Source | hl7.fhir.us.bfdr#current:Vital Records Birth and Fetal Death Reporting (v4.0.1) |
resourceType | StructureDefinition |
id | Composition-jurisdiction-fetal-death-report |
canonical | http://hl7.org/fhir/us/bfdr/StructureDefinition/Composition-jurisdiction-fetal-death-report |
version | 1.1.0 |
status | active |
publisher | HL7 International - Public Health Work Group |
name | CompositionJurisdictionFetalDeathReport |
title | Composition - Jurisdiction Fetal Death Report |
date | 2023-09-05T23:32:58+00:00 |
experimental | false |
description | This Composition profile contains information of a fetal death and the creation of a jurisdictional file to be recorded and communicated to the national statistics agency. |
jurisdictions | us |
fhirVersion | 4.0.1 |
kind | resource |
abstract | false |
sdTtype | Composition |
derivation | constraint |
base | http://hl7.org/fhir/StructureDefinition/Composition |
Usages |
|
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | Composition | |||
Slices for extension | S | 2.. | Slice: Unordered, Open by value:url | |
fetalDeathReportNumber | S | 1..1 | Identifier |
State File Number URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-fetal-death-report-number |
fetalDeathLocalFileNumber | S | 0..1 | Identifier |
Local File No. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-fetal-death-local-file-number |
dateReceivedByRegistrar | S | 1..1 | dateTime |
Extension
URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-date-received-by-registrar |
replacementStatus | S | 0..1 | CodeableConcept |
Extension
URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-replacement-status Binding: ValueSet - Replacement Status ( required ) |
status | S | In the case of a fetal death sent in error, a status of 'entered-in-error' must be set. | ||
type | S |
Jurisdiction fetal death report Document Required Pattern: At least the following |
||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 92010-8 |
|
subject | S | 1.. | Reference (Patient - Decedent Fetus - Vital Records) | The subject of the composition is the decedent fetus |
encounter | S | Reference (Encounter - Maternity) | The Encounter for the Composition is the mother's maternity encounter. | |
date | S | Date report completed | ||
author | S | ..1 | Reference (US Core Organization Profile) | The author is the jurisdictional Vital Records Office. |
Slices for section | S | 1 .. |
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 | ..1 | Mother (prenatal) Section on the Fetal Death Report | |
code | S | 1.. |
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.. | Reference (Patient - Mother - Vital Records) | The focus of this section is the mother |
Slices for entry | S | 1 .. |
Entries that are contained in the Mother Prenatal section
Slice: Unordered, Open by profile:$this.resolve() |
|
entry:plannedToDeliverAtHome | S | ..1 | Reference (Observation - Planned to Deliver at Home) | Planned to deliver at home |
entry:firstPrenatalCareVisit | S | ..1 | Reference (Observation - Date of First Prenatal Care Visit) | First prenatal care visit |
entry:dateLastNormalMenses | S | ..1 | Reference (Observation - Last Menstrual Period - Vital Records) | Date last normal menses began |
entry:numberNowLiving | S | ..1 | Reference (Observation - Number of Births Now Living - Vital Records) | Number of previous live births now living |
entry:numberNowDead | S | ..1 | Reference (Observation - Number of Births Now Dead - Vital Records) | Number of previous live births now dead |
entry:dateLastLiveBirth | S | ..1 | Reference (Observation - Date of Last Live Birth) | Date of last live birth |
entry:mothersHeight | S | ..1 | Reference (Observation - Mother Height - Vital Records) | Mother's height |
entry:mothersPrepregnancyWeight | S | ..1 | Reference (Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight |
entry:motherReceivedWICFood | S | ..1 | Reference (Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother |
entry:cigaretteSmokingBeforeDuringPregnancy | S | ..4 | Reference (Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy |
section:medicalHealthInformation | S | ..1 | Medical and Health Information Section on the Fetal Death Report | |
code | S | 1.. |
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.. | Reference (Patient - Mother - Vital Records) | The focus of this section is the mother |
