Generated Narrative: Composition composition-provider-live-birth-babyg-quinn identifier: a03eab8c-11e8-4d0c-ad2a-b385395e27de status: Final type: U.S. standard certificate of live birth - 2003 revision encounter: Encounter - Birth (Baby G Quinn) date: 2019-02-12 author: Practitioner - Vital Records (Dr. Avery Jones, MD) title: Provider supplied live birth report Document
U.S. standard certificate of live birth - 2003 revision
Practitioner - Vital Records (Dr. Avery Jones, MD)
Provider supplied live birth report Document
Mother (prenatal) Section on the Live Birth Certificate
Observation - Planned to Deliver at Home (Jada Ann Quinn)
Observation - Date of First Prenantal Care Visit (Jada Ann Quinn)
Observation - Number Prenatal Visits (Jada Ann Quinn)
Observation - Last Menstrual Period (Jada Ann Quinn)
Observation - Number Births Now Living (Jada Ann Quinn)
Observation - Number Births Now Dead (Jada Ann Quinn)
Observation - Date of Last Live Birth (Jada Ann Quinn)
Observation - Number Other Pregnancy Outcomes (Jada Ann Quinn)
Observation - Date of Last Other Pregnancy Outcome (Jada Ann Quinn)
Coverage - Principal Payer for Delivery (Jada Ann Quinn)
Observation - Mother Delivery Weight (Jada Ann Quinn)
Observation - Observation - Mother Height (Jada Ann Quinn)
Observation - Mother Prepregnancy Weight (Jada Ann Quinn)
Observation - Mother Received WIC Food (Jada Ann Quinn)
Observation - Cigarette Smoking Before/During Pregnancy (3 months prior: Jada Ann Quinn)
Observation - Cigarette Smoking Before/During Pregnancy (first 3 months: Jada Ann Quinn)
Observation - Cigarette Smoking Before/During Pregnancy (second 3 months: Jada Ann Quinn)
Observation - Cigarette Smoking Before/During Pregnancy (last 3 months: Jada Ann Quinn)
Condition - Prepregnancy Diabetes - Jada Ann Quinn
Observation - Pregnancy Risk Factor (Jada Ann Quinn: Pregnancy-induced hypertension)
Observation - Number Previous Cesareans (Jada Ann Quinn)
Condition - Infection Present During Pregnancy (Jada Ann Quinn)
Procedure - Obstetric Procedure (Jada Ann Quinn)
Condition - Characteristic of Labor and Delivery (Jada Ann Quinn: Chorioamnionitis)
Procedure - Characteristic of Labor and Delivery (Jada Ann Quinn: Induction of Labor)
Observation - Fetal Presentation (Baby G Quinn)
Procedure - Final Route and Method of Delivery (Baby G Quinn)
Condition - Maternal Morbidity - Ruptured Uterus (Jada Ann Quinn)
Newborn section on the Live Birth Certificate
Observation - Birth Weight (Baby G Quinn)
Observation - Gestational Age at Delivery (Baby G Quinn)
Observation - Apgar Score (BabyG Quinn: 1 min)
Observation - Apgar Score (BabyG Quinn: 5 min)
Condition - Congenital Anomaly of Newborn (BabyG Quinn) 1
Condition - Congenital Anomaly of Newborn (Baby G Quinn) 2
Observation - Infant Living (Baby G Quinn)
Observation - Infant Breastfed at Discharge (Baby G Quinn)
Observation - Mother Married During Pregnancy (Jada Ann Quinn)
Observation - Parent Education Level (Jada Ann Quinn)
Observation - SSN Requested for Child (Jada Ann Quinn)
RelatedPerson - Father (James Brandon Quinn)
Observation - Paternity Acknowledgement Signed (James Brandon Quinn)
Observation - Parent Education Level (James Brandon Quinn)
QuestionnaireResponse - Mother's Worksheet for Live Birth Certificate
Generated Narrative: Patient patient-child-babyg-quinn Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, )) <td style="background-color: #f3f5da" title="Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The ethnicity codes used to represent these concepts are based upon the [CDC ethnicity and Ethnicity Code Set Version 1.0](http://www.cdc.gov/phin/resources/vocabulary/index.html) which includes over 900 concepts for representing race and ethnicity of which 43 reference ethnicity. The ethnicity concepts are grouped by and pre-mapped to the 2 OMB ethnicity categories: - Hispanic or Latino - Not Hispanic or Latino.">US Core Ethnicity Extension: ombCategory: Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino text: Not Hispanic or Latino Patient Birth Place Salt Lake City UT US Core Birth Sex Extension F <td style="background-color: #f3f5da" title="Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The race codes used to represent these concepts are based upon the [CDC Race and Ethnicity Code Set Version 1.0](http://www.cdc.gov/phin/resources/vocabulary/index.html) which includes over 900 concepts for representing race and ethnicity of which 921 reference race. The race concepts are grouped by and pre-mapped to the 5 OMB race categories: - American Indian or Alaska Native - Asian - Black or African American - Native Hawaiian or Other Pacific Islander - White.">US Core Race Extension: ombCategory: Race & Ethnicity - CDC 2106-3: White text: White
