry |
Content/Rules for all slices | |||
| entry:gestationalAgeAtDelivery |
S | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation |
| Slices for entry |
Content/Rules for all slices | |||
| entry:ApgarScore |
S | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:numberLiveBirthsThisDelivery |
S | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery |
| Slices for entry |
Content/Rules for all slices | |||
| entry:abnormalConditionsNewborn |
S | 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 |
| Slices for entry |
Content/Rules for all slices | |||
| entry:congenitalAnomaliesNewborn |
S | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infantLiving |
S | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infantBreastfedAtDischarge |
S | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| section:motherInformation |
S | 0..1 | BackboneElement | Mother administrative section on the Live Birth Certificate |
| code |
S | 1..1 | CodeableConcept | Mother's administrative information 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
S | 1..* | Reference(Resource) | Entries that are contained in the motherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:marriedDuringPregnancy |
S | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:ssnRequestedForChild |
S | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child |
| Slices for entry |
Content/Rules for all slices | |||
| entry:mothersEducation |
S | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education |
| section:fatherInformation |
S | 0..1 | BackboneElement | Father section on the Live Birth Certificate |
| code |
S | 1..1 | CodeableConcept | Father's administrative information 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 |
S | 1..1 | Reference(RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father |
| Slices for entry |
S | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:paternityAcknowledgementSigned |
S | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father |
| Slices for entry |
Content/Rules for all slices | |||
| entry:fathersEducation |
S | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education |
 section:EditFlags |
S | 1..1 | BackboneElement | Edit Flags Section |
| code |
S | 1..1 | CodeableConcept | Edit flags section Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 92012-4 | |
| Slices for entry |
S | 12..12 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagBirthweight |
1..1 | Reference(Observation - Edit Flag Birthweight) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagEstimateOfGestation |
1..1 | Reference(Observation - Edit Flag Estimate of Gestation) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagFathersDateOfBirth |
1..1 | Reference(Observation - Edit Flag Father's Date of Birth) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagFathersEducation |
1..1 | Reference(Observation - Edit Flag Father's Education) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersDateOfBirth |
1..1 | Reference(Observation - Edit Flag Mother's Date of Birth) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersDeliveryWeight |
1..1 | Reference(Observation - Edit Flag Mother's Delivery Weight) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersEducation |
1..1 | Reference(Observation - Edit Flag Mother's Education) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersHeight |
1..1 | Reference(Observation - Edit Flag Mother's Height) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersPrepregnancyWeight |
1..1 | Reference(Observation - Edit Flag Mother's Prepregnancy Weight) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagNumberPrenatalCareVisits |
1..1 | Reference(Observation - Edit Flag Number Prenatal Care Visits) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagNumberPreviousCesareans |
1..1 | Reference(Observation - Edit Flag Number of Previous Cesareans) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagPlurality |
1..1 | Reference(Observation - Edit Flag Plurality) | A reference to data that supports this section | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | Jurisdiction Live Birth Report | |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
S | 2..* | Extension | Extension Slice: Unordered, Open by value:url |
| liveBirthCertificateNumber |
S | 1..1 | Identifier | Birth Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-certificate-number |
| liveBirthLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-local-file-number |
| dateFiledByRegistrar |
S | 1..1 | dateTime | Date filed by registrar URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-filed-by-registrar |
| replacementStatus |
S | 0..1 | CodeableConcept | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 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 |
SΣ | 1..1 | CodeableConcept | Jurisdiction live birth report Document 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: 92011-6 | |
| subject |
SΣ | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby |
| encounter |
SΣ | 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) | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-encounter-maternity-reference Slice: Unordered, Open by value:url | |
| date |
SΣ | 1..1 | dateTime | Date report completed |
| author |
SΣ | 1..1 | Reference(US Core Organization Profile(5.0.1)) | The author is the jurisdictional Vital Records Office. |
| title |
Σ | 1..1 | string | Human Readable name/title |
| Slices for section |
SC | 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 |
SC | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Prenatal records 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
SC | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() |
| entry:plannedToDeliverAtHome |
SC | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit |
SC | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits |
SC | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits |
| entry:dateLastNormalMenses |
SC | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began |
| entry:numberNowLiving |
SC | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living |
| entry:numberNowDead |
SC | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead |
| entry:dateLastLiveBirth |
SC | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes |
SC | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome |
SC | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment |
SC | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery |
SC | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery |
| entry:mothersHeight |
SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height |
| entry:mothersPrepregnancyWeight |
SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight |
| entry:motherReceivedWICFood |
SC | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother |
| entry:cigaretteSmokingBeforeDuringPregnancy |
SC | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy |
| section:medicalHealthInformation |
SC | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Clinical information 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
SC | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:pregnancyRiskFactors |
SC | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:numberPreviousCesareans |
SC | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infectionsDuringPregnancy |
SC | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:obstetricProcedures |
SC | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures |
| Slices for entry |
Content/Rules for all slices | |||
| entry:characteristicsLaborDelivery |
SC | 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 |
| Slices for entry |
Content/Rules for all slices | |||
| entry:fetalPresentation |
SC | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| Slices for entry |
Content/Rules for all slices | |||
| entry:finalRouteMethodDelivery |
SC | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| Slices for entry |
Content/Rules for all slices | |||
| entry:maternalMorbidity |
SC | 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 |
SC | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Newborn delivery information 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:birthWeight |
SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight |
| Slices for entry |
Content/Rules for all slices | |||
| entry:gestationalAgeAtDelivery |
SC | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation |
| Slices for entry |
Content/Rules for all slices | |||
| entry:ApgarScore |
SC | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:numberLiveBirthsThisDelivery |
SC | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery |
| Slices for entry |
Content/Rules for all slices | |||
| entry:abnormalConditionsNewborn |
SC | 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 |
| Slices for entry |
Content/Rules for all slices | |||
| entry:congenitalAnomaliesNewborn |
SC | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infantLiving |
SC | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infantBreastfedAtDischarge |
SC | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| section:motherInformation |
SC | 0..1 | BackboneElement | Mother administrative section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Mother's administrative information 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
SC | 1..* | Reference(Resource) | Entries that are contained in the motherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:marriedDuringPregnancy |
SC | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:ssnRequestedForChild |
SC | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child |
| Slices for entry |
Content/Rules for all slices | |||
| entry:mothersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education |
| section:fatherInformation |
SC | 0..1 | BackboneElement | Father section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Father's administrative information 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 |
S | 1..1 | Reference(RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father |
| Slices for entry |
SC | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:paternityAcknowledgementSigned |
SC | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father |
| Slices for entry |
Content/Rules for all slices | |||
| entry:fathersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education |
| section:EditFlags |
SC | 1..1 | BackboneElement | Edit Flags Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
S | 1..1 | CodeableConcept | Edit flags section Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 92012-4 | |
| Slices for entry |
SC | 12..12 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagBirthweight |
C | 1..1 | Reference(Observation - Edit Flag Birthweight) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagEstimateOfGestation |
C | 1..1 | Reference(Observation - Edit Flag Estimate of Gestation) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagFathersDateOfBirth |
C | 1..1 | Reference(Observation - Edit Flag Father's Date of Birth) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagFathersEducation |
C | 1..1 | Reference(Observation - Edit Flag Father's Education) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersDateOfBirth |
C | 1..1 | Reference(Observation - Edit Flag Mother's Date of Birth) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersDeliveryWeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Delivery Weight) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersEducation |
C | 1..1 | Reference(Observation - Edit Flag Mother's Education) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersHeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Height) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersPrepregnancyWeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Prepregnancy Weight) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagNumberPrenatalCareVisits |
C | 1..1 | Reference(Observation - Edit Flag Number Prenatal Care Visits) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagNumberPreviousCesareans |
C | 1..1 | Reference(Observation - Edit Flag Number of Previous Cesareans) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagPlurality |
C | 1..1 | Reference(Observation - Edit Flag Plurality) | A reference to data that supports this section |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | preferred | Pattern: LOINC Code 92011-6http://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.section:motherPrenatal.code | example | Pattern: LOINC Code 57073-9http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:medicalHealthInformation.code | example | Pattern: LOINC Code 55752-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:newbornInformation.code | example | Pattern: LOINC Code 57075-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:motherInformation.code | example | Pattern: LOINC Code 92014-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:fatherInformation.code | example | Pattern: LOINC Code 92013-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:EditFlags.code | example | Pattern: LOINC Code 92012-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:EditFlags | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:EditFlags | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | Jurisdiction 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 | |||||
| Slices for extension |
S | 2..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| liveBirthCertificateNumber |
S | 1..1 | Identifier | Birth Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-certificate-number | ||||
| liveBirthLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-local-file-number | ||||
| dateFiledByRegistrar |
S | 1..1 | dateTime | Date filed by registrar URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-filed-by-registrar | ||||
| replacementStatus |
S | 0..1 | CodeableConcept | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status |
?!SΣ | 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 |
SΣ | 1..1 | CodeableConcept | Jurisdiction live birth report Document 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: 92011-6 | |||||
| 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 | |||||
| category |
Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
SΣ | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby | ||||
| encounter |
SΣ | 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) | Extension URL: https://profiles.ihe.net/QRPH/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 |
SΣ | 1..1 | dateTime | Date report completed | ||||
| author |
SΣ | 1..1 | Reference(US Core Organization Profile(5.0.1)) | The author is the jurisdictional Vital Records Office. | ||||
| 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 |
SC | 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 |
SC | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Prenatal records 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 |
S | 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:plannedToDeliverAtHome |
SC | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:firstPrenatalCareVisit |
SC | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberPrenatalCareVisits |
SC | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:dateLastNormalMenses |
SC | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberNowLiving |
SC | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberNowDead |
SC | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:dateLastLiveBirth |
SC | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberOtherOutcomes |
SC | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:dateLastOtherOutcome |
SC | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:principalSourceOfPayment |
SC | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:mothersWeightAtDelivery |
SC | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:mothersHeight |
SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:mothersPrepregnancyWeight |
SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:motherReceivedWICFood |
SC | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:cigaretteSmokingBeforeDuringPregnancy |
SC | 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 |
SC | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Clinical information 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 |
S | 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:pregnancyRiskFactors |
SC | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberPreviousCesareans |
SC | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:infectionsDuringPregnancy |
SC | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:obstetricProcedures |
SC | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:characteristicsLaborDelivery |
SC | 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 | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:fetalPresentation |
SC | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:finalRouteMethodDelivery |
SC | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:maternalMorbidity |
SC | 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 |
SC | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Newborn delivery information 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:birthWeight |
SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:gestationalAgeAtDelivery |
SC | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:ApgarScore |
SC | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberLiveBirthsThisDelivery |
SC | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:abnormalConditionsNewborn |
SC | 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 | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:congenitalAnomaliesNewborn |
SC | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:infantLiving |
SC | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:infantBreastfedAtDischarge |
SC | 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 |
SC | 0..1 | BackboneElement | Mother administrative section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Mother's administrative information 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 |
S | 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the motherInformation section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:marriedDuringPregnancy |
SC | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:ssnRequestedForChild |
SC | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:mothersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education | ||||
| 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 |
SC | 0..1 | BackboneElement | Father section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Father's administrative information 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 |
S | 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:paternityAcknowledgementSigned |
SC | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:fathersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education | ||||
| 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:EditFlags |
SC | 1..1 | BackboneElement | Edit Flags Section 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 |
S | 1..1 | CodeableConcept | Edit flags section 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: 92012-4 | |||||
| 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 |
SC | 12..12 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagBirthweight |
C | 1..1 | Reference(Observation - Edit Flag Birthweight) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagEstimateOfGestation |
C | 1..1 | Reference(Observation - Edit Flag Estimate of Gestation) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagFathersDateOfBirth |
C | 1..1 | Reference(Observation - Edit Flag Father's Date of Birth) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagFathersEducation |
C | 1..1 | Reference(Observation - Edit Flag Father's Education) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagMothersDateOfBirth |
C | 1..1 | Reference(Observation - Edit Flag Mother's Date of Birth) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagMothersDeliveryWeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Delivery Weight) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagMothersEducation |
C | 1..1 | Reference(Observation - Edit Flag Mother's Education) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagMothersHeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Height) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagMothersPrepregnancyWeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Prepregnancy Weight) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagNumberPrenatalCareVisits |
C | 1..1 | Reference(Observation - Edit Flag Number Prenatal Care Visits) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagNumberPreviousCesareans |
C | 1..1 | Reference(Observation - Edit Flag Number of Previous Cesareans) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagPlurality |
C | 1..1 | Reference(Observation - Edit Flag Plurality) | 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 | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | Pattern: LOINC Code 92011-6http://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:motherPrenatal.code | example | Pattern: LOINC Code 57073-9http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:motherPrenatal.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:motherPrenatal.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:motherPrenatal.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:medicalHealthInformation.code | example | Pattern: LOINC Code 55752-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:medicalHealthInformation.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:medicalHealthInformation.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:medicalHealthInformation.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:newbornInformation.code | example | Pattern: LOINC Code 57075-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:newbornInformation.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:newbornInformation.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:newbornInformation.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:motherInformation.code | example | Pattern: LOINC Code 92014-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:motherInformation.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:motherInformation.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:motherInformation.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:fatherInformation.code | example | Pattern: LOINC Code 92013-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:fatherInformation.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:fatherInformation.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:fatherInformation.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:EditFlags.code | example | Pattern: LOINC Code 92012-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:EditFlags.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:EditFlags.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:EditFlags.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:EditFlags | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:EditFlags | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 18 elements(15 nested mandatory elements)
Must-Support: 70 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | Jurisdiction Live Birth Report | |
| Slices for extension |
S | 2..* | Extension | Extension Slice: Unordered, Open by value:url |
| liveBirthCertificateNumber |
S | 1..1 | Identifier | Birth Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-certificate-number |
| liveBirthLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-local-file-number |
| dateFiledByRegistrar |
S | 1..1 | dateTime | Date filed by registrar URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-filed-by-registrar |
| replacementStatus |
S | 0..1 | CodeableConcept | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) |
| status |
S | 1..1 | code | In the case of a live birth sent in error, a status of 'entered-in-error' must be set. |
| type |
S | 1..1 | CodeableConcept | Jurisdiction live birth report 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: 92011-6 | |
| subject |
S | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby |
| encounter |
S | 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) | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-encounter-maternity-reference | |
| date |
S | 1..1 | dateTime | Date report completed |
| author |
S | 1..1 | Reference(US Core Organization Profile(5.0.1)) | The author is the jurisdictional Vital Records Office. |
| Slices for section |
S | 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 |
S | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate |
| code |
S | 1..1 | CodeableConcept | Prenatal records 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
S | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() |
| entry:plannedToDeliverAtHome |
S | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit |
S | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits |
S | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits |
| entry:dateLastNormalMenses |
S | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began |
| entry:numberNowLiving |
S | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living |
| entry:numberNowDead |
S | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead |
| entry:dateLastLiveBirth |
S | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes |
S | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome |
S | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment |
S | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery |
S | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery |
| entry:mothersHeight |
S | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height |
| entry:mothersPrepregnancyWeight |
S | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight |
| entry:motherReceivedWICFood |
S | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother |
| entry:cigaretteSmokingBeforeDuringPregnancy |
S | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy |
| section:medicalHealthInformation |
S | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate |
| code |
S | 1..1 | CodeableConcept | Clinical information 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
S | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:pregnancyRiskFactors |
S | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:numberPreviousCesareans |
S | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infectionsDuringPregnancy |
S | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:obstetricProcedures |
S | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures |
| Slices for entry |
Content/Rules for all slices | |||
| entry:characteristicsLaborDelivery |
S | 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 |
| Slices for entry |
Content/Rules for all slices | |||
| entry:fetalPresentation |
S | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| Slices for entry |
