UV_Vital Records Birth and Fetal Death Reporting
1.1.0 - STU 1.1 International flag

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

Resource Profile: Composition - Provider Live Birth Report

Official URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Composition-provider-live-birth-report Version: 1.1.0
Active as of 2024-07-09 Computable Name: CompositionProviderLiveBirthReport

This Composition profile defines constraints to address the use case in which information for live birth information is recorded and communicated to the jurisdictional Vital Records Office.

For the most part, labor and delivery takes place at a healthcare provider site. When a baby is delivered at home, or on the way to the hospital, the mother and baby are typically 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 condition of the newborn is collected from the responsible party at the healthcare facility.

The data requirements for provider supplied live birth information are based on the

The jurisdiction may have additional data requirements and edit specifications that will be addressed at the jurisdictional level.

See Patient Worksheet Questionnaires for information about including a QuestionnaireResponse in this Composition.

Usage:

Formal Views of Profile Content

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

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* Composition Provider Live Birth Report
... Slices for extension S 1..* Extension Extension
Slice: Unordered, Open by value:url
.... liveBirthCertificateNumber S 0..1 Identifier Birth Number
URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-certificate-number
.... liveBirthLocalFileNumber S 0..1 Identifier Local File No.
URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-live-birth-local-file-number
.... dateFiledByRegistrar S 1..1 dateTime Date filed by registrar
URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-date-filed-by-registrar
.... replacementStatus S 0..1 CodeableConcept Extension
URL: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Extension-replacement-status
Binding: ValueSet - Replacement Status (required)
... status S 1..1 code In the case of a live birth sent in error, a status of 'entered-in-error' must be set.
... type S 1..1 CodeableConcept U.S. standard certificate of live birth - 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: 68998-4
... encounter S 0..1 Reference(Encounter - Birth) The Encounter for the Composition is the newborn's birth encounter.
.... Extension-encounter-maternity-reference 0..1 Reference(Encounter - Maternity) The Encounter is the maternity encounter.
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 Live Birth Certificate.
Slice: Unordered, Open by pattern:code
.... section:motherPrenatal S 0..1 BackboneElement Mother (prenatal) section on the Live Birth Certificate
..... code S 1..1 CodeableConcept Prenatal records
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 57073-9
..... focus S 1..1 Reference(Patient - Mother - Vital Records) The focus of this section is the mother: the "US Standard Mothers Worksheet for Child’s Birth Certificate" 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:numberPrenatalCareVisits S 0..1 Reference(Observation - Number of Prenatal Visits - Vital Records) Number of prenatal care visits
...... entry:dateLastNormalMenses S 0..1 Reference(Observation - Last Menstrual Period - Vital Records) Date last normal menses began
...... entry:numberNowLiving S 0..1 Reference(Observation - Number of Births Now Living - Vital Records) Number of previous live births now living
...... entry:numberNowDead S 0..1 Reference(Observation - Number of Births Now Dead - Vital Records) Number of previous live births now dead
...... entry:dateLastLiveBirth S 0..1 Reference(Observation - Date of Last Live Birth) Date of last live birth
...... entry:numberOtherOutcomes S 0..1 Reference(Observation - Number of Other Pregnancy Outcomes - Vital Records) Number of other pregnancy outcomes
...... entry:dateLastOtherOutcome S 0..1 Reference(Observation - Date of Last Other Pregnancy Outcome) Date of last other pregnancy outcome
...... entry:principalSourceOfPayment S 0..1 Reference(Coverage - Principal Payer for Delivery) Principal source of payment for this delivery
...... entry:mothersWeightAtDelivery S 0..1 Reference(Observation - Mother Delivery Weight - Vital Records) Mother's weight at delivery
...... entry:mothersHeight S 0..1 Reference(Observation - Mother Height - Vital Records) Mother's height: the "US Standard Mother's Worksheet for Child’s Birth Certificate" 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 Mother's Worksheet for Child’s Birth Certificate" 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 Mother's Worksheet for Child’s Birth Certificate" 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 Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
.... section:medicalHealthInformation S 0..1 BackboneElement Medical and Health Information section on the Live Birth Certificate
..... code S 1..1 CodeableConcept Clinical information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 55752-0
..... focus S 1..1 Reference(Patient - Mother - Vital Records) The focus of this section is the mother
..... Slices for entry S 1..* Reference(Resource) Entries that are contained in the medical and health information section
Slice: Unordered, Open by profile:$this.resolve()
..... Slices for entry Content/Rules for all slices
...... entry:pregnancyRiskFactors S 0..* Reference(Condition - Prepregnancy Diabetes - Vital Records | Condition - Gestational Diabetes - Vital Records | Condition - Prepregnancy Hypertension - Vital Records | Condition - Gestational Hypertension - Vital Records | Condition - Eclampsia Hypertension - Vital Records | Observation - Previous Preterm Birth - Vital Records | Procedure - Infertility Treatment - Vital Records | Procedure - Artificial Insemination - Vital Records | Procedure - Assisted Fertilization - Vital Records | Observation - Previous Cesarean - Vital Records | Observation - None Of Specified Pregnancy Risk Factors - Vital Records) Risk factors in this pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements.
