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-provider-fetal-death-report | Version: 1.1.0 | |||
| Active as of 2024-07-09 | Computable Name: CompositionProviderFetalDeathReport | |||
This Composition profile contains constraints to address the use case describing the need for fetal death information to be recorded and communicated to the jurisdictional Vital Records Office.
For the most part, labor and delivery takes place at a healthcare provider site. When the delivery takes place at home, or on the way to the hospital, the mother and fetus will be taken to the hospital for evaluation and possible treatment. Personal and pregnancy information is collected from the mother or an informant, while information regarding labor and delivery and the fetus is collected from the responsible party at the healthcare facility.
The data requirements for provider supplied fetal death information are based on the
The jurisdiction may have additional data requirements and edit specifications that will be addressed at the jurisdictional level.
The 1992 Revision of the Model State Vital Statistics Act and Regulations recommends the following definition of fetal death:
“Fetal death” means death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy. The death is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory efforts or gasps.
See Patient Worksheet Questionnaires for information about including a QuestionnaireResponse in this Composition.
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 | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  Slices for extension |
S | 1..* | Extension | Extension Slice: Unordered, Open by value:url |
   fetalDeathReportNumber |
S | 0..1 | Identifier | State File Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-report-number |
| fetalDeathLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-local-file-number |
| dateReceivedByRegistrar |
S | 1..1 | dateTime | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-received-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 fetal death sent in error, a status of 'entered-in-error' must be set. |
| type |
S | 1..1 | CodeableConcept | U.S. standard report of fetal death - 2003 revision Required Pattern: At least the following |
  coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 69045-3 | |
 subject |
S | 1..1 | Reference(Patient - Decedent Fetus - Vital Records) | The subject of the composition is the decedent fetus: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the name of the decedent fetus. |
| encounter |
S | 0..1 | Reference(Encounter - Maternity) | The Encounter for the Composition is the mother's maternity encounter. |
| Extension-encounter-maternity-reference |
0..* | 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(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. |
 Slices for section |
S | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Fetal Death Report. Slice: Unordered, Open by pattern:code |
 section:motherPrenatal |
S | 0..1 | BackboneElement | Mother (prenatal) section on the Fetal Death Report |
  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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. |
 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: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:mothersHeight |
S | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:mothersPrepregnancyWeight |
S | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:motherReceivedWICFood |
S | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:cigaretteSmokingBeforeDuringPregnancy |
S | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| section:medicalHealthInformation |
S | 0..1 | BackboneElement | Medical and Health Information section on the Fetal Death Report |
| 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: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:fetus |
S | 0..1 | BackboneElement | fetus section on the Fetal Death Report |
| code |
S | 1..1 | CodeableConcept | Fetal delivery information Document [US Standard Report of Fetal Death] 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: 76400-1 | |
| Slices for entry |
S | 1..* | Reference(Resource) | Entries that are contained in the fetus section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:deliveryWeight |
S | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Delivery weight |
| 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:causeOfFetalDeath |
S | 0..1 | Reference(Condition - Fetal Death Cause or Condition) | Initiating cause or condition of fetal death |
| Slices for entry |
Content/Rules for all slices | |||
| entry:otherCauseOfDeath |
S | 0..* | Reference(Condition - Fetal Death Other Cause or Condition) | Another significant cause or condition for the death of the fetus. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:estimatedTimeFetalDeath |
S | 1..1 | Reference(Observation - Fetal Death Time Point) | The estimated time of fetal death; the time of death is characterized by the relationship to the time of delivery. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:autopsyPerformed |
S | 0..1 | Reference(Observation - Autopsy Performed Indicator - Vital Records) | An indication if an autopsy has been performed on the subject. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:histologicalExamPerformed |
S | 0..1 | Reference(Observation - Histological Placental Exam Performed) | Whether or not a histological placental examination was performed. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:autopsyOrHistologicalExamUsed |
S | 0..1 | Reference(Observation - Autopsy or Histological Exam Results Used) | Whether or not the results of a performed autopsy or a performed histological placental examination were used as part of determining the cause of death. |
| 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:numberFetalDeathsThisDelivery |
S | 0..1 | Reference(Observation - Number of Fetal Deaths This Delivery - Vital Records) | Number of fetal deaths this delivery |
| section:motherInformation |
S | 0..1 | BackboneElement | Mother administrative section on the Fetal Death Report |
| 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:mothersEducation |
S | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| section:fatherInformation |