Content/Rules for all slices | |||
| entry:finalRouteMethodDelivery |
S | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| Slices for entry |
Content/Rules for all slices | |||
| entry:maternalMorbidity |
S | 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 |
S | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate |
| code |
S | 1..1 | CodeableConcept | Newborn delivery information 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 |
S | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:birthWeight |
S | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight |
| Slices for entry |
Content/Rules for all slices | |||
| entry:gestationalAgeAtDelivery |
S | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation |
| Slices for entry |
Content/Rules for all slices | |||
| entry:ApgarScore |
S | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:numberLiveBirthsThisDelivery |
S | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery |
| Slices for entry |
Content/Rules for all slices | |||
| entry:abnormalConditionsNewborn |
S | 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 |
| Slices for entry |
Content/Rules for all slices | |||
| entry:congenitalAnomaliesNewborn |
S | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infantLiving |
S | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infantBreastfedAtDischarge |
S | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| section:motherInformation |
S | 0..1 | BackboneElement | Mother administrative section on the Live Birth Certificate |
| code |
S | 1..1 | CodeableConcept | Mother's administrative information 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
S | 1..* | Reference(Resource) | Entries that are contained in the motherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:marriedDuringPregnancy |
S | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:ssnRequestedForChild |
S | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child |
| Slices for entry |
Content/Rules for all slices | |||
| entry:mothersEducation |
S | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education |
| section:fatherInformation |
S | 0..1 | BackboneElement | Father section on the Live Birth Certificate |
| code |
S | 1..1 | CodeableConcept | Father's administrative information 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 |
S | 1..1 | Reference(RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father |
| Slices for entry |
S | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:paternityAcknowledgementSigned |
S | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father |
| Slices for entry |
Content/Rules for all slices | |||
| entry:fathersEducation |
S | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education |
| section:EditFlags |
S | 1..1 | BackboneElement | Edit Flags Section |
| code |
S | 1..1 | CodeableConcept | Edit flags section Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 92012-4 | |
| Slices for entry |
S | 12..12 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagBirthweight |
1..1 | Reference(Observation - Edit Flag Birthweight) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagEstimateOfGestation |
1..1 | Reference(Observation - Edit Flag Estimate of Gestation) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagFathersDateOfBirth |
1..1 | Reference(Observation - Edit Flag Father's Date of Birth) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagFathersEducation |
1..1 | Reference(Observation - Edit Flag Father's Education) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersDateOfBirth |
1..1 | Reference(Observation - Edit Flag Mother's Date of Birth) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersDeliveryWeight |
1..1 | Reference(Observation - Edit Flag Mother's Delivery Weight) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersEducation |
1..1 | Reference(Observation - Edit Flag Mother's Education) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersHeight |
1..1 | Reference(Observation - Edit Flag Mother's Height) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersPrepregnancyWeight |
1..1 | Reference(Observation - Edit Flag Mother's Prepregnancy Weight) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagNumberPrenatalCareVisits |
1..1 | Reference(Observation - Edit Flag Number Prenatal Care Visits) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagNumberPreviousCesareans |
1..1 | Reference(Observation - Edit Flag Number of Previous Cesareans) | A reference to data that supports this section | |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagPlurality |
1..1 | Reference(Observation - Edit Flag Plurality) | A reference to data that supports this section | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | Jurisdiction Live Birth Report | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
S | 2..* | Extension | Extension Slice: Unordered, Open by value:url |
| liveBirthCertificateNumber |
S | 1..1 | Identifier | Birth Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-certificate-number |
| liveBirthLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-local-file-number |
| dateFiledByRegistrar |
S | 1..1 | dateTime | Date filed by registrar URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-filed-by-registrar |
| replacementStatus |
S | 0..1 | CodeableConcept | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 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 |
SΣ | 1..1 | CodeableConcept | Jurisdiction live birth report Document 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: 92011-6 | |
| subject |
SΣ | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby |
| encounter |
SΣ | 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) | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-encounter-maternity-reference Slice: Unordered, Open by value:url | |
| date |
SΣ | 1..1 | dateTime | Date report completed |
| author |
SΣ | 1..1 | Reference(US Core Organization Profile(5.0.1)) | The author is the jurisdictional Vital Records Office. |
| title |
Σ | 1..1 | string | Human Readable name/title |
| Slices for section |
SC | 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 |
SC | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Prenatal records 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
SC | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() |
| entry:plannedToDeliverAtHome |
SC | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home |
| entry:firstPrenatalCareVisit |
SC | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
| entry:numberPrenatalCareVisits |
SC | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits |
| entry:dateLastNormalMenses |
SC | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began |
| entry:numberNowLiving |
SC | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living |
| entry:numberNowDead |
SC | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead |
| entry:dateLastLiveBirth |
SC | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth |
| entry:numberOtherOutcomes |
SC | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes |
| entry:dateLastOtherOutcome |
SC | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
| entry:principalSourceOfPayment |
SC | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
| entry:mothersWeightAtDelivery |
SC | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery |
| entry:mothersHeight |
SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height |
| entry:mothersPrepregnancyWeight |
SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight |
| entry:motherReceivedWICFood |
SC | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother |
| entry:cigaretteSmokingBeforeDuringPregnancy |
SC | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy |
| section:medicalHealthInformation |
SC | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Clinical information 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
SC | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:pregnancyRiskFactors |
SC | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:numberPreviousCesareans |
SC | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infectionsDuringPregnancy |
SC | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:obstetricProcedures |
SC | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures |
| Slices for entry |
Content/Rules for all slices | |||
| entry:characteristicsLaborDelivery |
SC | 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 |
| Slices for entry |
Content/Rules for all slices | |||
| entry:fetalPresentation |
SC | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
| Slices for entry |
Content/Rules for all slices | |||
| entry:finalRouteMethodDelivery |
SC | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
| Slices for entry |
Content/Rules for all slices | |||
| entry:maternalMorbidity |
SC | 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 |
SC | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Newborn delivery information 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:birthWeight |
SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight |
| Slices for entry |
Content/Rules for all slices | |||
| entry:gestationalAgeAtDelivery |
SC | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation |
| Slices for entry |
Content/Rules for all slices | |||
| entry:ApgarScore |
SC | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:numberLiveBirthsThisDelivery |
SC | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery |
| Slices for entry |
Content/Rules for all slices | |||
| entry:abnormalConditionsNewborn |
SC | 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 |
| Slices for entry |
Content/Rules for all slices | |||
| entry:congenitalAnomaliesNewborn |
SC | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infantLiving |
SC | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? |
| Slices for entry |
Content/Rules for all slices | |||
| entry:infantBreastfedAtDischarge |
SC | 0..1 | Reference(Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
| section:motherInformation |
SC | 0..1 | BackboneElement | Mother administrative section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Mother's administrative information 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 |
S | 1..1 | Reference(Patient - Mother - Vital Records) | The focus of this section is the mother |
| Slices for entry |
SC | 1..* | Reference(Resource) | Entries that are contained in the motherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:marriedDuringPregnancy |
SC | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy |
| Slices for entry |
Content/Rules for all slices | |||
| entry:ssnRequestedForChild |
SC | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child |
| Slices for entry |
Content/Rules for all slices | |||
| entry:mothersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education |
| section:fatherInformation |
SC | 0..1 | BackboneElement | Father section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Father's administrative information 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 |
S | 1..1 | Reference(RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father |
| Slices for entry |
SC | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:paternityAcknowledgementSigned |
SC | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father |
| Slices for entry |
Content/Rules for all slices | |||
| entry:fathersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education |
| section:EditFlags |
SC | 1..1 | BackboneElement | Edit Flags Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
S | 1..1 | CodeableConcept | Edit flags section Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 92012-4 | |
| Slices for entry |
SC | 12..12 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagBirthweight |
C | 1..1 | Reference(Observation - Edit Flag Birthweight) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagEstimateOfGestation |
C | 1..1 | Reference(Observation - Edit Flag Estimate of Gestation) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagFathersDateOfBirth |
C | 1..1 | Reference(Observation - Edit Flag Father's Date of Birth) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagFathersEducation |
C | 1..1 | Reference(Observation - Edit Flag Father's Education) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersDateOfBirth |
C | 1..1 | Reference(Observation - Edit Flag Mother's Date of Birth) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersDeliveryWeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Delivery Weight) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersEducation |
C | 1..1 | Reference(Observation - Edit Flag Mother's Education) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersHeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Height) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagMothersPrepregnancyWeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Prepregnancy Weight) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagNumberPrenatalCareVisits |
C | 1..1 | Reference(Observation - Edit Flag Number Prenatal Care Visits) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagNumberPreviousCesareans |
C | 1..1 | Reference(Observation - Edit Flag Number of Previous Cesareans) | A reference to data that supports this section |
| Slices for entry |
Content/Rules for all slices | |||
| entry:editFlagPlurality |