..... Slices for entry Content/Rules for all slices
...... entry:numberPreviousCesareans S 0..1 Reference(Observation - Number of Previous Cesareans - Vital Records) If mother had a previous cesarean delivery, how many
..... Slices for entry Content/Rules for all slices
...... entry:infectionsDuringPregnancy S 0..* Reference(Condition - Infection Present During Pregnancy) Infections present and/or treated during this pregnancy
..... Slices for entry Content/Rules for all slices
...... entry:obstetricProcedures S 1..1 Reference(Procedure - Obstetric) Obstetric procedures
..... Slices for entry Content/Rules for all slices
...... entry:characteristicsLaborDelivery S 0..* Reference(Procedure - Induction of Labor | Procedure - Augmentation of Labor | Observation - Administration of Steroids for Fetal Lung Maturation | Observation - Antibiotics Administered During Labor | Condition - Chorioamnionitis | Procedure - Epidural or Spinal Anesthesia | Observation - None Of Specified Characteristics of Labor and Delivery) Characteristics of labor and delivery
..... Slices for entry Content/Rules for all slices
...... entry:fetalPresentation S 0..1 Reference(Observation - Fetal Presentation at Birth/Delivery) Fetal presentation at birth
..... Slices for entry Content/Rules for all slices
...... entry:finalRouteMethodDelivery S 0..1 Reference(Procedure - Final Route and Method of Delivery) Final route and method of delivery
..... Slices for entry Content/Rules for all slices
...... entry:maternalMorbidity S 0..* Reference(Procedure - Blood Transfusion | Condition - Perineal Laceration | Condition - Ruptured Uterus | Procedure - Unplanned Hysterectomy | Observation - ICU Admission | Observation - None Of Specified Maternal Morbidities) Maternal morbidity (complications associated with labor and delivery)
.... section:newbornInformation S 0..1 BackboneElement Newborn section on the Live Birth Certificate
..... code S 1..1 CodeableConcept Newborn delivery information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 57075-4
..... Slices for entry S 1..* Reference(Resource) Entries that are contained in the newborn section
Slice: Unordered, Open by profile:$this.resolve()
..... Slices for entry Content/Rules for all slices
...... entry:birthWeight S 0..1 Reference(Observation - Birth Weight - Vital Records) Birthweight
..... Slices for entry Content/Rules for all slices
...... entry:gestationalAgeAtDelivery S 0..1 Reference(Observation - Gestational Age at Delivery - Vital Records) Obstetric estimate of gestation
..... Slices for entry Content/Rules for all slices
...... entry:ApgarScore S 0..2 Reference(Observation - Apgar Score - Vital Records) Apgar Score - while the Apgar timing value set contains 3 possible values, 5 and 10 are the only scores used.
..... Slices for entry Content/Rules for all slices
...... entry:numberLiveBirthsThisDelivery S 0..1 Reference(Observation - Number of Live Births This Delivery - Vital Records) Number of live births this delivery
..... Slices for entry Content/Rules for all slices
...... entry:abnormalConditionsNewborn S 0..* Reference(Procedure - Assisted Ventilation Following Delivery | Procedure - Assisted Ventilation More Than Six Hours | Observation - NICU Admission | Procedure - Surfactant Replacement Therapy | Procedure - Antibiotic for Suspected Neonatal Sepsis | Condition - Seizure | Observation - None Of Specified Abnormal Conditions of Newborn) Abnormal conditions of the newborn
..... Slices for entry Content/Rules for all slices
...... entry:congenitalAnomaliesNewborn S 0..* Reference(Condition - Congenital Anomaly of Newborn) Congenital anomolies of the newborn
..... Slices for entry Content/Rules for all slices
...... entry:infantLiving S 0..1 Reference(Observation - Infant Living - Vital Records) Is infant living at time of report?
..... Slices for entry Content/Rules for all slices
...... entry:infantBreastfedAtDischarge S 0..1 Reference(Observation - Infant Breastfed at Discharge) Is infant being breastfed at discharge?
.... section:motherInformation S 0..1 BackboneElement Composition is broken into sections
..... 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) Who/what the section is about, when it is not about the subject of composition
..... Slices for entry S 1..* Reference(Resource) A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:marriedDuringPregnancy S 0..1 Reference(Observation - Mother Married During Pregnancy) Mother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
..... Slices for entry Content/Rules for all slices
...... entry:ssnRequestedForChild S 0..1 Reference(Observation - Social Security Number Requested For Child) Was social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
..... 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 Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element.
.... section:fatherInformation S 0..1 BackboneElement Father section on the Live Birth Certificate
..... code S 1..1 CodeableConcept Father's administrative information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 92013-2
..... focus S 1..1 Reference(RelatedPerson - Father Natural - Vital Records) The focus of this section is the father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity.
..... Slices for entry S 1..* Reference(Resource) Entries that are contained in the fatherInformation section
Slice: Unordered, Open by profile:$this.resolve()
..... Slices for entry Content/Rules for all slices
...... entry:paternityAcknowledgementSigned S 0..1 Reference(Observation - Paternity Acknowledgement Signed) Paternity acknowledgement signed by father: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
..... Slices for entry Content/Rules for all slices
...... entry:fathersEducation S 0..1 Reference(Observation - Parent Education Level - Vital Records) Father's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element.
.... section:patientsQuestionnaireResponse 0..1 BackboneElement Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate
..... 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

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron