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 
XML Format: Questionnaire-hai-ltcf-questionnaire-mdro-cdi-event
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<Questionnaire xmlns="http://hl7.org/fhir"> <id value="hai-ltcf-questionnaire-mdro-cdi-event"/> <!-- **TODO** This needs to be un-commented once the HAI has been published (before publication of the HAI-LTCF IG) --> <!-- <profile value="http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire"/> --> <meta> <versionId value="10"/> <lastUpdated value="2019-07-04T19:12:37.000-04:00"/> </meta> <language value="en-US"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml" lang="en-US"> <h1 xmlns:xsl="http://www.w3.org/1999/XSL/Transform">HAI Laboratory Identified MDRO or CDI Event Report for LTCF</h1> <p xmlns:xsl="http://www.w3.org/1999/XSL/Transform"> <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> <p>Key Encounter data in the report includes:</p> <ul> <li>The date of the current admission to the facility location where the specimen was collected.</li> <li>The date of specimen collection.</li> </ul> <p>Key Finding data in this report includes:</p> <ul> <li>Information on the type of organism and the date which it was collected.</li> </ul> <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> </p> <h2 xmlns:xsl="http://www.w3.org/1999/XSL/Transform">Questionnaire Details</h2> <table xmlns:xsl="http://www.w3.org/1999/XSL/Transform"> <tr> <td> <b>Id:</b> </td> <td>hai-ltcf-questionnaire-mdro-cdi-event</td> </tr> <tr> <td> <b>Meta:</b> </td> <td> <ul style="list-style:none; padding-left:0; margin:0 0;"> <li>10</li> <li>2019-07-04T19:12:37.000-04:00</li> <li>http://hl7.org/fhir/us/hai-ltcf/StructureDefinition/hai-single-person-report-questionnaire</li> </ul> </td> </tr> <tr> <td> <b>Language:</b> </td> <td>en-US</td> </tr> <tr> <td> <b>Url:</b> </td> <td>http://hl7.org/fhir/us/hai-ltcf/Questionnaire/hai-ltcf-questionnaire-mdro-cdi-event</td> </tr> <tr> <td> <b>Identifier:</b> </td> <td> <span>hai-questionnaire-los-event-v1</span> </td> </tr> <tr> <td> <b>Version:</b> </td> <td>Version: 1.0.0</td> </tr> <tr> <td> <b>Name:</b> </td> <td>HAI_LTCF_questionnaire_mdro_cdi_event</td> </tr> <tr> <td> <b>Status:</b> </td> <td>draft</td> </tr> <tr> <td> <b>Subject Type:</b> </td> <td>Patient</td> </tr> <tr> <td> <b>Date:</b> </td> <td>2019-08-01</td> </tr> <tr> <td> <b>Publisher:</b> </td> <td>HL7</td> </tr> <tr> <td> <b>Jurisdiction:</b> </td> <td> <span title="Code system: urn:iso:std:iso:3166">Code: US</span> </td> </tr> <tr> <td> <b>Code:</b> </td> <td> <ul style="list-style:none; padding-left:0; margin:0 0;"> <li>Healthcare Associated Infection report Document</li> <li>Code system: <a href="http://loinc.org">http://loinc.org</a> </li> <li>Code: 51897-7</li> </ul> </td> </tr> </table> <br xmlns:xsl="http://www.w3.org/1999/XSL/Transform"/> <br xmlns:xsl="http://www.w3.org/1999/XSL/Transform"/> <h2 xmlns:xsl="http://www.w3.org/1999/XSL/Transform">Questionnaire Items</h2> <table border="1" xmlns:xsl="http://www.w3.org/1999/XSL/Transform"> <tr> <th align="left">Group</th> <th align="left">text</th> <th align="left">linkId</th> <th align="left">type</th> <th align="left">required</th> <th align="left">repeats</th> <th align="left">enableWhen</th> <th align="left">answerValueSet</th> </tr> <tr> <td/> <td>Facility ID</td> <td>facility-id</td> <td>url</td> <td>true</td> <td>false</td> <td/> <td/> </tr> <tr> <td/> <td>Date of First Admission to Facility</td> <td>date-of-first-admission-to-facility</td> <td>date</td> <td>true</td> <td>false</td> <td/> <td/> </tr> <tr> <td/> <td>Date of Current Admission to Facility</td> <td>date-of-current-admission-to-facility</td> <td>date</td> <td>true</td> <td>false</td> <td/> <td/> </tr> <tr> <td colspan="8">The Event Details Group records details about the event.