S | 0..1 | BackboneElement | Father section on the Fetal Death Report |
| 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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the father's name, dob, and birthplace. |
 section:patientsQuestionnaireResponse |
0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | |
| code |
1..1 | CodeableConcept | Questionnaire response Document Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |
| entry |
1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
S | 1..* | Extension | Extension Slice: Unordered, Open by value:url |
| fetalDeathReportNumber |
S | 0..1 | Identifier | State File Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-report-number |
| fetalDeathLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-local-file-number |
| dateReceivedByRegistrar |
S | 1..1 | dateTime | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-received-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 fetal death 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 | U.S. standard report of fetal death - 2003 revision Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 69045-3 | |
| subject |
SΣ | 1..1 | Reference(Patient - Decedent Fetus - Vital Records) | The subject of the composition is the decedent fetus: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the name of the decedent fetus. |
| encounter |
SΣ | 0..1 | Reference(Encounter - Maternity) | The Encounter for the Composition is the mother's maternity encounter. |
| Extension-encounter-maternity-reference |
0..* | 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(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. |
| title |
Σ | 1..1 | string | Human Readable name/title |
| Slices for section |
SC | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Fetal Death Report. 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 Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. |
| 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: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:mothersHeight |
SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:mothersPrepregnancyWeight |
SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:motherReceivedWICFood |
SC | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:cigaretteSmokingBeforeDuringPregnancy |
SC | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| section:medicalHealthInformation |
SC | 0..1 | BackboneElement | Medical and Health Information section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
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: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:fetus |
SC | 0..1 | BackboneElement | fetus section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
S | 1..1 | CodeableConcept | Fetal delivery information Document [US Standard Report of Fetal Death] 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: 76400-1 | |
| Slices for entry |
SC | 1..* | Reference(Resource) | Entries that are contained in the fetus section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:deliveryWeight |
SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Delivery weight |
| 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:causeOfFetalDeath |
SC | 0..1 | Reference(Condition - Fetal Death Cause or Condition) | Initiating cause or condition of fetal death |
| Slices for entry |
Content/Rules for all slices | |||
| entry:otherCauseOfDeath |
SC | 0..* | Reference(Condition - Fetal Death Other Cause or Condition) | Another significant cause or condition for the death of the fetus. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:estimatedTimeFetalDeath |
SC | 1..1 | Reference(Observation - Fetal Death Time Point) | The estimated time of fetal death; the time of death is characterized by the relationship to the time of delivery. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:autopsyPerformed |
SC | 0..1 | Reference(Observation - Autopsy Performed Indicator - Vital Records) | An indication if an autopsy has been performed on the subject. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:histologicalExamPerformed |
SC | 0..1 | Reference(Observation - Histological Placental Exam Performed) | Whether or not a histological placental examination was performed. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:autopsyOrHistologicalExamUsed |
SC | 0..1 | Reference(Observation - Autopsy or Histological Exam Results Used) | Whether or not the results of a performed autopsy or a performed histological placental examination were used as part of determining the cause of death. |
| 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:numberFetalDeathsThisDelivery |
SC | 0..1 | Reference(Observation - Number of Fetal Deaths This Delivery - Vital Records) | Number of fetal deaths this delivery |
| section:motherInformation |
SC | 0..1 | BackboneElement | Mother administrative section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
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:mothersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| section:fatherInformation |
SC | 0..1 | BackboneElement | Father section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the father's name, dob, and birthplace. |
| section:patientsQuestionnaireResponse |
C | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
1..1 | CodeableConcept | Questionnaire response Document Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |
| entry |
C | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report |
| 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 69045-3http://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:fetus.code | example | Pattern: LOINC Code 76400-1http://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:patientsQuestionnaireResponse.code | example | Pattern: LOINC Code 74465-6http://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:fetus, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | 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:fetus, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | 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 | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| 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 | 1..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| fetalDeathReportNumber |
S | 0..1 | Identifier | State File Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-report-number | ||||
| fetalDeathLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-local-file-number | ||||
| dateReceivedByRegistrar |
S | 1..1 | dateTime | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-received-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 fetal death 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 | U.S. standard report of fetal death - 2003 revision Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 69045-3 | |||||
| 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 - Decedent Fetus - Vital Records) | The subject of the composition is the decedent fetus: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the name of the decedent fetus. | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter - Maternity) | The Encounter for the Composition is the mother's maternity encounter. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Extension-encounter-maternity-reference |
0..* | 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(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. | ||||
| title |
Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester |
0..* | BackboneElement | Attests to accuracy of composition | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian |
Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo |
0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] |
1..1 | Target of the relationship | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(Composition) | |||||||
| event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period |
Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section |
SC | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Fetal Death Report. 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 Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. | ||||
| 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: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:mothersHeight |
SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:mothersPrepregnancyWeight |
SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. | ||||
| 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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. | ||||
| 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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. | ||||
| 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 Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
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: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:fetus |
SC | 0..1 | BackboneElement | fetus section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
S | 1..1 | CodeableConcept | Fetal delivery information Document [US Standard Report of Fetal Death] 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: 76400-1 | |||||
| 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 fetus section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:deliveryWeight |
SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Delivery weight | ||||
| 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:causeOfFetalDeath |
SC | 0..1 | Reference(Condition - Fetal Death Cause or Condition) | Initiating cause or condition of fetal death | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:otherCauseOfDeath |
SC | 0..* | Reference(Condition - Fetal Death Other Cause or Condition) | Another significant cause or condition for the death of the fetus. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:estimatedTimeFetalDeath |
SC | 1..1 | Reference(Observation - Fetal Death Time Point) | The estimated time of fetal death; the time of death is characterized by the relationship to the time of delivery. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:autopsyPerformed |
SC | 0..1 | Reference(Observation - Autopsy Performed Indicator - Vital Records) | An indication if an autopsy has been performed on the subject. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:histologicalExamPerformed |
SC | 0..1 | Reference(Observation - Histological Placental Exam Performed) | Whether or not a histological placental examination was performed. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:autopsyOrHistologicalExamUsed |
SC | 0..1 | Reference(Observation - Autopsy or Histological Exam Results Used) | Whether or not the results of a performed autopsy or a performed histological placental examination were used as part of determining the cause of death. | ||||
| 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:numberFetalDeathsThisDelivery |
SC | 0..1 | Reference(Observation - Number of Fetal Deaths This Delivery - Vital Records) | Number of fetal deaths this 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:motherInformation |
SC | 0..1 | BackboneElement | Mother administrative section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
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:mothersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. | ||||
| 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 Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the father's name, dob, and birthplace. | ||||
| 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:patientsQuestionnaireResponse |
C | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
1..1 | CodeableConcept | Questionnaire response Document Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry |
C | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | ||||
| 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 69045-3http://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:fetus.code | example | Pattern: LOINC Code 76400-1http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:fetus.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:fetus.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:fetus.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:patientsQuestionnaireResponse.code | example | Pattern: LOINC Code 74465-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:patientsQuestionnaireResponse.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:patientsQuestionnaireResponse.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:patientsQuestionnaireResponse.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:fetus, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | 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:fetus, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | 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: 4 elements(16 nested mandatory elements)