Generated Narrative: Encounter encounter-birth-babyg-quinn identifier: http://hospital.smarthealthit.org/9937012 status: Finished class: ActCode IMP: inpatient encounter type: Under Observation or Inpatient Care Services (Including Admission and Discharge Services) subject: BabyG Quinn participant type: Birth certifier [Extended Identifier] period: 2019-02-12 13:30:00-0700 --> (ongoing) individual: Practitioner - Vital Records (Avery Jones, MD) participant type: Birth attendant [Extended Identifier] individual: Practitioner - Vital Records (Avery Jones, MD) period: 2019-02-12 13:00:00-0700 --> 2019-02-15 10:00:00-0700 Hospitalizations - Destination DischargeDisposition * East Hospital Location The patient was transferred to another healthcare facility. Locations - Location PhysicalType * Location - US Core Location (South Hospital) Hospital partOf: Maternity Encounter - Jada Ann Quinn
Under Observation or Inpatient Care Services (Including Admission and Discharge Services)
Practitioner - Vital Records (Avery Jones, MD)
The patient was transferred to another healthcare facility.
Location - US Core Location (South Hospital)
Generated Narrative: Encounter encounter-maternity-jada-ann-quinn identifier: http://hospital.smarthealthit.org/9937012 status: Finished class: ActCode IMP: inpatient encounter type: Under Observation or Inpatient Care Services (Including Admission and Discharge Services) subject: Patient - Mother (Jada Ann Quinn) Participants - Type Individual * Birth attendant [Extended Identifier] Practitioner - Vital Records (Avery Jones, MD) period: 2019-02-11 10:00:00-0700 --> 2019-02-15 10:00:00-0700 Hospitalizations - Origin AdmitSource * Location - US Core Location (North Hospital) The Patient has been transferred from another hospital for this encounter. Locations - Location PhysicalType * Location - US Core Location (South Hospital) Hospital serviceProvider: Organization - US Core Organization (South Hospital Organization)
Location - US Core Location (North Hospital)
The Patient has been transferred from another hospital for this encounter.
Organization - US Core Organization (South Hospital Organization)
Generated Narrative: Practitioner practitioner-vital-records-avery-jones identifier: NPI/112247003 name: Avery Jones Qualifications - Code * Osteopath (occupation)
Generated Narrative: Patient patient-mother-jada-ann-quinn Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) Other Id: Social Security number/132225986 (use: usual, ) Alt. Name: Jada Ann King (Name changed for Marriage) Contact Detail ph: 1-(404)555-1212(Home) jadaann.quinn@example.com 1875 West Morton Avenue Salt Lake City UT 84116 US (home) 1848 South 1300 East Salt Lake City UT 84401 US (billing) Links: Also see: RelatedPerson Jada Ann Quinn (official) <td style="background-color: #f3f5da" title="Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The ethnicity codes used to represent these concepts are based upon the [CDC ethnicity and Ethnicity Code Set Version 1.0](http://www.cdc.gov/phin/resources/vocabulary/index.html) which includes over 900 concepts for representing race and ethnicity of which 43 reference ethnicity. The ethnicity concepts are grouped by and pre-mapped to the 2 OMB ethnicity categories: - Hispanic or Latino - Not Hispanic or Latino.">US Core Ethnicity Extension: ombCategory: Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino text: Not Hispanic or Latino Patient Birth Place UT US Core Birth Sex Extension F <td style="background-color: #f3f5da" title="Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The