</td> </tr> <tr> <td/> <td>Event Details</td> <td>event-details-group</td> <td>group</td> <td>true</td> <td>false</td> <td/> <td/> <tr> <td>Event Details</td> <td>Date Specimen Collected</td> <td>date-specimen-collected</td> <td>date</td> <td>true</td> <td>false</td> <td/> <td/> </tr> <tr> <td>Event Details</td> <td>Specimen Type</td> <td>specimen-type</td> <td>choice</td> <td>true</td> <td>false</td> <td/> <td> <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> </td> </tr> <tr> <td>Event Details</td> <td>Resident Care Location</td> <td>resident-care-location</td> <td>url</td> <td>true</td> <td>false</td> <td/> <td/> </tr> <tr> <td>Event Details</td> <td>Primary Resident Service Type</td> <td>primary-resident-service-type</td> <td>choice</td> <td>true</td> <td>false</td> <td/> <td> <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> </td> </tr> </tr> <tr> <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> </tr> <tr> <td/> <td>Encounters Group</td> <td>encounters-group</td> <td>group</td> <td>true</td> <td>true</td> <td/> <td/> <tr> <td>Encounters Group</td> <td>Transfer From Acute Care Facility to LTCF in Past Four Weeks</td> <td>transfer-from-acute-care-facility</td> <td>boolean</td> <td>true</td> <td>false</td> <td/> <td/> </tr> <tr> <td>Encounters Group</td> <td>Date of Last Transfer From Acute Care to LTCF</td> <td>date-of-last-transfer</td> <td>date</td> <td>false</td> <td>false</td> <td>transfer-from-acute-care-facility="true"</td> <td/> </tr> <tr> <td>Encounters Group</td> <td>Resident on Antibiotic Therapy for Specific Organism at Time of Transfer to Facility</td> <td>antibiotic-at-time-of-transfer</td> <td>boolean</td> <td>false</td> <td>false</td> <td>transfer-from-acute-care-facility="true"</td> <td/> </tr> </tr> <tr> <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> </tr> <tr> <td/> <td>Findings Group</td> <td>findings-group</td> <td>group</td> <td>true</td> <td>true</td> <td/> <td/> <tr> <td>Findings Group</td> <td>Specific Organism Type</td> <td>specific-organism-type</td> <td>choice</td> <td>true</td> <td>false</td> <td/> <td> <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> </td> </tr> </tr> <tr> <td/> <td>Comments</td> <td>nhsn-comment</td> <td>text</td> <td>false</td> <td>false</td> <td/> <td/> </tr> </table> </div> </text> <url value="http://hl7.org/fhir/us/hai-ltcf/Questionnaire/hai-ltcf-questionnaire-mdro-cdi-event"/> <identifier> <value value="hai-questionnaire-los-event-v1"/> </identifier> <version value="1.0.0"/> <name value="HAI_LTCF_questionnaire_mdro_cdi_event"/> <title value="HAI Laboratory Identified MDRO or CDI Event Report for LTCF"/> <status value="draft"/> <subjectType value="Patient"/> <date value="2019-08-01"/> <publisher value="HL7"/> <description value="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. Key Encounter data in the report includes: * The date of the current admission to the facility location where the specimen was collected. * The date of specimen collection. Key Finding data in this report includes: * Inormation on the type of organism and the date which it was collected. For 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*". "/> <jurisdiction> <coding> <system value="urn:iso:std:iso:3166"/> <code value="US"/> </coding> </jurisdiction> <code> <system value="http://loinc.org"/> <code value="51897-7"/> <display value="Healthcare Associated Infection report Document"/> </code> <item> <linkId value="facility-id"/> <text value="Facility ID"/> <type value="url"/> <required value="true"/> <repeats value="false"/> </item> <item> <linkId value="date-of-first-admission-to-facility"/> <text value="Date of First Admission to Facility"/> <type value="date"/> <required value="true"/> <repeats value="false"/> </item> <item> <linkId