Must-Support: 56 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 | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| Slices for extension |
S | 1..* | Extension | Extension Slice: Unordered, Open by value:url |
| fetalDeathReportNumber |
S | 0..1 | Identifier | State File Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-report-number |
| fetalDeathLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-local-file-number |
| dateReceivedByRegistrar |
S | 1..1 | dateTime | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-received-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 fetal death sent in error, a status of 'entered-in-error' must be set. |
| type |
S | 1..1 | CodeableConcept | U.S. standard report of fetal death - 2003 revision Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 69045-3 | |
| subject |
S | 1..1 | Reference(Patient - Decedent Fetus - Vital Records) | The subject of the composition is the decedent fetus: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the name of the decedent fetus. |
| encounter |
S | 0..1 | Reference(Encounter - Maternity) | The Encounter for the Composition is the mother's maternity encounter. |
| Extension-encounter-maternity-reference |
0..* | 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(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. |
| Slices for section |
S | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Fetal Death Report. Slice: Unordered, Open by pattern:code |
| section:motherPrenatal |
S | 0..1 | BackboneElement | Mother (prenatal) section on the Fetal Death Report |
| 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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. |
| 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: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:mothersHeight |
S | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:mothersPrepregnancyWeight |
S | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:motherReceivedWICFood |
S | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:cigaretteSmokingBeforeDuringPregnancy |
S | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| section:medicalHealthInformation |
S | 0..1 | BackboneElement | Medical and Health Information section on the Fetal Death Report |
| 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: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:fetus |
S | 0..1 | BackboneElement | fetus section on the Fetal Death Report |
| code |
S | 1..1 | CodeableConcept | Fetal delivery information Document [US Standard Report of Fetal Death] 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: 76400-1 | |
| Slices for entry |
S | 1..* | Reference(Resource) | Entries that are contained in the fetus section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:deliveryWeight |
S | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Delivery weight |
| 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:causeOfFetalDeath |
S | 0..1 | Reference(Condition - Fetal Death Cause or Condition) | Initiating cause or condition of fetal death |
| Slices for entry |
Content/Rules for all slices | |||
| entry:otherCauseOfDeath |
S | 0..* | Reference(Condition - Fetal Death Other Cause or Condition) | Another significant cause or condition for the death of the fetus. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:estimatedTimeFetalDeath |
S | 1..1 | Reference(Observation - Fetal Death Time Point) | The estimated time of fetal death; the time of death is characterized by the relationship to the time of delivery. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:autopsyPerformed |
S | 0..1 | Reference(Observation - Autopsy Performed Indicator - Vital Records) | An indication if an autopsy has been performed on the subject. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:histologicalExamPerformed |
S | 0..1 | Reference(Observation - Histological Placental Exam Performed) | Whether or not a histological placental examination was performed. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:autopsyOrHistologicalExamUsed |
S | 0..1 | Reference(Observation - Autopsy or Histological Exam Results Used) | Whether or not the results of a performed autopsy or a performed histological placental examination were used as part of determining the cause of death. |
| 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:numberFetalDeathsThisDelivery |
S | 0..1 | Reference(Observation - Number of Fetal Deaths This Delivery - Vital Records) | Number of fetal deaths this delivery |
| section:motherInformation |
S | 0..1 | BackboneElement | Mother administrative section on the Fetal Death Report |
| 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:mothersEducation |
S | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| section:fatherInformation |
S | 0..1 | BackboneElement | Father section on the Fetal Death Report |
| 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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the father's name, dob, and birthplace. |
| section:patientsQuestionnaireResponse |
0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | |
| code |
1..1 | CodeableConcept | Questionnaire response Document Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |
| entry |
1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
S | 1..* | Extension | Extension Slice: Unordered, Open by value:url |
| fetalDeathReportNumber |
S | 0..1 | Identifier | State File Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-report-number |
| fetalDeathLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-local-file-number |
| dateReceivedByRegistrar |
S | 1..1 | dateTime | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-received-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 fetal death 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 | U.S. standard report of fetal death - 2003 revision Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 69045-3 | |
| subject |
SΣ | 1..1 | Reference(Patient - Decedent Fetus - Vital Records) | The subject of the composition is the decedent fetus: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the name of the decedent fetus. |