Slices for entry | S | 1 .. |
Entries that are contained in the medical and health information section
Slice: Unordered, Open by profile:$this.resolve() |
|
entry:pregnancyRiskFactors | S | 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 | |
entry:numberPreviousCesareans | S | ..1 | Reference (Observation - Number of Previous Cesareans - Vital Records) | If mother had a previous cesarean delivery, how many |
entry:fetalPresentation | S | ..1 | Reference (Observation - Fetal Presentation at Birth/Delivery) | Fetal presentation at birth |
entry:finalRouteMethodDelivery | S | ..1 | Reference (Procedure - Final Route and Method of Delivery) | Final route and method of delivery |
entry:maternalMorbidity | S | 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 | ..1 | Fetus Section on the Fetal Death Report | |
code | S | 1.. |
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 .. |
Entries that are contained in the fetus section
Slice: Unordered, Open by profile:$this.resolve() |
|
entry:deliveryWeight | S | ..1 | Reference (Observation - Birth Weight - Vital Records) | Delivery weight |
entry:gestationalAgeAtDelivery | S | ..1 | Reference (Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation |
entry:causeOfFetalDeath | S | ..1 | Reference (Condition - Fetal Death Cause or Condition) | Initiating cause or condition of fetal death |
entry:otherCauseOfDeath | S | Reference (Condition - Fetal Death Other Cause or Condition) | Another significant cause or condition for the death of the fetus. | |
entry:estimatedTimeFetalDeath | S | 0..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. |
entry:autopsyPerformed | S | ..1 | Reference (Observation - Autopsy Performed Indicator - Vital Records) | An indication if an autopsy has been performed on the subject. |
entry:histologicalExamPerformed | S | ..1 | Reference (Observation - Histological Placental Exam Performed) | Whether or not a histological placental examination was performed. |
entry:autopsyOrHistologicalExamUsed | S | ..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. |
entry:numberLiveBirthsThisDelivery | S | ..1 | Reference (Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery |
entry:numberFetalDeathsThisDelivery | S | ..1 | Reference (Observation - Number of Fetal Deaths This Delivery - Vital Records) | Number of fetal deaths this delivery |
section:motherInformation | S | ..1 | Mother Administrative Section on the Fetal Death Report | |
code | S | 1.. |
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.. | Reference (Patient - Mother - Vital Records) | The focus of this section is the mother |
Slices for entry | S | 1 .. |
Entries that are contained in the Mother Information section
Slice: Unordered, Open by profile:$this.resolve() |
|
entry:mothersEducation | S | ..1 | Reference (Observation - Parent Education Level - Vital Records) | Mother's Education |
section:fatherInformation | S | ..1 | Father section on the Fetal Death Report | |
code | S | 1.. |
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.. | Reference (RelatedPerson - Father Natural - Vital Records) | The focus of this section is the father |
section:editFlags | S | 1..1 | Edit Flags Section | |
code | S | 1.. |
Edit flags section Required Pattern: At least the following |
|
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 92012-4 |
|
Slices for entry | S | 8 .. 8 | Slice: Unordered, Open by profile:$this.resolve() | |
entry:editFlagWeightOfFetus | S | 1..1 | Reference (Observation - Edit Flag Birthweight) | |
entry:editFlagEstimateOfGestation | S | 1..1 | Reference (Observation - Edit Flag Estimate of Gestation) | |
entry:editFlagMothersDateOfBirth | S | 1..1 | Reference (Observation - Edit Flag Mother's Date of Birth) | |
entry:editFlagMothersEducation | S | 1..1 | Reference (Observation - Edit Flag Mother's Education) | |
entry:editFlagMothersHeight | S | 1..1 | Reference (Observation - Edit Flag Mother's Height) | |
entry:editFlagMothersPrepregnancyWeight | S | 1..1 | Reference (Observation - Edit Flag Mother's Prepregnancy Weight) | |
entry:editFlagNumberPreviousCesareans | S | 1..1 | Reference (Observation - Edit Flag Number of Previous Cesareans) | |
entry:editFlagPlurality | S | 1..1 | Reference (Observation - Edit Flag Plurality) | |
Documentation for this format |
Produced 08 Sep 2023