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-event
Raw json
{
"resourceType" : "Questionnaire",
"id" : "hai-questionnaire-los-event",
"meta" : {
"versionId" : "3",
"lastUpdated" : "2019-03-13T19:43:37.000-04:00",
"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 Event (LOS) Report. It records a late onset sepsis/meningitis infection event.\n <br/>For Late Onset Sepsis/Meningitis Event Reports, a Medicaid beneficiary number may be present.\n </p>\n <h2>Late Onset Sepsis/Meningitis Event (LOS) Instance Details</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-event</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 Event (LOS)</td>\n </tr>\n <tr>\n <td>Publish date</td>\n <td>2018-09-30</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>Facility ID</td>\n <td>url</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Event #</td>\n <td>url</td>\n <td>false</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Event Type</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Date of Event</td>\n <td>date</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Facility Location</td>\n <td>choice</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>Inborn/Outborn</td>\n <td>boolean</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>Central line present prior to event, including umbilical catheter</td>\n <td>boolean</td>\n <td>false</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 at Birth</td>\n <td>quantity</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Event Details</td>\n <td>group</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Event Details</td>\n <td>Specific Event</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Event Details</td>\n <td>Laboratory Criteria Used</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Event Details</td>\n <td>Died</td>\n <td>boolean</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Event Details</td>\n <td>Infection contributed to death</td>\n <td>boolean</td>\n <td>true if died='true'</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Event Details</td>\n <td>Discharge date</td>\n <td>date</td>\n <td>false</td>\n <td>false</td>\n </tr>\n <tr>\n <td/>\n <td>Findings Group</td>\n <td>group</td>\n <td>false</td>\n <td>true</td>\n </tr>\n <tr>\n <td>Findings Group</td>\n <td>Pathogen Identified</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Findings Group</td>\n <td>Pathogen Ranking</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Findings Group</td>\n <td>Drug Susceptibility Test Group</td>\n <td>group</td>\n <td>false</td>\n <td>true</td>\n </tr>\n <tr>\n <td>Drug Susceptibility Test Group</td>\n <td>Drug Susceptibility Test</td>\n <td>choice</td>\n <td>true</td>\n <td>false</td>\n </tr>\n <tr>\n <td>Drug Susceptibility Test Group</td>\n <td>Drug Susceptibility Test Interpretation</td>\n <td>choice</td>\n <td>false</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-event",
"identifier" : [
{
"value" : "hai-questionnaire-los-event-v1"
}
],
"version" : "R1",
"title" : "Late Onset Sepsis/Meningitis Event (LOS)",
"status" : "draft",
"date" : "2018-09-30",
"publisher" : "HL7",
"description" : "This Questionnaire instance defines the questions and possible answers in the Late Onset Sepsis/Meningitis Event (LOS) Report. It records a late onset sepsis/meningitis infection event. For Late Onset Sepsis/Meningitis Event Reports, a Medicaid beneficiary number may be present.",
"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" : "facility",
"text" : "Facility ID",
"type" : "url",
"required" : true,
"repeats" : false
},
{
"linkId" : "event-number",
"text" : "Event #",
"type" : "url",
"required" : false,
"repeats" : false
},
{
"linkId" : "event-type",
"text" : "Event Type",
"type" : "choice",
"required" : true,
"repeats" : false,
"options" : {
"reference" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.20"
}
},
{
"linkId" : "date-of-event",
"text" : "Date of Event",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "facility-location",
"text" : "Facility Location",
"type" : "choice",
"required" : true,
"repeats" : false,
"options" : {
"reference" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.19"
}
},
{
"linkId" : "date-admitted-to-facility",
"text" : "Date Admitted to Facility:",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "inborn-outborn-observation",
"code" : [
{
"system" : "http://snomed.info/sct",
"code" : "445087001",
"display" : "Born before arrival to hospital (situation)"
}
],
"text" : "Inborn/Outborn: If the infant was outborn (born at a location other than the reporting hospital), select true. If the infant was inborn (born at the reporting hospital) select false.",
"type" : "boolean",
"required" : true,
"repeats" : false
},
{
"linkId" : "risk-factors",
"code" : [
{
"system" : "http://loinc.org",
"code" : "51898-5",
"display" : "Risk factors Document"
}
],
"text" : "Risk Factors: Contains central line present, birth weight, gestational age",
"type" : "group",
"repeats" : false,
"item" : [
{
"linkId" : "risk-factor-central-line",
"code" : [
{
"system" : "http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277",
"code" : "1006-6",
"display" : "central line including umbilical catheter"
}
],
"text" : "Risk Factor: Central line present prior to event, including umbilical catheter",
"type" : "boolean",
"required" : false,
"repeats" : false
},
{
"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" : "event-details",
"code" : [
{
"system" : "http://loinc.org",
"code" : "51899-3",
"display" : "Details Document"
}
],
"text" : "Event Details",
"type" : "group",
"repeats" : false,
"item" : [
{
"linkId" : "infection-condition",
"text" : "Specific Event",
"type" : "choice",
"required" : true,
"repeats" : false,
"options" : {
"reference" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3196"
}
},
{
"linkId" : "criteria-used",
"text" : "Laboratory Criteria Used",
"type" : "choice",
"required" : true,
"repeats" : false,
"options" : {
"reference" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3195"
}
},
{
"linkId" : "died",
"code" : [
{
"system" : "http://snomed.info/sct",
"code" : "419099009",
"display" : "dead"
}
],
"text" : "Died",
"type" : "boolean",
"required" : true,
"repeats" : false
},
{
"linkId" : "los-contributed-to-death",
"text" : "Infection contributed to death",
"type" : "boolean",
"enableWhen" : [
{
"question" : "died",
"answerBoolean" : true
}
],
"required" : true,
"repeats" : false
},
{
"linkId" : "discharge-date",
"text" : "Discharge Date",
"type" : "date",
"required" : false,
"repeats" : false
}
]
},
{
"linkId" : "findings-group",
"code" : [
{
"system" : "http://loinc.org",
"code" : "18769-0",
"display" : "Microbial susceptibility tests Set"
}
],
"text" : "Findings Group: Records whether infection organisms were identified and, if so, records details about them.",
"type" : "group",
"repeats" : true,
"item" : [
{
"linkId" : "pathogen-identified",
"text" : "Pathogen Identified",
"type" : "choice",
"required" : true,
"repeats" : false,
"options" : {
"reference" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.16"
}
},
{
"linkId" : "pathogen-ranking",
"text" : "Pathogen Ranking",
"type" : "choice",
"required" : true,
"repeats" : false,
"options" : {
"reference" : "http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking"
}
},
{
"linkId" : "drug-susceptibility-test-group",
"text" : "Drug Susceptibility Test Group",
"type" : "group",
"repeats" : true,
"item" : [
{
"linkId" : "drug-susceptibility-test",
"text" : "Drug Susceptibility Test",
"type" : "choice",
"required" : true,
"repeats" : false,
"options" : {
"reference" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.15"
}
},
{
"linkId" : "drug-susceptibility-test-interpretation",
"text" : "Drug Susceptibility Test Interpretation",
"type" : "choice",
"required" : false,
"repeats" : false,
"options" : {
"reference" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.13"
}
}
]
}
]
},
{
"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
}
]
}
