Healthcare Associated Infection Reports, FHIR STU 2 Ballot - US Realm Implementation Guide CI Build

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

QuestionnaireResponse: hai-questionnaireResponse-opc-ssi-event

This QuestionnaireResponse instance is an example of a completed Outpatient Procedure Component Surgical Site Infection (SSI) Event and is in response to the Questionnaire instance defining this report.

Example Outpatient Procedure Component Surgical Site Infection (SSI) Event

Authoring and Facility Information

Authoring Device Id: 2.16.840.1.113883.3.117.1.1.5.1.1.2:anAuthorID
Facility ID urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.1.1:9W
Date of encounter 2018-08-05

Patient

Patient ID Medical Record Number: 12345
Social Security # 12345
Medicaid # 959595
Patient Last Name Nuclear
Patient First Name Ned
Gender Male
Date of Birth 1954-11-25
Ethnicity Not Hispanic or Latino
Race White

Infection Details

Event Type Surgical Site Infection
Date of event 2018-08-06
NHSN Procedure Code Category 2108-9: Appendix surgery
CPT Procedure Code 44970: Laparoscopic Procedures on the Appendix
Procedure Id urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.2.1.1.5:21987654321
Surgical Site Infection (SSI) Level Superficial incisional primary SSI
Surveillence method type (active/passive) through which the SSI was detected Active SSI Detection Method
Surveillence method through which the SSI was detected Review of patient's medical record

Criteria of Diagnosis

Abscess false
Redness false
Fever false
Heat true
Purulent drainage true
Wound spontaneously dehisced false
Incision deliberately opened false
Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam false
Localized swelling false
Pain or tenderness false
Organism Identified true
Culture or non-culture based testing not performed false
Imaging test evidence of infection false
Diagnosis of superficial SSI by surgeon or attending physician false

Findings

Pathogen Identified Staphylococcus, coagulase negative (organism)
Pathogen Ranking First
Pathogen Identified Life form of parasite (organism)
Pathogen Ranking Second
Pathogen Identified Acid-fast bacillus
Pathogen Ranking Third

Comment

Comment NHSN text comment that is less than 2000 characters.