Source | hl7.fhir.us.bfdr#current:Vital Records Birth and Fetal Death Reporting (v4.0.1) |
resourceType | StructureDefinition |
id | Composition-jurisdiction-live-birth-report |
canonical | http://hl7.org/fhir/us/bfdr/StructureDefinition/Composition-jurisdiction-live-birth-report |
version | 1.1.0 |
status | active |
publisher | HL7 International - Public Health Work Group |
name | CompositionJurisdictionLiveBirthReport |
title | Composition - Jurisdiction Live Birth Report |
date | 2023-09-05T23:32:58+00:00 |
experimental | false |
description | This Composition profile contains information of a live birth and the issuance of a Birth Certificate 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 | Jurisdiction Live Birth Report | ||
Slices for extension | S | 2.. | Slice: Unordered, Open by value:url | |
liveBirthCertificateNumber | S | 1..1 | Identifier |
Birth Number URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-certificate-number |
liveBirthLocalFileNumber | S | 0..1 | Identifier |
Local File No. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-live-birth-local-file-number |
dateFiledByRegistrar | S | 1..1 | dateTime |
Date filed by registrar URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-date-filed-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 live birth sent in error, a status of 'entered-in-error' must be set. | ||
type | S |
Jurisdiction live birth 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: 92011-6 |
|
subject | S | 1.. | Reference (Patient - Child - Vital Records) | The subject of the composition is the newborn baby |
encounter | S | Reference (Encounter - Birth) | The Encounter for the Composition is the newborn's birth encounter. | |
Extension-encounter-maternity-reference | 0..1 | Reference (Encounter - Maternity) |
Extension
URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-encounter-maternity-reference |
|
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 Live Birth Certificate.
Slice: Unordered, Open by pattern:code |
|
section:motherPrenatal | S | ..1 | Mother (prenatal) section on the Live Birth Certificate | |
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:numberPrenatalCareVisits | S | ..1 | Reference (Observation - Number of Prenatal Visits - Vital Records) | Number of prenatal care visits |
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:numberOtherOutcomes | S | ..1 | Reference (Observation - Number of Other Pregnancy Outcomes - Vital Records) | Number of other pregnancy outcomes |
entry:dateLastOtherOutcome | S | ..1 | Reference (Observation - Date of Last Other Pregnancy Outcome) | Date of last other pregnancy outcome |
entry:principalSourceOfPayment | S | ..1 | Reference (Coverage - Principal Payer for Delivery) | Principal source of payment for this delivery |
entry:mothersWeightAtDelivery | S | ..1 | Reference (Observation - Mother Delivery Weight - Vital Records) | Mother's weight at delivery |
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 Live Birth Certificate | |
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:infectionsDuringPregnancy | S | Reference (Condition - Infection Present During Pregnancy) | Infections present and/or treated during this pregnancy | |
entry:obstetricProcedures | S | 1..1 | Reference (Procedure - Obstetric) | Obstetric procedures |
entry:characteristicsLaborDelivery | S | 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 | |
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:newbornInformation | S | ..1 | Newborn section on the Live Birth Certificate | |
code | S | 1.. |
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 .. |
Entries that are contained in the newborn section
Slice: Unordered, Open by profile:$this.resolve() |
|
entry:birthWeight | S | ..1 | Reference (Observation - Birth Weight - Vital Records) | Birthweight |
entry:gestationalAgeAtDelivery | S | ..1 | Reference (Observation - Gestational Age at Delivery - Vital Records) | Obstetric estimate of gestation |
entry:ApgarScore | S | ..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. |
entry:numberLiveBirthsThisDelivery | S | ..1 | Reference (Observation - Number of Live Births This Delivery - Vital Records) | Number of live births this delivery |
entry:abnormalConditionsNewborn | S | 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 | |
entry:congenitalAnomaliesNewborn | S | Reference (Condition - Congenital Anomaly of Newborn) | Congenital anomolies of the newborn | |
entry:infantLiving | S | ..1 | Reference (Observation - Infant Living - Vital Records) | Is infant living at time of report? |
entry:infantBreastfedAtDischarge | S | ..1 | Reference (Observation - Infant Breastfed at Discharge) | Is infant being breastfed at discharge? |
section:motherInformation | S | ..1 | Mother administrative section on the Live Birth Certificate | |
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 motherInformation section
Slice: Unordered, Open by profile:$this.resolve() |
|
entry:marriedDuringPregnancy | S | ..1 | Reference (Observation - Mother Married During Pregnancy) | Mother married during pregnancy |
entry:ssnRequestedForChild | S | ..1 | Reference (Observation - Social Security Number Requested For Child) | Was social security number requested for the child |
entry:mothersEducation | S | ..1 | Reference (Observation - Parent Education Level - Vital Records) | Mother's education |
section:fatherInformation | S | ..1 | Father section on the Live Birth Certificate | |
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 |
Slices for entry | S | 1 .. |
Entries that are contained in the fatherInformation section
Slice: Unordered, Open by profile:$this.resolve() |
|
entry:paternityAcknowledgementSigned | S | ..1 | Reference (Observation - Paternity Acknowledgement Signed) | Paternity acknowledgement signed by father |
entry:fathersEducation | S | ..1 | Reference (Observation - Parent Education Level - Vital Records) | Father's education |
section:EditFlags | S | 1..1 | Edit Flags Section | |
code | S | 1.. |
Edit flags section Required Pattern: At least the following |
|
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 92012-4 |
|
Slices for entry | S | 12 .. 12 | Slice: Unordered, Open by profile:$this.resolve() | |
entry:editFlagBirthweight | 1..1 | Reference (Observation - Edit Flag Birthweight) | ||
entry:editFlagEstimateOfGestation | 1..1 | Reference (Observation - Edit Flag Estimate of Gestation) | ||
entry:editFlagFathersDateOfBirth | 1..1 | Reference (Observation - Edit Flag Father's Date of Birth) | ||
entry:editFlagFathersEducation | 1..1 | Reference (Observation - Edit Flag Father's Education) | ||
entry:editFlagMothersDateOfBirth | 1..1 | Reference (Observation - Edit Flag Mother's Date of Birth) | ||
entry:editFlagMothersDeliveryWeight | 1..1 | Reference (Observation - Edit Flag Mother's Delivery Weight) | ||
entry:editFlagMothersEducation | 1..1 | Reference (Observation - Edit Flag Mother's Education) | ||
entry:editFlagMothersHeight | 1..1 | Reference (Observation - Edit Flag Mother's Height) | ||
entry:editFlagMothersPrepregnancyWeight | 1..1 | Reference (Observation - Edit Flag Mother's Prepregnancy Weight) | ||
entry:editFlagNumberPrenatalCareVisits | 1..1 | Reference (Observation - Edit Flag Number Prenatal Care Visits) | ||
entry:editFlagNumberPreviousCesareans | 1..1 | Reference (Observation - Edit Flag Number of Previous Cesareans) | ||
entry:editFlagPlurality | 1..1 | Reference (Observation - Edit Flag Plurality) | ||
Documentation for this format |
Produced 08 Sep 2023