DSTU2
This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
LOINC perspective on the AHRQ form found in the SDC - Combination set of questionnaires (id = "questionnaire-sdc-profile-example-loinc")
<Questionnaire xmlns="http://hl7.org/fhir"> <id value="questionnaire-sdc-profile-example-loinc"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">Todo</div> </text> <contained> <ValueSet> <id value="ll2654-3"/> <name value="AHRQ_Medication_Q1"/> <status value="active"/> <description value="The answer list for question 1 on the AHRQ "Medication or Other Substance" form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org"/> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="1"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="a."/> </extension> <code value="LA20271-5"/> <display value="Medications"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="2"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="b."/> </extension> <code value="LA20335-8"/> <display value="Biological products"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="3"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="c."/> </extension> <code value="LA20336-6"/> <display value="Nutritional products"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="4"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="d."/> </extension> <code value="LA20337-4"/> <display value="Expressed human breast milk"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="5"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="e."/> </extension> <code value="LA20338-2"/> <display value="Medical gases (e.g., oxygen, nitrogen, nitrous oxide)"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="6"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="f."/> </extension> <code value="LA20339-0"/> <display value="Contrast media"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="7"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="g."/> </extension> <code value="LA20340-8"/> <display value="Radiopharmaceuticals"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="8"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="h."/> </extension> <code value="LA20341-6"/> <display value="Patient food (not suspected in drug-food interactions)"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="9"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="i."/> </extension> <code value="LA20342-4"/> <display value="Drug-drug, drug-food, or adverse drug reaction as a result of a prescription and/or administration of a drug and/or food prior to admission"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="10"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="j."/> </extension> <code value="LA20343-2"/> <display value="Other"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2655-0"/> <name value="AHRQ_Medication_Q2"/> <status value="active"/> <description value="The answer list for question 2 on the AHRQ "Medication or Other Substance" form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org/vs/LL2655-0"/> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="1"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="a."/> </extension> <code value="LA20278-0"/> <display value="Prescription or over-the-counter (including herbal supplements)"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="2"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="b."/> </extension> <code value="LA20298-8"/> <display value="Compounded preparations"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="3"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="c."/> </extension> <code value="LA20299-6"/> <display value="Investigational drugs"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="4"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="d."/> </extension> <code value="LA4489-6"/> <display value="Unknown"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2657-6"/> <name value="AHRQ_Medication_Q4"/> <status value="active"/> <description value="The answer list for question 4 on the AHRQ "Medication or Other Substance" form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org/vs/LL2657-6"/> <concept> <code value="LA20283-0"/> <display value="Vaccines"/> </concept> <concept> <code value="LA20287-1"/> <display value="Other biological products (e.g., thrombolytic)"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2659-2"/> <name value="AHRQ_Medication_Q6"/> <status value="active"/> <description value="The answer list for question 6 on the AHRQ "Medication or Other Substance" form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org"/> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="1"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="a."/> </extension> <code value="LA20273-1"/> <display value="Dietary supplements (other than vitamins or minerals)"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="2"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="b."/> </extension> <code value="LA16117-6"/> <display value="Vitamins or minerals"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="3"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="c."/> </extension> <code value="LA20320-0"/> <display value="Enteral nutritional products, including infant formula"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="4"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="d."