This page is part of the Healthcare Associated Infection Reports (HAI) Long Term Care Facilities (LTCF) (v0.1.0: STU 1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions 
JSON Format: Questionnaire-hai-ltcf-questionnaire-mdro-cdi-event
Raw json
{
"resourceType" : "Questionnaire",
"id" : "hai-ltcf-questionnaire-mdro-cdi-event",
"meta" : {
"versionId" : "10",
"lastUpdated" : "2019-07-04T19:12:37.000-04:00"
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" lang=\"en-US\">\n <h1 xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">HAI Laboratory Identified MDRO or CDI Event Report for LTCF</h1>\n <p xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">\n <p>This Questionnaire instance records the laboratory identification of a MDRO or CDI microorganism. These reports are submitted if the LTCF is monitoring the organism specified. Each report records a single organism event. Information regarding the resident's care location, type of primary service and date of current admission are recorded. </p>\n <p>Key Encounter data in the report includes:</p>\n <ul>\n <li>The date of the current admission to the facility location where the specimen was collected.</li>\n <li>The date of specimen collection.</li>\n </ul>\n <p>Key Finding data in this report includes:</p>\n <ul>\n <li>Information on the type of organism and the date which it was collected.</li>\n </ul>\n <p>For further details see the NHSN website <a href=\"https://www.cdc.gov/nhsn/\">https://www.cdc.gov/nhsn/</a> for reporting healthcare-associated infections in long-term care facilities. The concepts reported in this Questionnaire are defined for the NHSN "<i>LabID Event Protocol for LTCF</i>" and the corresponding data collection form "<i>Laboratory-identified MDRO or CDI Event for LTCF (CDC 57.138)</i>".</p>\n </p>\n <h2 xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">Questionnaire Details</h2>\n <table xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">\n <tr>\n <td>\n <b>Id:</b>\n </td>\n <td>hai-ltcf-questionnaire-mdro-cdi-event</td>\n </tr>\n <tr>\n <td>\n <b>Meta:</b>\n </td>\n <td>\n <ul style=\"list-style:none; padding-left:0; margin:0 0;\">\n <li>10</li>\n <li>2019-07-04T19:12:37.000-04:00</li>\n <li>http://hl7.org/fhir/us/hai-ltcf/StructureDefinition/hai-single-person-report-questionnaire</li>\n </ul>\n </td>\n </tr>\n <tr>\n <td>\n <b>Language:</b>\n </td>\n <td>en-US</td>\n </tr>\n <tr>\n <td>\n <b>Url:</b>\n </td>\n <td>http://hl7.org/fhir/us/hai-ltcf/Questionnaire/hai-ltcf-questionnaire-mdro-cdi-event</td>\n </tr>\n <tr>\n <td>\n <b>Identifier:</b>\n </td>\n <td>\n <span>hai-questionnaire-los-event-v1</span>\n </td>\n </tr>\n <tr>\n <td>\n <b>Version:</b>\n </td>\n <td>Version: 1.0.0</td>\n </tr>\n <tr>\n <td>\n <b>Name:</b>\n </td>\n <td>HAI_LTCF_questionnaire_mdro_cdi_event</td>\n </tr>\n <tr>\n <td>\n <b>Status:</b>\n </td>\n <td>draft</td>\n </tr>\n <tr>\n <td>\n <b>Subject Type:</b>\n </td>\n <td>Patient</td>\n </tr>\n <tr>\n <td>\n <b>Date:</b>\n </td>\n <td>2019-08-01</td>\n </tr>\n <tr>\n <td>\n <b>Publisher:</b>\n </td>\n <td>HL7</td>\n </tr>\n <tr>\n <td>\n <b>Jurisdiction:</b>\n </td>\n <td>\n <span title=\"Code system: urn:iso:std:iso:3166\">Code: US</span>\n </td>\n </tr>\n <tr>\n <td>\n <b>Code:</b>\n </td>\n <td>\n <ul style=\"list-style:none; padding-left:0; margin:0 0;\">\n <li>Healthcare Associated Infection report Document</li>\n <li>Code system: <a href=\"http://loinc.org\">http://loinc.org</a>\n </li>\n <li>Code: 51897-7</li>\n </ul>\n </td>\n </tr>\n </table>\n <br xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\"/>\n <br xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\"/>\n <h2 xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">Questionnaire Items</h2>\n <table border=\"1\" xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">\n <tr>\n <th align=\"left\">Group</th>\n <th align=\"left\">text</th>\n <th align=\"left\">linkId</th>\n <th align=\"left\">type</th>\n <th align=\"left\">required</th>\n <th align=\"left\">repeats</th>\n <th align=\"left\">enableWhen</th>\n <th align=\"left\">answerValueSet</th>\n </tr>\n <tr>\n <td/>\n <td>Facility ID</td>\n <td>facility-id</td>\n <td>url</td>\n <td>true</td>\n <td>false</td>\n <td/>\n <td/>\n </tr>\n <tr>\n <td/>\n <td>Date of First Admission to Facility</td>\n <td>date-of-first-admission-to-facility</td>\n <td>date</td>\n <td>true</td>\n <td>false</td>\n <td/>\n <td/>\n </tr>\n <tr>\n <td/>\n <td>Date of Current Admission to Facility</td>\n <td>date-of-current-admission-to-facility</td>\n <td>date</td>\n <td>true</td>\n <td>false</td>\n <td/>\n <td/>\n </tr>\n <tr>\n <td colspan=\"8\">The Event Details Group records details about the event.