| encounter |
SΣ | 0..1 | Reference(Encounter - Maternity) | The Encounter for the Composition is the mother's maternity encounter. |
| Extension-encounter-maternity-reference |
0..* | 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(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. |
| title |
Σ | 1..1 | string | Human Readable name/title |
| Slices for section |
SC | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Fetal Death Report. 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 Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. |
| 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: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:mothersHeight |
SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:mothersPrepregnancyWeight |
SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:motherReceivedWICFood |
SC | 0..1 | Reference(Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| entry:cigaretteSmokingBeforeDuringPregnancy |
SC | 0..4 | Reference(Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| section:medicalHealthInformation |
SC | 0..1 | BackboneElement | Medical and Health Information section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
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: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:fetus |
SC | 0..1 | BackboneElement | fetus section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
S | 1..1 | CodeableConcept | Fetal delivery information Document [US Standard Report of Fetal Death] 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: 76400-1 | |
| Slices for entry |
SC | 1..* | Reference(Resource) | Entries that are contained in the fetus section Slice: Unordered, Open by profile:$this.resolve() |
| Slices for entry |
Content/Rules for all slices | |||
| entry:deliveryWeight |
SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Delivery weight |
| 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:causeOfFetalDeath |
SC | 0..1 | Reference(Condition - Fetal Death Cause or Condition) | Initiating cause or condition of fetal death |
| Slices for entry |
Content/Rules for all slices | |||
| entry:otherCauseOfDeath |
SC | 0..* | Reference(Condition - Fetal Death Other Cause or Condition) | Another significant cause or condition for the death of the fetus. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:estimatedTimeFetalDeath |
SC | 1..1 | Reference(Observation - Fetal Death Time Point) | The estimated time of fetal death; the time of death is characterized by the relationship to the time of delivery. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:autopsyPerformed |
SC | 0..1 | Reference(Observation - Autopsy Performed Indicator - Vital Records) | An indication if an autopsy has been performed on the subject. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:histologicalExamPerformed |
SC | 0..1 | Reference(Observation - Histological Placental Exam Performed) | Whether or not a histological placental examination was performed. |
| Slices for entry |
Content/Rules for all slices | |||
| entry:autopsyOrHistologicalExamUsed |
SC | 0..1 | Reference(Observation - Autopsy or Histological Exam Results Used) | Whether or not the results of a performed autopsy or a performed histological placental examination were used as part of determining the cause of death. |
| 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:numberFetalDeathsThisDelivery |
SC | 0..1 | Reference(Observation - Number of Fetal Deaths This Delivery - Vital Records) | Number of fetal deaths this delivery |
| section:motherInformation |
SC | 0..1 | BackboneElement | Mother administrative section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
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:mothersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. |
| section:fatherInformation |
SC | 0..1 | BackboneElement | Father section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the father's name, dob, and birthplace. |
| section:patientsQuestionnaireResponse |
C | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
1..1 | CodeableConcept | Questionnaire response Document Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |
| entry |
C | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report |
| 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 69045-3http://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:fetus.code | example | Pattern: LOINC Code 76400-1http://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:patientsQuestionnaireResponse.code | example | Pattern: LOINC Code 74465-6http://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:fetus, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | 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:fetus, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | 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 | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| 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 | 1..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| fetalDeathReportNumber |
S | 0..1 | Identifier | State File Number URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-report-number | ||||
| fetalDeathLocalFileNumber |
S | 0..1 | Identifier | Local File No. URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-fetal-death-local-file-number | ||||
| dateReceivedByRegistrar |
S | 1..1 | dateTime | Extension URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-received-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 fetal death 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 | U.S. standard report of fetal death - 2003 revision Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 69045-3 | |||||
| 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 - Decedent Fetus - Vital Records) | The subject of the composition is the decedent fetus: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the name of the decedent fetus. | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter - Maternity) | The Encounter for the Composition is the mother's maternity encounter. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Extension-encounter-maternity-reference |
0..* | 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(Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. | ||||
