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

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

Document Details

Generated Narrative: Bundle Provider supplied live birth report Document

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

Profile: Bundle - Document Birth and Fetal Death

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

Document Subject

Document Content

## Mother (prenatal) Section on the Live Birth Certificate

## Medical Health Information Section

## Newborn section on the Live Birth Certificate

## Mother's Information Section

## Father's Information Section

## Mother's QuestionnaireResponse Section

## Additional Resources Included in Document

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

Resource Composition:

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

> identifier: a03eab8c-11e8-4d0c-ad2a-b385395e27de

> status: Final

> type: U.S. standard certificate of live birth - 2003 revision

> encounter: Encounter - Birth (Baby G Quinn)

> date: 2019-02-12

> author: Practitioner - Vital Records (Dr. Avery Jones, MD)

> title: Provider supplied live birth report Document

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

Resource Patient:

> Generated Narrative: Patient patient-child-babyg-quinn

> Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, ))

> US Core Ethnicity Extension: | ombCategory: Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino text: Not Hispanic or Latino
> Patient Birth Place | Salt Lake City UT
> US Core Birth Sex Extension | F
> US Core Race Extension: | ombCategory: Race & Ethnicity - CDC 2106-3: White text: White

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

Resource Encounter:

> Generated Narrative: Encounter encounter-birth-babyg-quinn

> Not done yet

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

Resource Encounter:

> Generated Narrative: Encounter encounter-maternity-jada-ann-quinn

> Not done yet

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

Resource Practitioner:

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

> identifier: NPI/112247003

> name: Avery Jones

> ### Qualifications

> - | Code
> * | Osteopath (occupation)

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

Resource Patient:

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

> Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Social Security number: SSN#132225986 (use: usual, ))

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

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

Resource Observation:

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

> status: Final

> code: Planned to deliver at home?

> subject: BabyG Quinn

> focus: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: true

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

Resource Observation:

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

> status: Final

> code: Date of first prenatal care visit

> subject: BabyG Quinn

> focus: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 2018-07-20

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

Resource Observation:

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

> status: Final

> code: Prenatal visits for this pregnancy #

> subject: BabyG Quinn

> focus: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 8

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

Resource Observation:

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

> status: Final

> code: Last menstrual period start date

> subject: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 2018-06-05

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

Resource Observation:

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

> status: Final

> code: [#] Births.still living

> subject: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 1

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

Resource Observation:

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

> status: Final

> code: Previous live births now dead #

> subject: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 0

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

Resource Observation:

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

> status: Final

> code: Date of last live birth

> subject: BabyG Quinn

> focus: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 2014-11-20

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

Resource Observation:

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

> status: Final

> code: Other pregnancy outcomes #

> subject: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 0

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

Resource Observation:

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

> status: Final

> code: Date of last other pregnancy outcome

> subject: BabyG Quinn

> focus: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 2015-05

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

Resource Coverage:

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

> status: Active

> type: Private Health Insurance

> beneficiary: Patient - Mother (Jada Ann Quinn)

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

Resource Observation:

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

> status: Final

> category: Vital Signs

> code: Mother's body weight --at delivery

> subject: Patient - Mother (Jada Ann Quinn)

> effective: 2019-02-12

> performer: Practitioner Avery Jones

> value: 175 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')

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

Resource Observation:

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

> status: Final

> category: Vital Signs

> code: Body height Measured

> subject: Patient - Mother (Jada Ann Quinn)

> effective: 2019-02-10

> performer: Practitioner Avery Jones

> value: 67 [in_i] (Details: UCUM code[in_i] = '[in_i]')

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

Resource Observation:

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

> status: Final

> category: Vital Signs

> code: Body weight --pre current pregnancy

> subject: Patient - Mother (Jada Ann Quinn)

> effective: 2019-06-20

> performer: Practitioner Avery Jones

> value: 145 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')

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

Resource Observation:

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

> status: Final

> code: Did mother get WIC food for herself during this pregnancy?

> subject: BabyG Quinn

> focus: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: Yes

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

Resource Observation:

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

> status: Final

> code: In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day [PhenX]

> subject: Patient - Mother (Jada Ann Quinn)

> focus: BabyG Quinn

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: 20

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

Resource Observation:

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

> status: Final

> code: Cigarettes smoked per day by Mother--1st trimester

> subject: Patient - Mother (Jada Ann Quinn)

> focus: BabyG Quinn

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: 3

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

Resource Observation:

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

> status: Final

> code: Cigarettes smoked per day by Mother--2nd trimester

> subject: Patient - Mother (Jada Ann Quinn)

> focus: BabyG Quinn

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: 1

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

Resource Observation:

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

> status: Final

> code: In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day [PhenX]

> subject: Patient - Mother (Jada Ann Quinn)

> focus: BabyG Quinn

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: 0

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

Resource Condition:

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

> clinicalStatus: Active

> category: Problem List Item

> code: Diabetes mellitus (disorder)

> subject: Patient - Mother (Jada Ann Quinn)

> onset: 2015-02-12

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

Resource Condition:

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

> clinicalStatus: Active

> category: Problem List Item

> code: Pregnancy-induced hypertension (disorder)

> subject: Patient - Mother (Jada Ann Quinn)

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

Resource Observation:

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

> status: Final

> code: Previous cesarean deliveries #

> subject: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 1

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

Resource Condition:

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

> clinicalStatus: Active

> category: Problem List Item, Infections present AndOr treated during this pregnancy for live birth [US Standard Certificate of Live Birth]

> code: Chlamydial infection (disorder)

> subject: Patient - Mother (Jada Ann Quinn)