/> </extension> <code value="LA20321-8"/> <display value="Parenteral nutritional products"/> </concept> <concept> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder"> <valueInteger value="5"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-label"> <valueString value="e."/> </extension> <code value="LA20318-4"/> <display value="Other"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2660-0"/> <name value="AHRQ_Medication_Q7"/> <status value="active"/> <description value="The answer list for question 7 on the AHRQ 'Medication or Other Substance' form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org"/> <concept> <code value="LA20275-6"/> <display value="Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication)"> <extension url="http://hl7.org/fhir/StructureDefinition/markup"> <valueString value="Incorrect action (process failure or error) <i>(e.g., such as administering overdose or incorrect medication)</i>"/> </extension> </display> </concept> <concept> <code value="LA20314-3"/> <display value="Unsafe condition"> <extension url="http://hl7.org/fhir/StructureDefinition/style"> <valueString value="color:green"/> </extension> </display> </concept> <concept> <code value="LA20315-0"/> <display value="Adverse reaction in patient to the administered substance without any apparent incorrect action"/> </concept> <concept> <code value="LA4489-6"/> <display value="Unknown"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2661-8"/> <name value="AHRQ_Medication_Q8"/> <status value="active"/> <description value="The answer list for question 8 on the AHRQ 'Medication or Other Substance' form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org"/> <concept> <code value="LA20276-4"/> <display value="Incorrect patient"/> </concept> <concept> <code value="LA20302-8"/> <display value="Incorrect medication/substance"/> </concept> <concept> <code value="LA20303-6"/> <display value="Incorrect dose(s)"/> </concept> <concept> <code value="LA20304-4"/> <display value="Incorrect route of administration"/> </concept> <concept> <code value="LA20305-1"/> <display value="Incorrect timing"/> </concept> <concept> <code value="LA20306-9"/> <display value="Incorrect rate"/> </concept> <concept> <code value="LA20307-7"/> <display value="Incorrect duration of administration or course of therapy"/> </concept> <concept> <code value="LA20308-5"/> <display value="Incorrect dosage form (e.g., sustained release instead of immediate release)"/> </concept> <concept> <code value="LA20309-3"/> <display value="Incorrect strength or concentration"/> </concept> <concept> <code value="LA20310-1"/> <display value="Incorrect preparation, including inappropriate cutting of tablets, error in compounding, mixing, etc."/> </concept> <concept> <code value="LA20311-9"/> <display value="Expired or deteriorated medication/substance"/> </concept> <concept> <code value="LA20312-7"/> <display value="Medication/substance that is known to be an allergen to the patient"/> </concept> <concept> <code value="LA20345-7"/> <display value="Medication/substance that is known to be contraindicated for the patient"/> </concept> <concept> <code value="LA20313-5"/> <display value="Incorrect patient/family action (e.g., self-administration error)"/> </concept> <concept> <code value="LA20318-4"/> <display value="Other"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2662-6"/> <name value="AHRQ_Medication_Q9"/> <status value="active"/> <description value="The answer list for question 9 on the AHRQ 'Medication or Other Substance' form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org/vs/LL2662-6"/> <concept> <code value="LA20277-2"/> <display value="Overdose"/> </concept> <concept> <code value="LA20300-2"/> <display value="Underdose"/> </concept> <concept> <code value="LA20301-0"/> <display value="Missed or omitted dose"/> </concept> <concept> <code value="LA7271-5"/> <display value="Extra dose"/> </concept> <concept> <code value="LA4489-6"/> <display value="Unknown"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2663-4"/> <name value="AHRQ_Medication_Q10"/> <status value="active"/> <description value="The answer list for question 10 on the AHRQ 'Medication or Other Substance' form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org/vs/LL2663-4"/> <concept> <code value="LA20280-6"/> <display value="Too early"/> </concept> <concept> <code value="LA20290-5"/> <display value="Too late"/> </concept> <concept> <code value="LA4489-6"/> <display value="Unknown"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2664-2"/> <name value="AHRQ_Medication_Q11"/> <status value="active"/> <description value="The answer list for question 11 on the AHRQ 'Medication or Other Substance' form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org/vs/LL2664-2"/> <concept> <code value="LA20282-2"/> <display value="Too quickly"/> </concept> <concept> <code value="LA20288-"/> <display value="Too slowly"/> </concept> <concept> <code value="LA4489-6"/> <display value="Unknown"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2665-9"/> <name value="AHRQ_Medication_Q12"/> <status value="active"/> <description value="The answer list for question 12 on the AHRQ 'Medication or Other Substance' form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org/vs/LL2665-9"/> <concept> <code value="LA20281-4"/> <display value="Too high"/> </concept> <concept> <code value="LA20289-7"/> <display value="Too low"/> </concept> <concept> <code value="LA4489-6"/> <display value="Unknown"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2817-6"/> <name