C | 1..1 | Reference(Observation - Edit Flag Plurality) | A reference to data that supports this section |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | preferred | Pattern: LOINC Code 92011-6http://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.section:motherPrenatal.code | example | Pattern: LOINC Code 57073-9http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:medicalHealthInformation.code | example | Pattern: LOINC Code 55752-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:newbornInformation.code | example | Pattern: LOINC Code 57075-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:motherInformation.code | example | Pattern: LOINC Code 92014-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:fatherInformation.code | example | Pattern: LOINC Code 92013-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | |
| Composition.section:EditFlags.code | example | Pattern: LOINC Code 92012-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:EditFlags | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:EditFlags | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | Jurisdiction 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 | |||||
| Slices for extension |
S | 2..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| liveBirthCertificateNumber |
S | 1..1 | Identifier | Birth Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-certificate-number | ||||
| liveBirthLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-local-file-number | ||||
| dateFiledByRegistrar |
S | 1..1 | dateTime | Date filed by registrar URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-filed-by-registrar | ||||
| replacementStatus |
S | 0..1 | CodeableConcept | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status (required) | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status |
?!SΣ | 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 |
SΣ | 1..1 | CodeableConcept | Jurisdiction live birth report Document 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: 92011-6 | |||||
| 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 | |||||
| category |
Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
SΣ | 1..1 | Reference(Patient - Child - Vital Records) | The subject of the composition is the newborn baby | ||||
| encounter |
SΣ | 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) | Extension URL: https://profiles.ihe.net/QRPH/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 |
SΣ | 1..1 | dateTime | Date report completed | ||||
| author |
SΣ | 1..1 | Reference(US Core Organization Profile(5.0.1)) | The author is the jurisdictional Vital Records Office. | ||||
| 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 |
SC | 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 |
SC | 0..1 | BackboneElement | Mother (prenatal) section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Prenatal records 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 |
S | 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the Mother Prenatal section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:plannedToDeliverAtHome |
SC | 0..1 | Reference(Observation - Planned to Deliver at Home) | Planned to deliver at home | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:firstPrenatalCareVisit |
SC | 0..1 | Reference(Observation - Date of First Prenatal Care Visit) | First prenatal care visit | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberPrenatalCareVisits |
SC | 0..1 | Reference(Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:dateLastNormalMenses |
SC | 0..1 | Reference(Observation - Last Menstrual Period - Vital Records) | Date last normal menses began | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberNowLiving |
SC | 0..1 | Reference(Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberNowDead |
SC | 0..1 | Reference(Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:dateLastLiveBirth |
SC | 0..1 | Reference(Observation - Date of Last Live Birth) | Date of last live birth | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberOtherOutcomes |
SC | 0..1 | Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:dateLastOtherOutcome |
SC | 0..1 | Reference(Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:principalSourceOfPayment |
SC | 0..1 | Reference(Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:mothersWeightAtDelivery |
SC | 0..1 | Reference(Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:mothersHeight |
SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:mothersPrepregnancyWeight |
SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:motherReceivedWICFood |
SC | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:cigaretteSmokingBeforeDuringPregnancy |
SC | 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 |
SC | 0..1 | BackboneElement | Medical and Health Information section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Clinical information 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 |
S | 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the medical and health information section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:pregnancyRiskFactors |
SC | 0..* | Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) | Risk factors in this pregnancy | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberPreviousCesareans |
SC | 0..1 | Reference(Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:infectionsDuringPregnancy |
SC | 0..* | Reference(Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:obstetricProcedures |
SC | 1..1 | Reference(Procedure - Obstetric) | Obstetric procedures | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:characteristicsLaborDelivery |
SC | 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 | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:fetalPresentation |
SC | 0..1 | Reference(Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:finalRouteMethodDelivery |
SC | 0..1 | Reference(Procedure - Final Route and Method of Delivery) | Final route and method of delivery | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:maternalMorbidity |
SC | 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 |
SC | 0..1 | BackboneElement | Newborn section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Newborn delivery information 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the newborn section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:birthWeight |
SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Birthweight | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:gestationalAgeAtDelivery |
SC | 0..1 | Reference(Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:ApgarScore |
SC | 0..2 | Reference(Observation - Apgar Score - Vital Records) | Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:numberLiveBirthsThisDelivery |
SC | 0..1 | Reference(Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:abnormalConditionsNewborn |