value="date-of-current-admission-to-facility"/> <text value="Date of Current Admission to Facility"/> <type value="date"/> <required value="true"/> <repeats value="false"/> </item> <item> <linkId value="event-details-group"/> <code> <system value="http://loinc.org"/> <code value="51899-3"/> <display value="Details Document"/> </code> <text value="Event Details Group"/> <type value="group"/> <required value="true"/> <repeats value="false"/> <item> <linkId value="event-details-group-display"/> <text value="The Event Details Group records details about the event."/> <type value="display"/> </item> <item> <linkId value="date-specimen-collected"/> <text value="Date Specimen Collected"/> <type value="date"/> <required value="true"/> <repeats value="false"/> </item> <item> <linkId value="specimen-type"/> <text value="Specimen Type"/> <type value="choice"/> <required value="true"/> <repeats value="false"/> <answerValueSet value="http://hl7.org/fhir/us/hai-ltcf/ValueSet/2.16.840.1.114222.4.11.3249"/> </item> <item> <linkId value="resident-care-location"/> <text value="Resident Care Location"/> <type value="url"/> <required value="true"/> <repeats value="false"/> </item> <item> <linkId value="primary-resident-service-type"/> <text value="Primary Resident Service Type"/> <type value="choice"/> <required value="true"/> <repeats value="false"/> <answerValueSet value="http://hl7.org/fhir/us/hai-ltcf/ValueSet/2.16.840.1.113883.10.20.5.1.5.9.3"/> </item> </item> <item> <linkId value="encounters-group"/> <code> <system value="http://loinc.org"/> <code value="46240-8"/> <display value="Hx of Hospitalizations+OP visits"/> </code> <text value="Encounters Group"/> <type value="group"/> <required value="true"/> <repeats value="true"/> <item> <linkId value="encounters-group-display"/> <text value="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 value="display"/> </item> <item> <linkId value="transfer-from-acute-care-facility"/> <text value="Transfer From Acute Care Facility to LTCF in Past Four Weeks"/> <type value="boolean"/> <required value="true"/> <repeats value="false"/> </item> <item> <linkId value="date-of-last-transfer"/> <text value="Date of Last Transfer From Acute Care to LTCF"/> <type value="date"/> <enableWhen> <question value="transfer-from-acute-care-facility"/> <operator value="="/> <answerBoolean value="true"/> </enableWhen> <required value="false"/> <repeats value="false"/> </item> <item> <linkId value="antibiotic-at-time-of-transfer"/> <text value="Resident on Antibiotic Therapy for Specific Organism at Time of Transfer to Facility"/> <type value="boolean"/> <enableWhen> <question value="transfer-from-acute-care-facility"/> <operator value="="/> <answerBoolean value="true"/> </enableWhen> <required value="false"/> <repeats value="false"/> </item> </item> <item> <linkId value="findings-group"/> <code> <system value="http://loinc.org"/> <code value="18769-0"/> <display value="Microbial susceptibility tests Set"/> </code> <text value="Findings Group"/> <type value="group"/> <required value="true"/> <repeats value="true"/> <item> <linkId value="findings-group-display"/> <text value="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 value="display"/> </item> <item> <linkId value="specific-organism-type"/> <text value="Specific Organism Type"/> <type value="choice"/> <required value="true"/> <repeats value="false"/> <answerValueSet value="http://hl7.org/fhir/us/hai-ltcf/ValueSet/2.16.840.1.114222.4.11.3194"/> </item> </item> <item> <linkId value="nhsn-comment"/> <code> <system value="http://www.loinc.org"/> <code value="86468-6"/> <display value="Report Comment Section"/> </code> <text value="Comments"/> <type value="text"/> <required value="false"/> <repeats value="false"/> <maxLength value="2000"/> </item> </Questionnaire>