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

Resource Procedure:

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

> status: Completed

> code: External cephalic version: Failed

> subject: Patient - Mother (Jada Ann Quinn)

> outcome: External cephalic version: Unsuccessful

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

Resource Condition:

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

> clinicalStatus: Active

> category: Problem List Item

> code: Chorioamnionitis (disorder)

> subject: Patient - Mother (Jada Ann Quinn)

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

Resource Procedure:

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

> status: Completed

> code: Induction of labor (procedure)

> subject: Patient - Mother (Jada Ann Quinn)

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

Resource Observation:

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

> status: Final

> code: Fetal presentation--at birth [US Standard Certificate of Live Birth]

> subject: Patient - Child (Baby G Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: Breech presentation (finding)

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

Resource Procedure:

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

> status: Completed

> code: Cesarean section

> subject: Patient - Mother (Jada Ann Quinn)

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

Resource Condition:

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

> clinicalStatus: Active

> category: Problem List Item

> code: Rupture of uterus (disorder)

> subject: Patient - Mother (Jada Ann Quinn)

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

Resource Observation:

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

> status: Final

> category: Vital Signs

> code: Birth weight Measured

> subject: BabyG Quinn

> effective: 2019-02-10

> performer: Practitioner Avery Jones

> value: 2500 g (Details: UCUM codeg = 'g')

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

Resource Observation:

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

> status: Final

> code: Gestational age Estimated

> subject: BabyG Quinn

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 36 wk (Details: UCUM codewk = 'wk')

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

Resource Observation:

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

> status: Final

> category: Survey

> code: 1 minute Apgar Score

> subject: BabyG Quinn

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 5

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

Resource Observation:

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

> status: Final

> category: Survey

> code: 5 minute Apgar Score

> subject: BabyG Quinn

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: 7

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

Resource Condition:

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

> clinicalStatus: Active

> category: Problem List Item, Congenital anomalies of the newborn [US Standard Certificate of Live Birth]

> code: Cyanotic congenital heart disease (disorder)

> subject: BabyG Quinn

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

Resource Condition:

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

> clinicalStatus: Active

> category: Problem List Item, Congenital anomalies of the newborn [US Standard Certificate of Live Birth]

> code: Anomaly of chromosome pair 21 (disorder)

> subject: Patient - Child (Baby G Quinn)

> > evidence

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

Resource Observation:

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

> status: Final

> code: Infant living at time of report [US Standard Certificate of Live Birth]

> subject: BabyG Quinn

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: true

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

Resource Observation:

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

> status: Final

> code: Infant is being breastfed at discharge [US Standard Certificate of Live Birth]

> subject: BabyG Quinn

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: true

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

Resource Observation:

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

> status: Final

> code: Was mother married at conception, at the time of birth, or at any time between conception and giving birth?

> subject: BabyG Quinn

> focus: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: Yes

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

Resource Observation:

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

> status: Final

> code: Highest level of education Mother

> subject: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, ))

> focus: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: Doctorate Degree or Professional Degree

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

Resource Observation:

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

> status: Final

> code: Social security number requested for child

> subject: BabyG Quinn

> focus: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: true

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

Resource RelatedPerson:

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

> identifier: Social Security number/132225987

> active: true

> patient: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, ))

> relationship: Natural Father

> name: James Brandon Quinn (Official)

> gender: Male

> birthDate: 1972-11-24

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

Resource Observation:

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

> status: Final

> code: Paternity acknowledgment form signed Father

> subject: Patient - Child (Baby G Quinn)

> focus: RelatedPerson - Father (James Brandon Quinn)

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: Yes

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

Resource Observation:

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

> status: Final

> code: Highest level of education Father

> subject: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, ))

> focus: RelatedPerson James Brandon Quinn (official)

> effective: 2019-12-02

> performer: Jada Ann Quinn (official) Female, DoB: 1985-01-15 ( Medical Record Number: 1032702 (use: usual, ))

> value: Doctorate Degree or Professional Degree

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

Resource QuestionnaireResponse:

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

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

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

Resource Location:

> Generated Narrative: Location location-east-hospital

> status: Active

> name: East Hospital

> type: Hospital

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

Resource Location:

> Generated Narrative: Location location-south-hospital

> status: Active

> name: South Hospital

> type: Hospital

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

Resource Location:

> Generated Narrative: Location location-north-hospital

> status: Active

> name: North Hospital

> type: Hospital

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

Resource Organization:

> Generated Narrative: Organization organization-south-hospital

> identifier: NPI/5555512

> active: true

> type: Hospital

> name: South Hospital

> > contact

> > telecom: +1-555-555-1111, mail@southhospital.com

> > address: 2100 North Ave Salt Lake City UT 84116 US

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

Resource Observation:

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

> status: Final

> code: If cesarean, a trial of labor was attempted [US Standard Certificate of Live Birth]

> subject: BabyG Quinn

> focus: Patient - Mother (Jada Ann Quinn)

> effective: 2019-12-02

> performer: Practitioner Avery Jones

> value: true

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

Resource RelatedPerson:

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

> identifier: Social Security number/132225986 (use: usual, )

> active: true

> patient: Baby G Quinn Female, DoB: 2019-02-12 ( Medical Record Number: 9932702 (use: usual, ))

> relationship: Gestational Mother

> name: Jada Ann Quinn (Official)

> telecom: ph: 1-(404)555-1212(Home), jadaann.quinn@example.com

> gender: Female

> birthDate: 1985-01-15

> address: 1875 West Morton Avenue Salt Lake City UT 84116 US (home)