value="AHRQ_Y/N/UNK"/> <status value="active"/> <description value="AHRQ Common Format Answer list for Yes (A15), No (A18), Unknown (UNK)"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org/vs/LL2817-6"/> <concept> <code value="LA33-6"/> <display value="Yes"/> </concept> <concept> <code value="LA32-8"/> <display value="No"/> </concept> <concept> <code value="LA4489-6"/> <display value="Unkown"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2668-3"/> <name value="AHRQ_Medication_Q15"/> <status value="active"/> <description value="The answer list for question 15 on the AHRQ 'Medication or Other Substance' form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org/vs/LL2668-3"/> <concept> <code value="LA20274-9"/> <display value="Drug-drug"/> </concept> <concept> <code value="LA20316-8"/> <display value="Drug-food"/> </concept> <concept> <code value="LA20317-6"/> <display value="Drug-disease"/> </concept> <concept> <code value="LA20318-4"/> <display value="Other"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2669-1"/> <name value="AHRQ_Medication_Q16"/> <status value="active"/> <description value="The answer list for question 16 on the AHRQ 'Medication or Other Substance' form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org/vs/LL2669-1"/> <concept> <code value="LA20279-8"/> <display value="Purchasing"/> </concept> <concept> <code value="LA20291-3"/> <display value="Storing"/> </concept> <concept> <code value="LA20292-1"/> <display value="Prescribing/ordering"/> </concept> <concept> <code value="LA20293-9"/> <display value="Transcribing"/> </concept> <concept> <code value="LA20294-7"/> <display value="Preparing"/> </concept> <concept> <code value="LA20295-4"/> <display value="Dispensing"/> </concept> <concept> <code value="LA20296-2"/> <display value="Administering"/> </concept> <concept> <code value="LA20297-0"/> <display value="Monitoring"/> </concept> <concept> <code value="LA4489-6"/> <display value="Unknown"/> </concept> <concept> <code value="LA20318-4"/> <display value="Other"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2828-3"/> <name value="AHRQ_Y/N"/> <status value="active"/> <description value="AHRQ Common Format Answer list for Yes (A15) and No (A18)"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org/vs/LL2828-3"/> <concept> <code value="LA33-6"/> <display value="Yes"/> </concept> <concept> <code value="LA32-8"/> <display value="No"/> </concept> </include> </compose> </ValueSet> </contained> <contained> <ValueSet> <id value="ll2682-4"/> <name value="AHRQ_Medication_Q28_Q29"/> <status value="active"/> <description value="The answer list for questions 28 and 29 on the AHRQ 'Medication or Other Substance' form"/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use"/> <compose> <include> <system value="http://loinc.org"/> <concept> <code value="LA20272-3"/> <display value="Cutaneous, topical application, including ointment, spray, patch"/> </concept> <concept> <code value="LA9451-1"/> <display value="Subcutaneous"/> </concept> <concept> <code value="LA9444-6"/> <display value="Ophthalmic"/> </concept> <concept> <code value="LA20324-2"/> <display value="Oral, including sublingual or buccal"/> </concept> <concept> <code value="LA9445-"/> <display value="Otic"/> </concept> <concept> <code value="LA9263-0"/> <display value="Nasal"/> </concept> <concept> <code value="LA9427-1"/> <display value="Inhalation"/> </concept> <concept> <code value="LA9437-0"/> <display value="Intravenous"/> </concept> <concept> <code value="LA9429-7"/> <display value="Intramuscular"/> </concept> <concept> <code value="LA9435-4"/> <display value="Intrathecal"/> </concept> <concept> <code value="LA9418-0"/> <display value="Epidural"/> </concept> <concept> <code value="LA20332-5"/> <display value="Gastric"/> </concept> <concept> <code value="LA9369-5"/> <display value="Rectal"/> </concept> <concept> <code value="LA9459-4"/> <display value="Vaginal"/> </concept> <concept> <code value="LA4489-6"/> <display value="Unknown"/> </concept> <concept> <code value="LA20318-4"/> <display value="Other"/> </concept> </include> </compose> </ValueSet> </contained> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-category"> <valueCodeableConcept> <coding> <code value="Acute Care Hospitals"/> </coding> </valueCodeableConcept> </extension> <identifier> <system value="http://loinc.org/vs"/> <value value="74080-3"/> </identifier> <status value="published"/> <date value="2012-04-01"/> <publisher value="Agency for Healthcare Research and Quality (AHRQ)"/> <subjectType value="Patient"/> <group> <linkId value="root"/> <title value="Medication or Other Substance"> <extension url="http://hl7.org/fhir/StructureDefinition/style"> <valueString value="color:#0000FF"/> </extension> </title> <required value="true"/> <group> <extension url="http://hl7.org/fhir/StructureDefinition/sdc-questionnaire-specialGroup"> <valueCode value="header"/> </extension> <linkId value="Medication/header"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-defaultValue"> <valueString value="AHRQ F8"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-readOnly"> <valueBoolean value="true"/> </extension> <text value="Form ID:"/> <type value="string"/> <required value="true"/> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="3"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="9"/> </extension> <linkId value="74080-3/74081-1"/> <text value="Event ID:"/> <type value="string"/> <required