This page is part of the Healthcare Associated Infection Implementation Guide (v1.1.0: STU 2 Ballot 1) based on FHIR R3. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions 
JSON Format: Questionnaire-hai-questionnaire-los-denom
Raw json
{
"resourceType" : "Questionnaire",
"id" : "hai-questionnaire-los-denom",
"meta" : {
"versionId" : "5",
"lastUpdated" : "2019-03-13T21:32:00.000-04:00",
"profile" : [
"http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire"
]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" lang=\"en-US\">\n <p>This Questionnaire instance defines the questions and possible answers in the Late Onset Sepsis/Meningitis Denominator. This report records the denominator information for neonatal component late onset sepsis and meningitis (LOS/Men).</p>\n <h2>Late Onset Sepsis/Meningitis Denominator</h2>\n <table border=\"1\">\n <tbody>\n <tr>\n <td>url</td>\n <td>http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-denom</td>\n </tr>\n <tr>\n <td>Version</td>\n <td>R1</td>\n </tr>\n <tr>\n <td>title</td>\n <td>Late Onset Sepsis/Meningitis Denominator</td>\n </tr>\n <tr>\n <td>Publish date</td>\n <td>2019-04-01</td>\n </tr>\n <tr>\n <td>Realm</td>\n <td>US</td>\n </tr>\n <tr>\n <td>Code</td>\n <td>LOINC 51897-7: Healthcare Associated Infection report Document</td>\n </tr>\n <tr>\n <td>Subject type</td>\n <td>Patient</td>\n </tr>\n </tbody>\n </table>\n <h2>Questionnaire Items</h2>\n <table border=\"1\">\n <thead>\n <tr>\n <th>Group</th>\n <th>Item</th>\n <th>Type</th>\n <th>Required</th>\n <th>Repeats</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td/>\n <td>Year and month data collected for this location</td>\n <td>date</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Facility ID</td>\n <td>url</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Date Admitted to Facility</td>\n <td>date</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Location Within Facility Encounter</td>\n <td>group</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Location Within Facility Encounter</td>\n <td>Facility Location Type</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Location Within Facility Encounter</td>\n <td>Facility Location</td>\n <td>url</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Location Within Facility Encounter</td>\n <td>Date admitted or transferred to location</td>\n <td>date</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Location Within Facility Encounter</td>\n <td>Disposition of infant</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Location Within Facility Encounter</td>\n <td>Disposition date if discharged, transferred, or expired</td>\n <td>date</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Risk Factors</td>\n <td>group</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Risk Factors</td>\n <td>Birth weight (grams)</td>\n <td>quantity</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Risk Factors</td>\n <td>Gestational age (days)</td>\n <td>quantity</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Comments</td>\n <td>text</td>\n <td>false</td>\n <td>false</td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"url" : "http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-denom",
"identifier" : [
{
"value" : "hai-questionnaire-los-denom-v1"
}
],
"version" : "R1",
"name" : "hai-questionnaire-los-denom",
"title" : "Late Onset Sepsis/Meningitis Denominator",
"status" : "draft",
"experimental" : false,
"date" : "2019-04-01",
"publisher" : "HL7",
"description" : "This Questionnaire instance defines the questions and possible answers in the Late Onset Sepsis/Meningitis Event (LOS) Denominator. This report records the denominator information for neonatal component late onset sepsis and meningitis (LOS/Men).",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US"
}
]
}
],
"code" : [
{
"system" : "http://loinc.org",
"code" : "51897-7",
"display" : "Healthcare Associated Infection report Document"
}
],
"subjectType" : [
"Patient"
],
"item" : [
{
"linkId" : "date-collected",
"text" : "Year and month data collected for this location",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "facility",
"text" : "Facility ID",
"type" : "url",
"required" : true,
"repeats" : false
},
{
"linkId" : "date-admitted-to-facility",
"text" : "Date Admitted to Facility",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "location-within-facility-encounter-group",
"code" : [
{
"system" : "http://loinc.org",
"code" : "46240-8",
"display" : "History of Hospitalizations+Outpatient visits Narrative"
}
],
"text" : "Location Within Facility Encounter",
"type" : "group",
"repeats" : false,
"item" : [
{
"linkId" : "facility-location-type",
"text" : "Facility Location Type",
"type" : "choice",
"required" : true,
"repeats" : false,
"options" : {
"reference" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.19"
}
},
{
"linkId" : "facility-location",
"text" : "Facility Location",
"type" : "url",
"required" : true,
"repeats" : false
},
{
"linkId" : "location-admit-transfer-date",
"text" : "Date admitted or transferred to location",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "infant-disposition",
"text" : "Disposition of infant",
"type" : "choice",
"required" : true,
"repeats" : false,
"options" : {
"reference" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.10.20.5.9.30"
}
},
{
"linkId" : "disposition-date",
"text" : "Disposition date if discharged, transferred, or expired",
"type" : "date",
"enableWhen" : [
{
"question" : "infant-disposition",
"answerCoding" : {
"system" : "http://snomed.info/sct",
"code" : "183665006"
}
},
{
"question" : "infant-disposition",
"answerCoding" : {
"system" : "http://snomed.info/sct",
"code" : "266751003"
}
},
{
"question" : "infant-disposition",
"answerCoding" : {
"system" : "http://snomed.info/sct",
"code" : "371828006"
}
}
],
"required" : false,
"repeats" : false
}
]
},
{
"linkId" : "risk-factors",
"code" : [
{
"system" : "http://loinc.org",
"code" : "51898-5",
"display" : "Risk factors Document"
}
],
"text" : "Risk Factors: Contains birth weight and gestational age",
"type" : "group",
"repeats" : false,
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding" : {
"system" : "http://unitsofmeasure.org",
"code" : "g",
"display" : "g"
}
}
],
"linkId" : "risk-factor-birth-weight",
"code" : [
{
"system" : "http://snomed.info/sct",
"code" : "364589006",
"display" : "Birth Weight"
}
],
"text" : "Risk Factor: Birth weight (grams)",
"type" : "quantity",
"required" : true,
"repeats" : false
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding" : {
"system" : "http://unitsofmeasure.org",
"code" : "d",
"display" : "d"
}
}
],
"linkId" : "risk-factor-gestational-age",
"code" : [
{
"system" : "http://loinc.org",
"code" : "76516-4",
"display" : "Gestational age--at birth"
}
],
"text" : "Risk Factor: Gestational age (days)",
"type" : "quantity",
"required" : true,
"repeats" : false
}
]
},
{
"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
}
]
}