race codes used to represent these concepts are based upon the [CDC Race and Ethnicity Code Set Version 1.0](http://www.cdc.gov/phin/resources/vocabulary/index.html) which includes over 900 concepts for representing race and ethnicity of which 921 reference race. The race concepts are grouped by and pre-mapped to the 5 OMB race categories: - American Indian or Alaska Native - Asian - Black or African American - Native Hawaiian or Other Pacific Islander - White.">US Core Race Extension: ombCategory: Race & Ethnicity - CDC 2106-3: White ombCategory: Race & Ethnicity - CDC 1002-5: American Indian or Alaska Native text: White, American Indian or Alaska Native
Generated Narrative: Observation observation-planned-to-deliver-at-home-babyg-quinn status: Final code: Planned to deliver at home? subject: BabyG Quinn focus: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: true
Mother Planned to deliver at home [US Standard Certificate of Live Birth]
Generated Narrative: Observation observation-date-of-first-prenatal-care-visit-jada-ann-quinn status: Final code: Date of first prenatal care visit subject: BabyG Quinn focus: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: 2018-07-20
Generated Narrative: Observation observation-number-prenatal-visits-jada-ann-quinn status: Final code: Prenatal visits for this pregnancy # subject: BabyG Quinn focus: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: 8
Generated Narrative: Observation observation-last-menstrual-period-jada-ann-quinn status: Final code: Last menstrual period start date subject: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: 2018-06-05
Generated Narrative: Observation observation-number-births-now-living-jada-ann-quinn status: Final code: [#] Births.still living subject: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: 1
Generated Narrative: Observation observation-number-births-now-dead-jada-ann-quinn status: Final code: Previous live births now dead # subject: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: 0
Generated Narrative: Observation observation-date-of-last-live-birth-jada-ann-quinn status: Final code: Date of last live birth subject: BabyG Quinn focus: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: 2014-11-20
Generated Narrative: Observation observation-number-other-pregnancy-outcomes-jada-ann-quinn status: Final code: Other pregnancy outcomes # subject: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: 0
Generated Narrative: Observation observation-date-of-last-other-pregnancy-outcome-jada-ann-quinn status: Final code: Date of last other pregnancy outcome subject: BabyG Quinn focus: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: 2015-05
Generated Narrative: Coverage coverage-principal-payer-for-delivery-jada-ann-quinn status: Active type: Private Health Insurance beneficiary: Patient - Mother (Jada Ann Quinn) payor: Not asked
Generated Narrative: Observation observation-mother-delivery-weight-jada-ann-quinn status: Final category: Vital Signs code: Mother's body weight --at delivery subject: Patient - Mother (Jada Ann Quinn) effective: 2019-02-12 performer: Practitioner Avery Jones value: 175 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')
Generated Narrative: Observation observation-mother-height-jada-ann-quinn status: Final category: Vital Signs code: Body height Measured subject: Patient - Mother (Jada Ann Quinn) effective: 2019-02-10 performer: Practitioner Avery Jones value: 67 [in_i] (Details: UCUM code[in_i] = '[in_i]')
Generated Narrative: Observation observation-mother-prepregnancy-weight-jada-ann-quinn status: Final category: Vital Signs code: Body weight --pre current pregnancy subject: Patient - Mother (Jada Ann Quinn) effective: 2019-06-20 performer: Practitioner Avery Jones value: 145 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')
Generated Narrative: Observation observation-mother-received-wic-food-jada-ann-quinn status: Final code: Did mother get WIC food for herself during this pregnancy? subject: BabyG Quinn focus: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: Yes
Did mother get WIC food for herself during this pregnancy?