value="true"/> </question> <question> <linkId value="74080-3/30947-6"/> <text value="Initial Report Date (HERF Q1)"/> <type value="string"/> <required value="true"/> </question> </group> <group> <linkId value="Medication/SEC00"/> <title value="Medication or Other Substance"/> <text value="Use this form to report any patient safety event or unsafe condition involving a substance such as a medications, biological products, nutritional products, expressed human breast milk, medical gases, or contrast media. Do not complete this form if the event involves appropriateness of therapeutic choice or decision making (e.g., physician decision to prescribe medication despite known drug-drug interaction). If the event involves a device, please also complete the Device or Medical/Surgical Supply including Health Information Technology (HIT) form. Narrative detail can be captured on the Healthcare Event Reporting Form (HERF)."> <extension url="http://hl7.org/fhir/StructureDefinition/markup"> <valueString value="Use this form to report any patient safety event or unsafe condition involving a substance such as a medications, biological products, nutritional products, expressed human breast milk, medical gases, or contrast media. Do not complete this form if the event involves appropriateness of therapeutic choice or decision making (e.g., physician decision to prescribe medication despite known drug-drug interaction). If the event involves a device, please also complete the <i>Device or Medical/Surgical Supply including Health Information Technology (HIT)</i> form. Narrative detail can be captured on the <i>Healthcare Event Reporting Form (HERF)</i>."/> </extension> </text> <group> <linkId value="Medication/SEC01/74080-3"/> <required value="true"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="1."/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="1"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="30"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-deReference"> <valueReference> <reference value="http://loinc.org/74076-1"/> </valueReference> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-instruction"> <valueString value="CHECK ONE"/> </extension> <linkId value="74080-3/74076-1"/> <text value="What type of medication/substance was involved?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="ValueSet/sdc"/> </options> <group> <linkId value="74080-3/74076-1/LA20271-5"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="2."/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="7"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-deReference"> <valueReference> <reference value="http://loinc.org/vs/74075-3"/> </valueReference> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-instruction"> <valueString value="CHECK ONE"/> </extension> <linkId value="74080-3/74075-3"/> <text value="What type of medication?"/> <type value="choice"/> <required value="true"/> <options> <reference value="#ll2655-0"/> </options> <group> <linkId value="74080-3/74077-9"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="3."/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="0"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="500"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-deReference"> <valueReference> <reference value="http://loinc.org/74077-9"/> </valueReference> </extension> <linkId value="74080-3/74077-9-q"/> <text value="Please list all ingredients:"/> <type value="string"/> <repeats value="true"/> </question> </group> </question> </group> <group> <linkId value="74080-3/74076-1/LA20335-8"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="4."/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="8"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <linkId value="74080-3/74074-6"/> <text value="What type of biological product?"/> <type value="open-choice"/> <options> <reference value="#ll2657-6"/> </options> <group> <linkId value="74080-3/74074-6/LA20283-0"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="5."/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-trailing"> <valueString value="LOT NUMBER"/> </extension> <linkId value="74080-3/30959-1"/> <text value="What was the lot number of the vaccine?"/> <type value="string"/> <required value="true"/> </question> </group> </question> </group> <group> <linkId value="74080-3/74076-1/LA20336-6"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="6."/> </extension> <linkId value="74080-3/74073-8"/> <text value="What type of nutritional product?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2659-2"/> </options> <group> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"> <extension url="question"> <valueString value="74080-3/74073-8"/> </extension> <extension url="answer"> <valueCoding> <system value="http://loinc.org"/> <code value="LA20318-4"/> <display value="Other"/> </valueCoding> </extension> </extension> <linkId value="74080-3/74073-8/Other"/> <required value="true"/> <question> <linkId value="74080-3/74073-8/Other/Specify"/> <text value="PLEASE SPECIFY"/> <type value="string"/> <required value="true"/> </question> </group> </question> </group> <group> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"> <extension url="question"> <valueString value="74080-3/74076-1"/> </extension> <extension url="answer"> <valueCoding> <system value="http://loinc.org"/> <code value="LA20318-4"/> <display value="Other"/> </valueCoding> </extension> </extension> <linkId value="74080-3/74076-1/Other"/> <required value="true"/> <question> <linkId value="74080-3/74076-1/Other/Specify"/> <text value="PLEASE SPECIFY"/> <type value="string"/> <required value="true"/> </question> </group> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="7."