SC | 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 | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:congenitalAnomaliesNewborn |
SC | 0..* | Reference(Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:infantLiving |
SC | 0..1 | Reference(Observation - Infant Living - Vital Records) | Is infant living at time of report? | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:infantBreastfedAtDischarge |
SC | 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 |
SC | 0..1 | BackboneElement | Mother administrative section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Mother's administrative information 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 |
S | 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the motherInformation section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:marriedDuringPregnancy |
SC | 0..1 | Reference(Observation - Mother Married During Pregnancy) | Mother married during pregnancy | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:ssnRequestedForChild |
SC | 0..1 | Reference(Observation - Social Security Number Requested For Child) | Was social security number requested for the child | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:mothersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education | ||||
| 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 |
SC | 0..1 | BackboneElement | Father section on the Live Birth Certificate 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 |
S | 1..1 | CodeableConcept | Father's administrative information 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 |
S | 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 |
SC | 1..* | Reference(Resource) | Entries that are contained in the fatherInformation section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:paternityAcknowledgementSigned |
SC | 0..1 | Reference(Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:fathersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Father's education | ||||
| 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:EditFlags |
SC | 1..1 | BackboneElement | Edit Flags Section 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 |
S | 1..1 | CodeableConcept | Edit flags section 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: 92012-4 | |||||
| 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 |
SC | 12..12 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagBirthweight |
C | 1..1 | Reference(Observation - Edit Flag Birthweight) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagEstimateOfGestation |
C | 1..1 | Reference(Observation - Edit Flag Estimate of Gestation) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagFathersDateOfBirth |
C | 1..1 | Reference(Observation - Edit Flag Father's Date of Birth) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagFathersEducation |
C | 1..1 | Reference(Observation - Edit Flag Father's Education) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagMothersDateOfBirth |
C | 1..1 | Reference(Observation - Edit Flag Mother's Date of Birth) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagMothersDeliveryWeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Delivery Weight) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagMothersEducation |
C | 1..1 | Reference(Observation - Edit Flag Mother's Education) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagMothersHeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Height) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagMothersPrepregnancyWeight |
C | 1..1 | Reference(Observation - Edit Flag Mother's Prepregnancy Weight) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagNumberPrenatalCareVisits |
C | 1..1 | Reference(Observation - Edit Flag Number Prenatal Care Visits) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagNumberPreviousCesareans |
C | 1..1 | Reference(Observation - Edit Flag Number of Previous Cesareans) | A reference to data that supports this section | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:editFlagPlurality |
C | 1..1 | Reference(Observation - Edit Flag Plurality) | 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 | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | Pattern: LOINC Code 92011-6http://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:motherPrenatal.code | example | Pattern: LOINC Code 57073-9http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:motherPrenatal.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:motherPrenatal.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:motherPrenatal.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:medicalHealthInformation.code | example | Pattern: LOINC Code 55752-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:medicalHealthInformation.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:medicalHealthInformation.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:medicalHealthInformation.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:newbornInformation.code | example | Pattern: LOINC Code 57075-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:newbornInformation.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:newbornInformation.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:newbornInformation.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:motherInformation.code | example | Pattern: LOINC Code 92014-0http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:motherInformation.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:motherInformation.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:motherInformation.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:fatherInformation.code | example | Pattern: LOINC Code 92013-2http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:fatherInformation.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:fatherInformation.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:fatherInformation.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:EditFlags.code | example | Pattern: LOINC Code 92012-4http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:EditFlags.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:EditFlags.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:EditFlags.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:EditFlags | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:motherPrenatal, Composition.section:medicalHealthInformation, Composition.section:newbornInformation, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:EditFlags | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 18 elements(15 nested mandatory elements)
Must-Support: 70 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ IHE International. Package ihe.qrph.bfdr#1.1.0 based on FHIR 4.0.1. Generated 2024-07-09
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