</td>\n </tr>\n <tr>\n <td/>\n <td>Event Details</td>\n <td>event-details-group</td>\n <td>group</td>\n <td>true</td>\n <td>false</td>\n <td/>\n <td/>\n <tr>\n <td>Event Details</td>\n <td>Date Specimen Collected</td>\n <td>date-specimen-collected</td>\n <td>date</td>\n <td>true</td>\n <td>false</td>\n <td/>\n <td/>\n </tr>\n <tr>\n <td>Event Details</td>\n <td>Specimen Type</td>\n <td>specimen-type</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n <td/>\n <td>\n <a href=\"ValueSet-2.16.840.1.114222.4.11.3249.html\">http://hl7.org/fhir/us/hai-ltcf/ValueSet/2.16.840.1.114222.4.11.3249</a>\n </td>\n </tr>\n <tr>\n <td>Event Details</td>\n <td>Resident Care Location</td>\n <td>resident-care-location</td>\n <td>url</td>\n <td>true</td>\n <td>false</td>\n <td/>\n <td/>\n </tr>\n <tr>\n <td>Event Details</td>\n <td>Primary Resident Service Type</td>\n <td>primary-resident-service-type</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n <td/>\n <td>\n <a href=\"ValueSet-2.16.840.1.113883.10.20.5.1.5.9.3.html\">http://hl7.org/fhir/us/hai-ltcf/ValueSet/2.16.840.1.113883.10.20.5.1.5.9.3</a>\n </td>\n </tr>\n </tr>\n <tr>\n <td colspan=\"8\">The Encounters Group records the first admission date to the facility along with whether or not the resident was transferred from an acute care facility in the past four weeks.</td>\n </tr>\n <tr>\n <td/>\n <td>Encounters Group</td>\n <td>encounters-group</td>\n <td>group</td>\n <td>true</td>\n <td>true</td>\n <td/>\n <td/>\n <tr>\n <td>Encounters Group</td>\n <td>Transfer From Acute Care Facility to LTCF in Past Four Weeks</td>\n <td>transfer-from-acute-care-facility</td>\n <td>boolean</td>\n <td>true</td>\n <td>false</td>\n <td/>\n <td/>\n </tr>\n <tr>\n <td>Encounters Group</td>\n <td>Date of Last Transfer From Acute Care to LTCF</td>\n <td>date-of-last-transfer</td>\n <td>date</td>\n <td>false</td>\n <td>false</td>\n <td>transfer-from-acute-care-facility="true"</td>\n <td/>\n </tr>\n <tr>\n <td>Encounters Group</td>\n <td>Resident on Antibiotic Therapy for Specific Organism at Time of Transfer to Facility</td>\n <td>antibiotic-at-time-of-transfer</td>\n <td>boolean</td>\n <td>false</td>\n <td>false</td>\n <td>transfer-from-acute-care-facility="true"</td>\n <td/>\n </tr>\n </tr>\n <tr>\n <td colspan=\"8\">The Findings Group records a laboratory-identified microorganism. It records one microorganism (if more were identified, each is recorded in a separate QuestionnaireResponse), and details about the specimen collection.</td>\n </tr>\n <tr>\n <td/>\n <td>Findings Group</td>\n <td>findings-group</td>\n <td>group</td>\n <td>true</td>\n <td>true</td>\n <td/>\n <td/>\n <tr>\n <td>Findings Group</td>\n <td>Specific Organism Type</td>\n <td>specific-organism-type</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n <td/>\n <td>\n <a href=\"ValueSet-2.16.840.1.114222.4.11.3194.html\">http://hl7.org/fhir/us/hai-ltcf/ValueSet/2.16.840.1.114222.4.11.3194</a>\n </td>\n </tr>\n </tr>\n <tr>\n <td/>\n <td>Comments</td>\n <td>nhsn-comment</td>\n <td>text</td>\n <td>false</td>\n <td>false</td>\n <td/>\n <td/>\n </tr>\n </table>\n </div>"
},
"url" : "http://hl7.org/fhir/us/hai-ltcf/Questionnaire/hai-ltcf-questionnaire-mdro-cdi-event",
"identifier" : [
{
"value" : "hai-questionnaire-los-event-v1"
}
],
"version" : "1.0.0",
"name" : "HAI_LTCF_questionnaire_mdro_cdi_event",
"title" : "HAI Laboratory Identified MDRO or CDI Event Report for LTCF",
"status" : "draft",
"subjectType" : [
"Patient"
],
"date" : "2019-08-01",
"publisher" : "HL7",