| title |
Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester |
0..* | BackboneElement | Attests to accuracy of composition | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian |
Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo |
0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] |
1..1 | Target of the relationship | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(Composition) | |||||||
| event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period |
Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section |
SC | 1..* | BackboneElement | The Composition is broken into sections that, where possible, align with the sections in the Fetal Death Report. 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 Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. | ||||
| 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: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:mothersHeight |
SC | 0..1 | Reference(Observation - Mother Height - Vital Records) | Mother's height: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:mothersPrepregnancyWeight |
SC | 0..1 | Reference(Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. | ||||
| 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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. | ||||
| 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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. | ||||
| 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 Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
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: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:fetus |
SC | 0..1 | BackboneElement | fetus section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
S | 1..1 | CodeableConcept | Fetal delivery information Document [US Standard Report of Fetal Death] 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: 76400-1 | |||||
| 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 fetus section Slice: Unordered, Open by profile:$this.resolve() | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:deliveryWeight |
SC | 0..1 | Reference(Observation - Birth Weight - Vital Records) | Delivery weight | ||||
| 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:causeOfFetalDeath |
SC | 0..1 | Reference(Condition - Fetal Death Cause or Condition) | Initiating cause or condition of fetal death | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:otherCauseOfDeath |
SC | 0..* | Reference(Condition - Fetal Death Other Cause or Condition) | Another significant cause or condition for the death of the fetus. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:estimatedTimeFetalDeath |
SC | 1..1 | Reference(Observation - Fetal Death Time Point) | The estimated time of fetal death; the time of death is characterized by the relationship to the time of delivery. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:autopsyPerformed |
SC | 0..1 | Reference(Observation - Autopsy Performed Indicator - Vital Records) | An indication if an autopsy has been performed on the subject. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:histologicalExamPerformed |
SC | 0..1 | Reference(Observation - Histological Placental Exam Performed) | Whether or not a histological placental examination was performed. | ||||
| Slices for entry |
Content/Rules for all slices | |||||||
| entry:autopsyOrHistologicalExamUsed |
SC | 0..1 | Reference(Observation - Autopsy or Histological Exam Results Used) | Whether or not the results of a performed autopsy or a performed histological placental examination were used as part of determining the cause of death. | ||||
| 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:numberFetalDeathsThisDelivery |
SC | 0..1 | Reference(Observation - Number of Fetal Deaths This Delivery - Vital Records) | Number of fetal deaths this 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:motherInformation |
SC | 0..1 | BackboneElement | Mother administrative section on the Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
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:mothersEducation |
SC | 0..1 | Reference(Observation - Parent Education Level - Vital Records) | Mother's education: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for this data element. | ||||
| 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 Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
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: the "US Standard Patient’s Worksheet for the Report of Fetal Death" should be the source of truth for the father's name, dob, and birthplace. | ||||
| 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:patientsQuestionnaireResponse |
C | 0..1 | BackboneElement | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
1..1 | CodeableConcept | Questionnaire response Document Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 74465-6 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry |
C | 1..1 | Reference(QuestionnaireResponse) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | ||||
| 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 69045-3http://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:fetus.code | example | Pattern: LOINC Code 76400-1http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:fetus.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:fetus.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:fetus.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:patientsQuestionnaireResponse.code | example | Pattern: LOINC Code 74465-6http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:patientsQuestionnaireResponse.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:patientsQuestionnaireResponse.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:patientsQuestionnaireResponse.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:fetus, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | 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:fetus, Composition.section:motherInformation, Composition.section:fatherInformation, Composition.section:patientsQuestionnaireResponse | 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: 4 elements(16 nested mandatory elements)
Must-Support: 56 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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