ME&C to FHIR Worksheet - gt-health/Death_Data_Hub GitHub Wiki

This document builds on the STU3 reference document of FHIR (https://www.hl7.org/fhir/) as well as the nightingale Standard Death Reporting Profile

Viewable	Priority	ME/C Data Field	Standard Death Record Profile	FHIR Resource	FHIR DataType	Derived /Non-Direct	Notes
Y	A	Residence of decedent, state	Decedent.Residency.state	Patient.Address, Address	string	N
Y	A	Date death was pronounced	CauseOfDeath.DatePronouncedDead.value	Patient.disesasedDateTime.value	dateTime	N
Y	A	Age of decedent	Decedent.Decedent.BirthDate	Patient.birthDate	date	N
Y	A	Gender of decdent	Decedent.Decedent.use-core-birthsex	Patient.gender	code	N	Binds to the valueset of http://hl7.org/fhir/us/core/1.0.1//ValueSet-us-core-birthsex.html
Y	A	Residence of decedent, city	Decident.Residency.city	Patient.Address, Address	string	N
N	A	Date death reported to the medical examiner	CauseOfDeath.ActualOrPresumedDateofDeath.value	Observation.dateTime	dateTime	N
N	A	Date found dead, unconscious, or in distress (if found)		Encounter, Patient.disceased	dateTime	Y	If diseased within the EHR system, can be traced back to an Encounter Encounter.period.end. Possibly filter on Encounter.class = 'Emergency' or Encounter.priority = 'A' | 'EM' | 'S' | 'UR'. Repesenting "ASAP", "Emergency", "Stat", and "Urgent"
N	A	Time found dead, unconscious, or in distress		Encounter, Patient.disceased	dateTime	Y	If diseased within the EHR system, can be traced back to an Encounter Encounter.period.end. Possibly filter on Encounter.class = 'Emergency' or Encounter.priority = 'A' | 'EM' | 'S' | 'UR'. Repesenting "ASAP", "Emergency", "Stat", and "Urgent"
N	A	Address where found dead, unconscious, or in distress
Y	A	Time death was pronounced	CauseOfDeath.DatePronouncedDead.value	Patient.disceasedDateTime	dateTime	N
N	A	Name of place where death was pronounced	CauseOfDeath.DatePronouncedDead.context.Location.name	Observation.context, Encounter.Location, Location.name, Patient	string		The DatePronouncedDead.context must be an "Encounter" reference, and not an "EpisodeOfCare" reference
N	A	State where death was pronounced	CauseOfDeath.DatePronouncedDead.context.Location.address.state	Observation.context, Encounter.Location, Location.Address, Address.state	string		The DatePronouncedDead.context must be an "Encounter" reference, and not an "EpisodeOfCare" reference
N	A	Disposition of case (accepted or declined)
N	A	Type of examination or case review
Y	A	Top line of cause of death statement	CauseOfDeath.CauseOfDeathCondition.text	Condition.note.text	Narrative/string	Y	When using the profile, text is a Narrative datatype, which contains an xhtml content which contains the human readable text within.
Y	A	Second line of cause of death statement	CauseOfDeath.ContributingCauseOfDeathCondition.text	Condition.note.text	Narrative/string	Y	When using the profile, text is a Narrative datatype, which contains an xhtml content which contains the human readable text within.
Y	A	Third line of cause of death statement	CauseOfDeath.ContributingCauseOfDeathCondition.text	Condition.note.text	Narrative/string	Y	When using the profile, text is a Narrative datatype, which contains an xhtml content which contains the human readable text within.
Y	A	Fourth line of cause of death statement	CauseOfDeath.ContributingCauseOfDeathCondition.text	Condition.note.text	Narrative/string	Y	When using the profile, text is a Narrative datatype, which contains an xhtml content which contains the human readable text within.
N	A	Manner of death	CauseOfDeath.MannerOfDeath.code	Observation.code	CodeableConcept	N
	A	Certified explanation of how injury occurred	CauseOfDeath.CauseOfDeathCondition
	A	Certified type of place where injury occurred	CauseOfDeath.DeathFromTransportInjury, CauseOfDeath.DeathFromWorkInjury
	A	Certified street address of injury	CauseOfDeath.InjuryLocation.line	Address.line	string	N
	A	Certified city of injury	CauseOfDeath.InjuryLocation.city	Address.city	string	N
	A	Certified state of injury	CauseOfDeath.InjuryLocation.state	Address.state	string	N
	A	Certified date of death	CauseOfDeath..value	Patient.disesasedDateTime.value	dateTime	N
	A	Certified time of death	CauseOfDeath.ActualOrPresumedDateOfDeath.value	Patient.disesasedDateTime.value	dateTime	N
	A	Name of person certifying death or finalizing case	DeathRecord.Certifier.name	Practictioner.name	Name	N
	A	Last name of decedent	Decedent.Decedent.name.text	Patient.name	string	N	Decedent profile only supports a text string field as a name, while the standard FHIR patient resource allows a HumanName datatype.
	A	Race of decedent	Decedent.Decedent.us-core-race	Unavailable	CodeableConcept	N	Refer to http://hl7.org/fhir/us/core/1.0.1//StructureDefinition-us-core-race.html for relevant codes.
	A	Residence of decedent (street number and name)	Decedent.Residency.line	Patient.Address.line	string	N
	A	Residence of decedent, county	Decedent.Residency.country	Patient.Address.country	string	N
	A	Residence of decedent, zip	Decedent.Residency.postalCode	Patient.Address.postalCode	string	N
	A	Police department name that has jurisdiction
	A	Narrative description of circumstances and follow up notes					Can possible reuse CaseOfDeath.MannerOfDeath here
	A	Categorization of place of death (e.g., dead on scene)	CauseOfDeath.InjuryLocation.use	Patient.Address.use	code	N	home | work | temp | old
	A	Type of place where events leading to death occurred					Can be interpreted from the condition.context
	A	Time death reported to the medical examiner		Patient.disesasedDateTime.value	dateTime	N
	A	Date of injury/onset of events leading to death (if not found)	CauseOfDeath.DetailsOfInjury.effective		dateTime	N
	A	Time of injury/onset of natural events leading to death	CauseOfDeath.CauseOfDeathCondition.onset	Condition.onset	dateTime,Period	N
	A	Address of injury or onset of natural fatal events	CauseOfDeath.InjuryLocation, CauseOfDeath.CauseOfDeathCondition.context.location	Encounter.location	Address	Y	CauseOfDeathCondition.context must be of resource type "Encounter" and not "EpisodeOfCare"
	A	Address where death was pronounced (street name and number)	DeathRecord.Certifier.address.line	Practitioner.address.line	string	N
	A	City where death was pronounced	DeathRecord.Certifier.address.city	Practitioner.address.city	string	N
	A	Date of examination or case review					NOTE: Depends of where the examination is the autopsy, or the death record certification process.
	A	Ancillary procedures by medical examiner.
	A	Other significant conditions		Condition.code	CodeableConcept	Y
Supporting Resource	A	Certified time of injury	CauseOfDeath.DetailsOfInjury.effective	Observation.effectivedateTime	dateTime	N
Supporting Resource	A	Certified county of injury	CauseOfDeath.InjuryLocation.country	Address.country	string	N
Supporting Resource	A	Certified zip code where injury occurred	CauseOfDeath.InjuryLocation.postalCode	Address.postalCode	string	N
	A	Date of certification or case closure.
	A	Toxicology results.
	A	Ethnicity of decedent	Decedent.Decedent.us-core-ethnicity	Unavailable	CodeableConcept	N	Refer to http://hl7.org/fhir/us/core/1.0.1//StructureDefinition-us-core-ethnicity.html for the accepted concept codes for this element
	A	Birth date of decedent	Deecedent.Decedent.birthDate	Patient.dateOfBirth	dateTime	N
	A	Date on which decedent arrived at hospital	CauseOfDeath.CauseOfDeathCondition.context.period.startTime, CauseOfDeath.CauseOfDeathCondition.context.episodeOfCare.period.startTime	Encounter.period.startTime EpisodeOfCare.period.startTime	dateTime	Y	Note: If encounter is not of class == 'inpatient', then refer to the EpisodeOfCare link if available
	A	Time at which decedent arrived at hospital	CauseOfDeath.CauseOfDeathCondition.context.period.startTime, CauseOfDeath.CauseOfDeathCondition.context.episodeOfCare.period.startTime	Encounter.period.startTime EpisodeOfCare.period.startTime	dateTime	Y	Note: If encounter is not of class == 'inpatient', then refer to the EpisodeOfCare link if available
	A	Name of hospital where decedent was first taken	CauseOfDeath.CauseOfDeathCondition.context.location.name	Location.name	string	Y
	A	Date on which next of kin were notified of death
	A	Time at which next of kin were notified of death
	A	Specific Autopsy Findings - Autopsy Report	CauseOfDeath.AutopsyPerformed, CauseOfDeath.AutopsyResultsAvailable.text		Narrative	Y	When using the profile, text is a Narrative datatype, which contains an xhtml content which contains the human readable text within.
	A	What specific tox tests performed - requested and results
	A	First name of decedent	Decedent.Decedent.name	Patient.name.given	string	N
	A	Middle name of decedent	Decedent.Decedent.name	Patient.name.last	string	N	Note: FHIR HumanNames don't track middle name by default
Supporting Resource	A	County where death was pronounced	DeathRecord.Certifier.address.country	Practitioner.address.country	string	N
Supporting Resource		Zip code where death was pronounced	DeathRecord.Certifier.address.city	Practitioner.address.city	string	N
	A	Who will sign the death certificate	DeathRecord.Certifier.name	Practitioner.name	string
	A	Disposition of the body (burial or cremation)
	A	Investigator conducting investigation
	A	Certified date of injury	CauseOfDeath.DetailsOfInjury.effective	Observation.effectivedateTime	dateTime	N	Injury being a previously tracked injury, and not one associated with the death
	A	Qualification/clarification of injury date (IS IT KNOWN? UNKNOWN?)
	A	Did the events leading to death occur while working?
	A	Will death certificate indicate an autopsy was performed?	CaseOfDeath.AutopsyPerformed.value		boolean	N
	A	Will certificate indicate that autopsy findings were used? - DEFINE AUTOPSY	DeathRecord.DeathRecord, CaseOfDeath.AutopsyResultsAvailable		boolean	Y	If any AutopseResultsAvailable are within the DeathRecord, then true. ow false
	A	Decedent's marital status at time of death	Decedent.Decedent.sdr-deceder-MaritalStatusAtDeath-extension	Patient.MartialStatus	CodeableConcept
	A	Date last known alive or alert
	A	Time last known alive or alert
	A	How decedent was last known to be alive or okay
	A	Number of other persons known to be dead from same incident
Supporting Resources	A	Details of medical history		Condition,Encounter,Medication, MedicationRequest, MedicationStatement, Observation	List[CodeableConcept]	Y
	A	Person or agency who transported decedent to hospital	CauseOfDeath.CauseOfDeathCondition.context.participant.individual.name	Encounter.participant.individual.name	string	Y	Check for participant-type of "emergency" or "ADM" for admittance
	A	Date scene investigation was conducted by investigator (if done)
	A	Name of person who conducted scene visit or scene investigation
	A	Type of agonal treatment or therapy
	A	Time of examination or case review
	A	Death scene investigation findings
	A	Suspected Child Abuse		Condition.code, Procedure.code, Observation.code			Possible conceptset related to child abuse?
	A	Method of identification
	A	Recent falls or hip fracture		Encounter.code, Condition.code, Observation.code			Possible conceptset related to hip fracture?
	A	Deaths in Custody
	A	Time of scene visit by investigator [ARRIVAL TIME]
	A	Where decedent was last known to be alive or okay
	A	Who last knew decedent to be alive or okay
	A	Year by which case is categorized	CauseOfDeath.MannerOfDeath.effective	Observation.effectivedateTime	dateTime	Y
	A	If decedent was found dead or unconscious, who found decedent	CauseOfDeath.CauseOfDeathCondition.context.participant.individual.name
	A	Address at which scene investigation was conducted
	A	Name of next of kin who was contacted about the death
	A	Name of decedent's personal physician or health provider		Provider			Possibly multiple physicians
	A	Suspected Domestic Violence (FOR REPORTS, PROCEDURES & REFERRAL)
	A	Suspected Elder Abuse (FOR REPORTS, PROCEDURES & REFERRAL)
	A	Religious Objections
	A	Person conducting examination or case review	CauseOfDeath.AutopsyPerformed.performer.name.text	Practitioner.name.text	string	N
	A	Case number assigned to examination or review
	A	Qualification of certified date of death
	A	Title of certifier
	A	Specimen for which result is reported in ETOH [ALL DRUGS NOT JUST ETOH]
	A	Companion case numbers
	A	Name of or type of decedent residence		Patient, Address.name			Clarification about what the "type" of residence would be
	A	If unidentified, putative name if available
	A	Number assigned to police report by police department
	A	What samples are available		Observation, Specimen
	A	Case load per forensic pathologist
	A	Workflow/turnaround times
	A	Case number assigned to the death by medical examiner office
	A	NAME annual report statistics (e.g., exhumations, procurements declined, cremation approvals, etc.)
	A	Social security number		Patient.Identifier	Identifier	N	Only if Identifier matches SSN uri
	A	Usual occupation of decedent	Decedent.Decendent.sdr-decedent-occupation-extension.sdr-decednet-Job-extension, Decedent.Decendent.sdr-decedent-occupation-extension.sdr-decednet-Industry-extension		string	N
	B	Social history, including IV drug use, prison record
	B	Informants/Witnesses
	B	Person's name who pronounced death	DeathRecord.Certifier.name.text	Practitioner.name.text	string	N
	B	Was surgery performed?		CarePlan.code, Procedure.code	boolean	Y
	B	Date of surgery, if performed		CarePlan.code, Procedure.code,Procedure.performedDateTime	dateTime	N
	B	Safety Issues/ Mechanisms Identified at Scene
	B	Family Medical History		RelatedPerson, Patient, Condition.code	CodeableConcept	Y
	B	Information source for medical history
	B	Status of medication history investigation (INVENTORY, PDMP, ETC)
	B	Property - brought in, released, chain of custody
	B	RISK FACTORS FOR INDIVIDUAL CAUSES (SEATBELT, HELMET, CO-SLEEPING, ETC.)
Supporting Resource	B	Duration of condition on top line of cause of death	CauseOfDeath.CauseOfDeathCondition.onset, CauseOfDeath.CauseOfDeathCondition.abatement,	Condition.onset, Condition.abatement	Period	N
Supporting Resource	B	Duration of condition on second line of cause of death	CauseOfDeath.ContributedToDeathCondition.onset, CauseOfDeath.ContributedToDeathCondition.abatement	Condition.onset, Condition.abatement	Period	N
Supporting Resource	B	Duration of condition on third line of cause of death	CauseOfDeath.ContributedToDeathCondition.onset, CauseOfDeath.ContributedToDeathCondition.abatement	Condition.onset, Condition.abatement	Period	N
Supporting Resource	B	Duration of condition on fourth line of cause of death	CauseOfDeath.ContributedToDeathCondition.onset, CauseOfDeath.ContributedToDeathCondition.abatement	Condition.onset, Condition.abatement	Period	N
	B	Organ Weights
	B	Type of residence (e.g., halfway house, homeless, nursing homes, etc.)
	B	Response times
	B	Type of person pronouncing death (Police, EMS, etc.)
	B	Key words or phrases about the circumstances of the death
	C	Condition when found (dead, unconscious, or in distress)
	C	Status of ethanol testing and result
	C	Status of drug testing and qualitative results
	C	Number of other persons injured in this incident but not killed
	C	Procedures that result in case being held as pending
	C	Inherited diseases/genetics/other family members at risk
	C	Industry or trade of decedent's occupation	Decedent.Decendent.sdr-decedent-occupation-extension.sdr-decednet-Industry-extension			string	N
	C	Reasons for surgery, if performed		Procedure.reasonCode	CodeableConcept	N	Refer to https://www.hl7.org/fhir/valueset-procedure-reason.html for valueset
	C	Name of person or agency who transported body from death site
	C	Indication of whether physical evidence was submitted for analysis
	C	Categorization code for onset of fatal events
	C	Does an injury constitute NIOSH injury at work?
	C	Are toxicology results representative of time of fatal incident?
	C	Status of medical history investigation.
	C	Status of referral of case to other agencies.
	C	Time of refrigeration
	C	Who gave consent for donation/are there any restrictions
	C	Will donation be pre or post autopsy
	C	Person who reported death to the medical examiner
	C	Employment status of decedent	Decedent.Decendent.sdr-decedent-occupation-extension.sdr-decednet-Job-extension, Decedent.Decendent.sdr-decedent-occupation-extension.sdr-decednet-Industry-extension		string	N	Note; if not included, assume "Unemployed" for default
	C	Was decedent unidentified at time of death report?
	C	Name of person or agency who notified next of kin
	C	Date on which investigator's report was first filed
	C	Duration at Scene
	C	Budget (TOX, # HOURS, ETC. NEEDED TO FORMULATE BUDGET)
	C	Ambient Temp at Scene
	C	Case Peer Reviewed?
	C	Key words or phrases to categorize decedent
	C	Name of person who first received the death report
	C	Key words or phrases about the place of fatal event
	D	Apparent actual date of death (if known)	CauseOfDeath.DatePronouncedDead.value		dateTime	N
	D	Apparent actual time of death	CauseOfDeath.DatePronouncedDead.value		dateTime	N
	D	Apparent address where death actually occurred	CauseOfDeath.InjuryLocation, CauseOfDeath.CauseOfDeathCondition.context.location	Encounter.location	Address	Y	CauseOfDeathCondition.context must be of resource type "Encounter" and not "EpisodeOfCare"
	D	Aggregate Statistics
	D	MDI process questions
	D	Date of additions/change to electronic case record
	D	Demographics of Jurisdiction
	D	Accreditation Status of Office
	D	Time of certification or finalization
	D	License number of person pronouncing death
	D