Generated Narrative: Observation observation-cig-smoking-pregnancy-1-jada-ann-quinn status: Final code: In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day [PhenX] subject: Patient - Mother (Jada Ann Quinn) focus: BabyG Quinn effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: 20
In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day [PhenX]
Generated Narrative: Observation observation-cig-smoking-pregnancy-2-jada-ann-quinn status: Final code: Cigarettes smoked per day by Mother--1st trimester subject: Patient - Mother (Jada Ann Quinn) focus: BabyG Quinn effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: 3
Cigarettes smoked per day by Mother--1st trimester
Generated Narrative: Observation observation-cig-smoking-pregnancy-3-jada-ann-quinn status: Final code: Cigarettes smoked per day by Mother--2nd trimester subject: Patient - Mother (Jada Ann Quinn) focus: BabyG Quinn effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: 1
Cigarettes smoked per day by Mother--2nd trimester
Generated Narrative: Observation observation-cig-smoking-pregnancy-4-jada-ann-quinn status: Final code: In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day [PhenX] subject: Patient - Mother (Jada Ann Quinn) focus: BabyG Quinn effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: 0
In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day [PhenX]
Generated Narrative: Condition condition-prepregnancy-diabetes-jada-ann-quinn clinicalStatus: Active category: Problem List Item code: Diabetes mellitus (disorder) subject: Patient - Mother (Jada Ann Quinn) onset: 2015-02-12
Generated Narrative: Condition condition-gestational-hypertension-jada-ann-quinn clinicalStatus: Active category: Problem List Item code: Pregnancy-induced hypertension (disorder) subject: Patient - Mother (Jada Ann Quinn)
Pregnancy-induced hypertension (disorder)
Generated Narrative: Observation observation-number-previous-cesareans-jada-ann-quinn status: Final code: Previous cesarean deliveries # subject: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: 1
Generated Narrative: Condition condition-infection-present-during-pregnancy-jada-ann-quinn clinicalStatus: Active category: Problem List Item, Infections present AndOr treated during this pregnancy for live birth [US Standard Certificate of Live Birth] code: Chlamydial infection (disorder) subject: Patient - Mother (Jada Ann Quinn)
Infections present AndOr treated during this pregnancy for live birth [US Standard Certificate of Live Birth]
Generated Narrative: Procedure procedure-obstetric-procedure-jada-ann-quinn status: Completed code: External cephalic version: Failed subject: Patient - Mother (Jada Ann Quinn) performed: 2019-02-07 08:30:00-0700 --> 2019-02-07 08:45:00-0700 outcome: External cephalic version: Unsuccessful
Generated Narrative: Condition condition-chorioamnionitis-jada-ann-quinn clinicalStatus: Active category: Problem List Item code: Chorioamnionitis (disorder) subject: Patient - Mother (Jada Ann Quinn)
Generated Narrative: Procedure procedure-induction-of-labor-jada-ann-quinn status: Completed code: Induction of labor (procedure) subject: Patient - Mother (Jada Ann Quinn) performed: 2019-02-07 08:30:00-0700 --> 2019-02-07 08:45:00-0700
Generated Narrative: Observation observation-fetal-presentation-babyg-quinn status: Final code: Fetal presentation--at birth [US Standard Certificate of Live Birth] subject: Patient - Child (Baby G Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: Breech presentation (finding)
Fetal presentation--at birth [US Standard Certificate of Live Birth]
Generated Narrative: Procedure procedure-final-route-method-delivery-babyg-quinn status: Completed code: Cesarean section subject: Patient - Mother (Jada Ann Quinn) performed: 2019-02-12 12:45:00-0700 --> 2019-02-12 13:15:00-0700 reasonReference: Labor trial attempted - true
Generated Narrative: Condition condition-ruptured-uterus-jada-ann-quinn clinicalStatus: Active category: Problem List Item code: Rupture of uterus (disorder) subject: Patient - Mother (Jada Ann Quinn)
Generated Narrative: Observation observation-birth-weight-babyg-quinn status: Final category: Vital Signs code: Birth weight Measured subject: BabyG Quinn effective: 2019-02-10 performer: Practitioner Avery Jones value: 2500 g (Details: UCUM codeg = 'g')
Generated Narrative: Observation observation-gestational-age-at-delivery-babyg-quinn status: Final code: Gestational age Estimated subject: BabyG Quinn effective: 2019-12-02 performer: Practitioner Avery Jones value: 36 wk (Details: UCUM codewk = 'wk')
Generated Narrative: Observation observation-apgar-score-babyg-quinn-1-min status: Final category: Survey code: 1 minute Apgar Score subject: BabyG Quinn effective: 2019-12-02 performer: Practitioner Avery Jones value: 5
Generated Narrative: Observation observation-apgar-score-babyg-quinn-5-min status: Final category: Survey code: 5 minute Apgar Score subject: BabyG Quinn effective: 2019-12-02 performer: Practitioner Avery Jones value: 7
Generated Narrative: Condition condition-congenital-anomaly-of-newborn-babyg-quinn clinicalStatus: Active category: Problem List Item, Congenital anomalies of the newborn [US Standard Certificate of Live Birth] code: Cyanotic congenital heart disease (disorder) subject: BabyG Quinn
Congenital anomalies of the newborn [US Standard Certificate of Live Birth]
Cyanotic congenital heart disease (disorder)
Generated Narrative: Condition condition-congenital-anomaly-of-newborn-babyg-quinn-2 clinicalStatus: Active category: Problem List Item, Congenital anomalies of the newborn [US Standard Certificate of Live Birth] code: Anomaly of chromosome pair 21 (disorder) subject: Patient - Child (Baby G Quinn) Evidences - Code * Karyotype determination pending
Anomaly of chromosome pair 21 (disorder)
Generated Narrative: Observation observation-infant-living-babyg-quinn status: Final code: Infant living at time of report [US Standard Certificate of Live Birth] subject: BabyG Quinn effective: 2019-12-02 performer: Practitioner Avery Jones value: true
Infant living at time of report [US Standard Certificate of Live Birth]
Generated Narrative: Observation observation-infant-breastfed-at-discharge-babyg-quinn status: Final code: Infant is being breastfed at discharge [US Standard Certificate of Live Birth] subject: BabyG Quinn effective: 2019-12-02 performer: Practitioner Avery Jones value: true
Infant is being breastfed at discharge [US Standard Certificate of Live Birth]
Generated Narrative: Observation observation-mother-married-during-pregnancy-jada-ann-quinn status: Final code: Was mother married at conception, at the time of birth, or at any time between conception and giving birth? subject: BabyG Quinn focus: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: Yes
Mother was married at any time during pregnancy
Was mother married at conception, at the time of birth, or at any time between conception and giving birth?
