This page is part of the Healthcare Associated Infection Implementation Guide (v0.1.0: STU 1 Ballot 1) based on FHIR v3.3.0. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

• QuestionnaireResponse Content
• QuestionnaireResponse XML
• QuestionnaireResponse JSON

{
  "resourceType" : "QuestionnaireResponse",
  "id" : "hai-questionnaireResponse-los-event",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
      <p>This QuestionnaireResponse instance is an example of a completed Late Onset Sepsis/Meningitis Event (LOS) Report and is in response to the Questionnaire instance defining this report.</p>
      <h2>Patient Details</h2>
      <table border="1"> 
        <tbody> 
          <tr> 
            <td>Name</td> 
            <td>Ned <b>Nuclear</b>
            </td> 
          </tr> 
          <tr> 
            <td>Id</td> 
            <td>MRN: 12345</td> 
          </tr> 
          <tr> 
            <td>Medicaid beneficiary number</td> 
            <td>959595</td> 
          </tr>
        </tbody> 
      </table> 
      <h2>Event Details</h2>
      <table border="1">
        <tbody>
          <tr>
            <td>Infection Type</td>
            <td>Late onset sepsis</td>
          </tr>
          <tr>
            <td>Specific Event</td>
            <td>NLCBI 2</td>
          </tr>
          <tr>
            <td>Criteria used</td>
            <td>Recognized pathogen from one or more blood specimens</td>
          </tr>
          <tr>
            <td>Date of Infection</td>
            <td>January 2, 2018</td>
          </tr>
          <tr>
            <td>Inborn/Outborn</td>
            <td>Inborn</td>
          </tr>
          <tr>
            <td>Dead</td>
            <td>Yes</td>
          </tr>
          <tr>
            <td>Infection Contributed to Death</td>
            <td>No</td>
          </tr>
        </tbody>
      </table>
      <h2>Risk Factors</h2>
      <table border="1">
        <tbody>
          <tr>
            <td>Central line present prior to event, including umbilical catheter</td>
            <td>Yes</td>
          </tr>
          <tr>
            <td>Birth Weight</td>
            <td>700 g</td>
          </tr>
          <tr>
            <td>Gestational Age</td>
            <td>276 d</td>
          </tr>
        </tbody>
      </table>

      <h2>Findings</h2>
      <table border="1">
        <tbody>
          <tr>
            <td>Microorganism
                identified</td>
            <td>Clostridium symbiosum (organism)</td>
          </tr>
          <tr>
            <td>Pathogen Ranking</td>
            <td>1</td>
          </tr>
          <tr>
            <td>Clarithro Susc Islt</td>
            <td> Not Applicable Resistant</td>
          </tr>
        </tbody>
      </table>
      <h2>Comment</h2>
      <table border="1">
        <tbody>
          <tr>
            <td>Comment</td>
            <td>NHSN text comment that is less than 2000 characters.</td>
          </tr>
        </tbody>
      </table>
    </div>"
  },
  "questionnaire" : "hai-questionnaire-los-event",
  "status" : "completed",
  "item" : [
    {
      "linkId" : "facility",
      "text" : "Facility ID",
      "answer" : [
        {
          "valueUri" : "2.16.840.1.113883.3.117.1.1.5.1.1"
        }
      ]
    },
    {
      "linkId" : "event-number",
      "text" : "Event #",
      "answer" : [
        {
          "valueUri" : "2.16.840.1.113883.3.117.1.1.5.2.1.1.3"
        }
      ]
    },
    {
      "linkId" : "event-type",
      "text" : "Event Type",
      "answer" : [
        {
          "valueCoding" : {
            "system" : "https://loinc.org/",
            "code" : "TEMP_SNOMED_LATE_ONSET_SEPSIS",
            "display" : "Late Onset Sepsis (LOS)"
          }
        }
      ]
    },
    {
      "linkId" : "date-of-event",
      "text" : "Date of Event",
      "answer" : [
        {
          "valueDate" : "2018-01-02"
        }
      ]
    },
    {
      "linkId" : "facility-location",
      "text" : "Facility Location",
      "answer" : [
        {
          "valueCoding" : {
            "system" : "urn:oid:2.16.840.1.113883.6.259",
            "code" : "1029-8",
            "display" : "Medical/Surgical Critical Care"
          }
        }
      ]
    },
    {
      "linkId" : "date-admitted-to-facility",
      "text" : "Date Admitted to Facility:",
      "answer" : [
        {
          "valueDate" : "2018-01-01"
        }
      ]
    },
    {
      "linkId" : "inborn-outborn-observation",
      "text" : "Select: Inborn or Outborn",
      "answer" : [
        {
          "valueCoding" : {
            "system" : "http://snomed.info/sct",
            "code" : "445087001",
            "display" : "Born before arrival to hospital (situation)"
          }
        }
      ]
    },
    {
      "linkId" : "questionnaire-patient",
      "text" : "Patient",
      "answer" : [
        {
          "valueReference" : {
            "reference" : "Patient/hai-patient-1",
            "type" : "Patient"
          }
        }
      ]
    },
    {
      "linkId" : "risk-factors",
      "text" : "Risk Factors",
      "item" : [
        {
          "linkId" : "risk-factor-central-line",
          "text" : "Central line present prior to event, including umbilical catheter",
          "answer" : [
            {
              "valueBoolean" : true
            }
          ]
        },
        {
          "linkId" : "risk-factor-birth-weight",
          "text" : "Birth Weight (grams)",
          "answer" : [
            {
              "valueQuantity" : {
                "value" : 700,
                "unit" : "g"
              }
            }
          ]
        },
        {
          "linkId" : "risk-factor-gestational-age",
          "text" : "Gestational Age",
          "answer" : [
            {
              "valueQuantity" : {
                "value" : 276,
                "unit" : "d"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId" : "event-details",
      "text" : "Event Details",
      "item" : [
        {
          "linkId" : "infection-condition",
          "text" : "Specific Event",
          "answer" : [
            {
              "valueCoding" : {
                "system" : "urn:oid:2.16.840.1.113883.6.277",
                "code" : "3067-6",
                "display" : "Neonatal Laboratory Confirmed Bloodstream Infection (NLCBI 2)"
              }
            }
          ]
        },
        {
          "linkId" : "criteria-used",
          "text" : "Laboratory Criteria Used",
          "answer" : [
            {
              "valueCoding" : {
                "system" : "urn:oid:2.16.840.1.113883.6.277",
                "code" : "1951-3",
                "display" : "Recognized pathogen from one or more blood specimens"
              }
            }
          ]
        },
        {
          "linkId" : "died",
          "text" : "Died",
          "answer" : [
            {
              "valueCoding" : {
                "system" : "http://snomed.info/sct",
                "code" : "419099009",
                "display" : "Dead"
              }
            }
          ]
        },
        {
          "linkId" : "los-contributed-to-death",
          "text" : "Infection contrubuted to death",
          "answer" : [
            {
              "valueBoolean" : false
            }
          ]
        },
        {
          "linkId" : "discharge-date",
          "text" : "Discharge Date",
          "answer" : [
            {
              "valueDate" : "2018-01-12"
            }
          ]
        }
      ]
    },
    {
      "linkId" : "findings-group",
      "text" : "Findings Group",
      "item" : [
        {
          "linkId" : "pathogen-identified",
          "text" : "Pathogen Identified",
          "answer" : [
            {
              "valueCoding" : {
                "system" : "http://snomed.info/sct",
                "code" : "48321006",
                "display" : "Clostridium symbiosum (organism)"
              }
            }
          ]
        },
        {
          "linkId" : "pathogen-ranking",
          "text" : "Pathogen Ranking",
          "answer" : [
            {
              "valueCoding" : {
                "system" : "http://snomed.info/sct",
                "code" : "255216001",
                "display" : "First"
              }
            }
          ]
        },
        {
          "linkId" : "drug-susceptibility-test-group",
          "text" : "Drug Susceptibility Test Group",
          "item" : [
            {
              "linkId" : "drug-susceptibility-test",
              "text" : "Drug Susceptibility Test",
              "answer" : [
                {
                  "valueCoding" : {
                    "system" : "https://loinc.org/",
                    "code" : "18907-6",
                    "display" : "Clarithro Susc Islt"
                  }
                }
              ]
            },
            {
              "linkId" : "drug-susceptibility-test-interpretation",
              "text" : "Drug Susceptibility Test Interpretation",
              "answer" : [
                {
                  "valueCoding" : {
                    "system" : "urn:oid:2.16.840.1.113883.5.83",
                    "code" : "R",
                    "display" : "Resistant"
                  }
                }
              ]
            }
          ]
        }
      ]
    },
    {
      "linkId" : "nhsn-comment",
      "text" : "nhsn-comment",
      "answer" : [
        {
          "valueString" : "NHSN text comment that is less than 2000 characters."
        }
      ]
    }
  ]
}