"description" : "This Questionnaire instance records the laboratory identification of a MDRO or CDI microorganism. These reports are submitted if the LTC facility is monitoring the organism specified. Each report records a single organism event. Information regarding the resident's care location, type of primary service and date of current admission are recorded. \n\nKey Encounter data in the report includes:\n* The date of the current admission to the facility location where the specimen was collected.\n* The date of specimen collection.\nKey Finding data in this report includes:\n* Inormation on the type of organism and the date which it was collected.\n\nFor further details see the NHSN website [https://www.cdc.gov/nhsn/](https://www.cdc.gov/nhsn/) for reporting healthcare-associated infections in long-term care facilities. The concepts reported in this Questionnaire are defined for the NHSN \"*LabID Event Protocol for LTCF*\" and the corresponding data collection form \"*57.138 LabID Event Form for LTCF*\".\n",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US"
}
]
}
],
"code" : [
{
"system" : "http://loinc.org",
"code" : "51897-7",
"display" : "Healthcare Associated Infection report Document"
}
],
"item" : [
{
"linkId" : "facility-id",
"text" : "Facility ID",
"type" : "url",
"required" : true,
"repeats" : false
},
{
"linkId" : "date-of-first-admission-to-facility",
"text" : "Date of First Admission to Facility",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "date-of-current-admission-to-facility",
"text" : "Date of Current Admission to Facility",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "event-details-group",
"code" : [
{
"system" : "http://loinc.org",
"code" : "51899-3",
"display" : "Details Document"
}
],
"text" : "Event Details Group",
"type" : "group",
"required" : true,
"repeats" : false,
"item" : [
{
"linkId" : "event-details-group-display",
"text" : "The Event Details Group records details about the event.",
"type" : "display"
},
{
"linkId" : "date-specimen-collected",
"text" : "Date Specimen Collected",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "specimen-type",
"text" : "Specimen Type",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai-ltcf/ValueSet/2.16.840.1.114222.4.11.3249"
},
{
"linkId" : "resident-care-location",
"text" : "Resident Care Location",
"type" : "url",
"required" : true,
"repeats" : false
},
{
"linkId" : "primary-resident-service-type",
"text" : "Primary Resident Service Type",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai-ltcf/ValueSet/2.16.840.1.113883.10.20.5.1.5.9.3"
}
]
},
{
"linkId" : "encounters-group",
"code" : [
{
"system" : "http://loinc.org",
"code" : "46240-8",
"display" : "Hx of Hospitalizations+OP visits"
}
],
"text" : "Encounters Group",
"type" : "group",
"required" : true,
"repeats" : true,
"item" : [
{
"linkId" : "encounters-group-display",
"text" : "The Encounters Group records the first admission date to the facility along with whether or not the resident was transferred from an acute care facility in the past four weeks.",
"type" : "display"
},
{
"linkId" : "transfer-from-acute-care-facility",
"text" : "Transfer From Acute Care Facility to LTCF in Past Four Weeks",
"type" : "boolean",
"required" : true,
"repeats" : false
},
{
"linkId" : "date-of-last-transfer",
"text" : "Date of Last Transfer From Acute Care to LTCF",
"type" : "date",
"enableWhen" : [
{
"question" : "transfer-from-acute-care-facility",
"operator" : "=",
"answerBoolean" : true
}
],
"required" : false,
"repeats" : false
},
{
"linkId" : "antibiotic-at-time-of-transfer",
"text" : "Resident on Antibiotic Therapy for Specific Organism at Time of Transfer to Facility",
"type" : "boolean",
"enableWhen" : [
{
"question" : "transfer-from-acute-care-facility",
"operator" : "=",
"answerBoolean" : true
}
],
"required" : false,
"repeats" : false
}
]
},
{
"linkId" : "findings-group",
"code" : [
{
"system" : "http://loinc.org",
"code" : "18769-0",
"display" : "Microbial susceptibility tests Set"
}
],
"text" : "Findings Group",
"type" : "group",
"required" : true,
"repeats" : true,
"item" : [
{
"linkId" : "findings-group-display",
"text" : "The Findings Group records a laboratory-identified microorganism. It records one microorganism (if more were identified, each is recorded in a separate QuestionnaireResponse), and details about the specimen collection.",
"type" : "display"
},
{
"linkId" : "specific-organism-type",
"text" : "Specific Organism Type",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai-ltcf/ValueSet/2.16.840.1.114222.4.11.3194"
}
]
},
{
"linkId" : "nhsn-comment",
"code" : [
{
"system" : "http://www.loinc.org",
"code" : "86468-6",
"display" : "Report Comment Section"
}
],
"text" : "Comments",
"type" : "text",
"required" : false,
"repeats" : false,
"maxLength" : 2000
}
]
}
