| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
Composition
|
Composition | Provider Live Birth Report | ||
Slices for extension
|
S | 1.. | Slice: Unordered, Open by value:url | |
liveBirthCertificateNumber
|
S | 0..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 |
U.S. standard certificate of live birth - 2003 revision Required Pattern: At least the following |
||
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 68998-4 |
|
subject
|
S | 1.. | Reference (Patient - Child - Vital Records) | The subject of the composition is the newborn baby: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the baby's name. |
|
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) |
The Encounter is the maternity encounter. URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Extension-encounter-maternity-reference |
|
|
date
|
S | Date report completed | ||
|
author
|
S | ..1 | Reference (Practitioner - Vital Records) | The author is the person who verifies/approves the accuracy of the data to be sent to the vital records system. |
Slices for section
|
S | 1 .. |
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: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for the mother's name, address, dob, birthplace, race, and ethnicity. |
Slices for entry
|
S | 1 .. |
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: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
|
entry:mothersPrepregnancyWeight
|
S | ..1 | Reference (Observation - Mother Prepregnancy Weight - Vital Records) | Mother's prepregnancy weight: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
|
entry:motherReceivedWICFood
|
S | ..1 | Reference (Observation - Mother Recieved WIC Food) | Use of the WIC nutritional program by the mother: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
entry:cigaretteSmokingBeforeDuringPregnancy
|
S | ..4 | Reference (Observation - Cigarette Smoking Before and During Pregnancy) | Cigarettes smoked by the mother before and during the pregnancy: the "US Standard Mothers Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
|
section:medicalHealthInformation
|
S | ..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: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the infertility treatment, artificial insemination, and assisted fertilization data elements. | |
|
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 | ||
|
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) | |
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
|
entry:marriedDuringPregnancy
|
S | ..1 | Reference (Observation - Mother Married During Pregnancy) | Mother married during pregnancy: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
|
entry:ssnRequestedForChild
|
S | ..1 | Reference (Observation - Social Security Number Requested For Child) | Was social security number requested for the child: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
|
entry:mothersEducation
|
S | ..1 | Reference (Observation - Parent Education Level - Vital Records) | Mother's education: the US Standard Mother's Worksheet for Child’s Birth Certificate should be the source of truth for this data element. |
|
section:fatherInformation
|
S | ..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: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for the father's name, dob, birthplace, ssn, race, and ethncity. |
|
Slices for entry
|
S | 1 .. |
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: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
|
entry:fathersEducation
|
S | ..1 | Reference (Observation - Parent Education Level - Vital Records) | Father's education: the "US Standard Mother's Worksheet for Child’s Birth Certificate" should be the source of truth for this data element. |
|
section:patientsQuestionnaireResponse
|
..1 | Optional section containing a QuestionnaireResponse with recorded answers to the Questionnaire - Mother's Worksheet for Child's Birth Certificate | ||
|
code
|
1.. |
Questionnaire response Document Required Pattern: At least the following |
||
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 74465-6 |
|
|
entry
|
1..1 | Reference ( QuestionnaireResponse ) | QuestionnaireResponse with recorded answers to the Questionnaire - Patient's Worksheet for Fetal Death Report | |
|
Documentation for this format
|
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