Generated Narrative: Observation observation-parent-education-level-jada-ann-quinn status: Final code: Highest level of education Mother subject: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, )) focus: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: Doctorate Degree or Professional Degree
Generated Narrative: Observation observation-ssn-requested-for-child-babyg-quinn status: Final code: Social security number requested for child subject: BabyG Quinn focus: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: true
Social security number requested for child
Generated Narrative: RelatedPerson relatedperson-father-natural-james-brandon-quinn identifier: Social Security number/132225987 active: true patient: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, )) relationship: Natural Father name: James Brandon Quinn (Official) gender: Male birthDate: 1972-11-24
Generated Narrative: Observation observation-paternity-acknowledgement-signed-james-quinn status: Final code: Paternity acknowledgment form signed Father subject: Patient - Child (Baby G Quinn) focus: RelatedPerson - Father (James Brandon Quinn) effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: Yes
Paternity acknowledgment form signed Father
Generated Narrative: Observation observation-parent-education-level-james-quinn status: Final code: Highest level of education Father subject: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, )) focus: RelatedPerson James Brandon Quinn (official) effective: 2019-12-02 performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, )) value: Doctorate Degree or Professional Degree
Generated Narrative: QuestionnaireResponse QuestionnaireResponse-mothers-live-birth-jada-quinn LinkID Text Definition Answer QuestionnaireResponse-mothers-live-birth-jada-quinn Questionnaire:Questionnaire - Mother's Worksheet for Child's Birth Certificate mother-current-legal-name What is your current legal name? mother-first-name First Jada mother-middle-name Middle Ann mother-last-name Last Quinn child-name What will be your baby's legal name (as it should appear on the birth certificate)? child-first-name First Baby child-middle-name Middle G child-last-name Last Quinn mother-address Where do you usually live - that is - where is your household/residence located? mother-nbr-street Complete number and street (do not enter rural route numbers) 1875 West Morton Avenue mother-city City, Town, or Location Salt Lake City mother-county County Salt Lake mother-state State (or U.S. Territory, Canadian Province) UT mother-zip Zip Code 84116 inside-city-limits Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? expandedYes-NoIndicator Y: Yes mother-mail What is your mailing address mother-mail-same Same as residence [Go to next question] false mother-mail-nbr-street Complete number and street 1848 South 1300 East mother-mail-city City, Town, or Location Salt Lake City mother-mail-state State (or U.S. Territory, Canadian Province) UT mother-mail-zip Zip Code 84401 mother-dob What is your date of birth? 1985-01-15 mother-birthplace In what State, U.S. territory, or foreign country were you born? Please specify one of the following: mother-birthplace-state State UT mother-education What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received). unknown PHC1455: Doctorate Degree or Professional Degree mother-ethnicity Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box. mother-shl Are you Spanish/Hispanic/Latina Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino mother-race What is your race? (Please check one or more races to indicate what you consider yourself to be). mother-race-category Race categories Race & Ethnicity - CDC 2106-3: White mother-detailed-race Extended race codes Race & Ethnicity - CDC 1004-1: American Indian receive-wic Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy? expandedYes-NoIndicator Y: Yes infertility-treatment Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b) true drugs-ai-ii If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination? false art-ivf-gift If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))? true mothers-height What is your height? mothers-height-feet Feet 5 ft (Details: UCUM codeft = 'ft') mothers-height-inches Inches 7 [in_i] (Details: UCUM code[in_i] = '[in_i]') mothers-prepregnancy-weight lbs 145 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]') mothers-smoking How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period. mothers-smoking-3-months-prior Three months before pregnancy mothers-smoking-3-months-prior-cig # of cigarettes* 0 mothers-smoking-3-months-prior-pck # of packs 1 mothers-smoking-trimester-1 First three months of pregnancy mothers-smoking-trimester-1-cig # of cigarettes* 3 mothers-smoking-trimester-1-pck # of packs 0 mothers-smoking-trimester-2 Second three months of pregnancy mothers-smoking-trimester-2-cig # of cigarettes* 1 mothers-smoking-trimester-2-pck # of packs 0 mothers-smoking-trimester-3 Third trimester of pregnancy mothers-smoking-trimester-3-cig # of cigarettes* 0 mothers-smoking-trimester-3-pck # of packs 0 mother-prior-name What name did you use prior to your first marriage? mother-prior-first-name First Jada mother-prior-middle-name Middle Ann mother-prior-last-name Last King married-conception Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below] true father-current-legal-name What is the current legal name of your baby's father? father-first-name First James father-middle-name Middle Brandon father-last-name Last Quinn father-dob What the father's date of birth? 