/> </extension> <linkId value="74080-3/74072-0"/> <text value="Which of the following best characterizes the event?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2660-0"/> </options> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="8."/> </extension> <linkId value="74080-3/74071-2"/> <text value="What was the incorrect action?"/> <type value="choice"/> <options> <reference value="#ll2661-8"/> </options> <group> <linkId value="74080-3/74071-2/A1275"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="9."/> </extension> <linkId value="74080-3/74070-4"/> <text value="Which best describes the incorrect dose(s)?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2662-6"/> </options> </question> </group> <group> <linkId value="74080-3/74071-2/LA20313-5"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="10."/> </extension> <linkId value="Medication/74069-6"/> <text value="Which best describes the incorrect timing?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2663-4"/> </options> </question> </group> <group> <linkId value="74080-3/74071-2/LA20306-9"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="11."/> </extension> <linkId value="74080-3/74068-8"/> <text value="Which best describes the incorrect rate?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2664-2"/> </options> </question> </group> <group> <linkId value="74080-3/74071-2/LA20309-3"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="12."/> </extension> <linkId value="Medication/74067-0"/> <text value="Which best describes the incorrect strength or concentration?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2665-9"/> </options> </question> </group> <group> <linkId value="74080-3/74071-2/LA20311-9"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="13."/> </extension> <linkId value="Medication/74066-2"/> <text value="What was the expiration date?"/> <type value="string"/> <required value="true"/> </question> </group> <group> <linkId value="74080-3/74071-2/LA20312-7"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="14."/> </extension> <linkId value="Medication/74065-4"/> <text value="Was there a documented history of allergies or sensitivities to the medication/substance administered?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2817-6"/> </options> </question> </group> <group> <linkId value="74080-3/74071-2/LA20345-7"/> <required value="false"/> <repeats value="false"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="15."/> </extension> <linkId value="Medication/74064-7"/> <text value="What was the contraindication (potential or actual interaction)?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2668-3"/> </options> <group> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"> <extension url="question"> <valueString value="Medication/74064-7"/> </extension> <extension url="answer"> <valueCoding> <system value="http://loinc.org"/> <code value="LA20318-4"/> <display value="Other"/> </valueCoding> </extension> </extension> <linkId value="Medication/74064-7/Other"/> <required value="true"/> <question> <linkId value="Medication/74064-7/Other/Specify"/> <text value="PLEASE SPECIFY"/> <type value="string"/> <required value="true"/> </question> </group> </question> </group> <group> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"> <extension url="question"> <valueString value="74080-3/74071-2"/> </extension> <extension url="answer"> <valueCoding> <system value="http://loinc.org"/> <code value="LA20318-4"/> <display value="Other"/> </valueCoding> </extension> </extension> <linkId value="74080-3/74071-2/Other"/> <required value="true"/> <question> <linkId value="74080-3/74071-2/Other/Specify"/> <text value="PLEASE SPECIFY"/> <type value="string"/> <required value="true"/> </question> </group> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="16."/> </extension> <linkId value="74080-3/74063-9"/> <text value="At what stage in the process did the event originate, regardless of the stage at which it was discovered?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2669-1"/> </options> <group> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"> <extension url="question"> <valueString value="74080-3/74063-9"/> </extension> <extension url="answer"> <valueCoding> <system value="http://loinc.org"/> <code value="LA20318-4"/> <display value="Other"/> </valueCoding> </extension> </extension> <linkId value="74080-3/74063-9/Other"/> <required value="true"/> <question> <linkId value="74080-3/74063-9/Other/Specify"/> <text value="PLEASE SPECIFY"/> <type value="string"/> <required value="true"/> </question> </group> </question> </group> <group> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs"> <valueInteger value="5"/> </extension> <linkId value="74080-3/74078-7"/> <text value="Please provide the following medication details for any medications or other substances directly involved in the event."/> <repeats value="true"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="17."/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="0"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <linkId value="74080-3/74078-7/74062-1"/> <text value="Generic name or investigational drug name"/> <type value="string"/> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="0"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <linkId value="74080-3/74078-7/74061-3"/> <text value="Ingredient RXCUI (if known)"/> <type value="string"/> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="18."/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="0"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <linkId value="74080-3/74078-7/74060-5"/> <text value="Brand name (if known)"/> <type value="string"/> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="0"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <linkId value="74080-3/74078-7/74059-7"/> <text value="Brand name RXCUI (if known)"/> <type value="string"/> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="19."/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="0"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <linkId value="74080-3/74078-7/74058-9"/> <text value="Manufacturer (if known)"/> <type value="string"/> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="20."/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="0"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <linkId value="74080-3/74078-7/74057-1"/> <text value="Strength or concentration of product"/> <type value="string"/> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="0"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <linkId value="74080-3/74078-7/74056-3"/> <text value="Clinical drug component RXCUI (if known)"/> <type value="string"/> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="21."/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="0"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <linkId value="74080-3/74078-7/74055-5"/> <text value="Dosage form of Product"/> <type value="string"/> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="0"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-maxLength"> <valueInteger value="65"/> </extension> <linkId value="74080-3/74078-7/74054-8"/> <text value="Dose form RXCUI (if known)"/> <type value="string"/> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="22."/> </extension> <linkId value="74080-3/74078-7/74053-0"/> <text value="Was this medication/substance prescribed for this patient?"/> <type value="choice"/> <required value="true"/> <options> <reference value="#ll2828-3"/> </options> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="23."/> </extension> <linkId value="Medication/74052-2"/> <text value="Was this medication/substance given to this patient?"/> <type value="choice"/> <required value="true"/> <options> <reference value="#ll2828-3"/> </options> </question> </group> <group> <linkId value="Medication/SEC03"/> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="24."/> </extension> <linkId value="74080-3/74051-4"/> <text value="What was the intended route of administration?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2682-4"/> </options> <group> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"> <extension url="question"> <valueString value="74080-3/74051-4"/> </extension> <extension url="answer"> <valueCoding> <system value="http://loinc.org"/> <code value="LA20318-4"/> <display value="Other"/> </valueCoding> </extension> </extension> <linkId value="74080-3/74051-4/Other"/> <required value="true"/> <question> <linkId value="74080-3/74051-4/Other/Specify"/> <text value="PLEASE SPECIFY"/> <type value="string"/> <required value="true"/> </question> </group> </question> <question> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-label"> <valueString value="25."/> </extension> <linkId value="74080-3/74050-6"/> <text value="What was the actual route of administration (attempted or completed)?"/> <type value="open-choice"/> <required value="true"/> <options> <reference value="#ll2682-4"/> </options> <group> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-enableWhen"> <extension url="question"> <valueString value="74080-3/74050-6"/> </extension> <extension url="answer"> <valueCoding> <system value="http://loinc.org"/> <code value="LA20318-4"/> <display value="Other"/> </valueCoding> </extension> </extension> <linkId value="74080-3/74050-6/Other"/> <required value="true"/> <question> <linkId value="74080-3/74050-6/Other/Specify"/> <text value="PLEASE SPECIFY"/> <type value="string"/> <required value="true"/> </question> </group> </question> </group> <group> <linkId value="Medication/SEC04"/> <title value="Thank you for completing these questions."/> <text value="OMB No. 0935-0143 Exp. Date 10/31/2014 Public reporting burden for the collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850."/> </group> </group> <group> <!-- This group was added for demonstration purposes and is not part of the base form --> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true"/> </extension> <linkId value="Reporting"/> <title value="Reporting information"/> <question> <linkId value="Reporting/who"/> <text value="Reported by:"/> <type value="string"/> </question> <question> <linkId value="Reporting/when"/> <text value="Reported date:"/> <type value="date"/> </question> </group> <group> <extension url="http://hl7.org/fhir/StructureDefinition/sdc-questionnaire-specialGroup"> <valueCode value="footer"/> </extension> <linkId value="Medication/footer"/> <text value="AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance"/> </group> </group> </Questionnaire>
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:44+1100.
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