1983-09-27 father-birthplace In what State, U.S. territory, or foreign country was the father born? Please specify one of the following: father-birthplace-state State NY father-education What is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received). unknown PHC1455: Doctorate Degree or Professional Degree father-ethnicity Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box. father-shl Is the father Spanish/Hispanic/Latina Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino father-race What is the father's race? (Please check one or more races to indicate what he considers himself to be). father-race-category Race categories Race & Ethnicity - CDC 2106-3: White parents-ssn Furnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance. mother-ssn What is your Social Security Number? 132-22-5986 father-ssn What is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank. 132-22-5987 baby-ssn Do you want a Social Security Number issued for your baby? [If yes, please sign request below false informant-name If other than the mother, what is the name of the person providing information for this worksheet? informant-first-name First Jane informant-last-name Last King informant-relationship What is your relationship to the baby's mother? unknown PHC1497: Other relative Documentation for this format
What will be your baby's legal name (as it should appear on the birth certificate)?
Where do you usually live - that is - where is your household/residence located?
Complete number and street (do not enter rural route numbers)
State (or U.S. Territory, Canadian Province)
Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?
In what State, U.S. territory, or foreign country were you born? Please specify one of the following:
What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
What is your race? (Please check one or more races to indicate what you consider yourself to be).
Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?
Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)
If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?
If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?
How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.
What name did you use prior to your first marriage?
Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below]
What is the current legal name of your baby's father?
In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
What is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received).
Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
What is the father's race? (Please check one or more races to indicate what he considers himself to be).
Furnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.
What is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank.
Do you want a Social Security Number issued for your baby? [If yes, please sign request below
If other than the mother, what is the name of the person providing information for this worksheet?
What is your relationship to the baby's mother?
Generated Narrative: Location location-east-hospital status: Active name: East Hospital type: Hospital
Generated Narrative: Location location-south-hospital status: Active name: South Hospital type: Hospital
Generated Narrative: Location location-north-hospital status: Active name: North Hospital type: Hospital
Generated Narrative: Organization organization-south-hospital identifier: NPI/5555512 active: true type: Hospital name: South Hospital telecom: +1-555-555-1111, mail@southhospital.com address: 2100 North Ave Salt Lake City UT 84116 US
Generated Narrative: Observation observation-labor-trial-attempted-babyg-quinn status: Final code: If cesarean, a trial of labor was attempted [US Standard Certificate of Live Birth] subject: BabyG Quinn focus: Patient - Mother (Jada Ann Quinn) effective: 2019-12-02 performer: Practitioner Avery Jones value: true
If cesarean, a trial of labor was attempted [US Standard Certificate of Live Birth]
Generated Narrative: RelatedPerson relatedperson-mother-jada-ann-quinn identifier: Social Security number/132225986 (use: usual, ) active: true patient: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, )) relationship: Gestational Mother name: Jada Ann Quinn (Official) telecom: ph: 1-(404)555-1212(Home), jadaann.quinn@example.com gender: Female birthDate: 1985-01-15 address: 1875 West Morton Avenue Salt Lake City UT 84116 US (home)