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

XML Format: QuestionnaireResponse-hai-questionnaireResponse-opc-ssi-event

Raw xml 


<QuestionnaireResponse xmlns="http://hl7.org/fhir">
  <id value="hai-questionnaireResponse-opc-ssi-event"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2019-03-14T00:03:04.000-04:00"/>
    <profile
             value="http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire-response"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml" lang="en-US">
      <p>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.</p>
      <h2>Example Outpatient Procedure Component Surgical Site Infection (SSI) Event</h2>
      <h3>Authoring and Facility Information</h3>
      <table border="1">
        <tbody>
          <tr>
            <td>Authoring Device</td>
            <td>Id: 2.16.840.1.113883.3.117.1.1.5.1.1.2:anAuthorID</td>
          </tr>
          <tr>
            <td>Facility ID</td>
            <td>urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.1.1:9W</td>
          </tr>
          <tr>
            <td>Date of encounter</td>
            <td>2018-08-05</td>
          </tr>
        </tbody>
      </table>
      <h3>Patient</h3>
      <table border="1">
        <tbody>
          <tr>
            <td>Patient ID</td>
            <td>Medical Record Number: 12345</td>
          </tr>
          <tr>
            <td>Social Security #</td>
            <td>12345</td>
          </tr>
          <tr>
            <td>Medicaid #</td>
            <td>959595</td>
          </tr>
          <tr>
            <td>Patient Last Name</td>
            <td>Nuclear</td>
          </tr>
          <tr>
            <td>Patient First Name</td>
            <td>Ned</td>
          </tr>
          <tr>
            <td>Gender</td>
            <td>Male</td>
          </tr>
          <tr>
            <td>Date of Birth</td>
            <td>1954-11-25</td>
          </tr>
          <tr>
            <td>Ethnicity</td>
            <td>Not Hispanic or Latino</td>
          </tr>
          <tr>
            <td>Race</td>
            <td>White</td>
          </tr>
        </tbody>
      </table>
      <h3>Infection Details</h3>
      <table border="1">
        <tbody>
          <tr>
            <td>Event Type</td>
            <td>Surgical Site Infection</td>
          </tr>
          <tr>
            <td>Date of event</td>
            <td>2018-08-06</td>
          </tr>
          <tr>
            <td>NHSN Procedure Code Category</td>
            <td>2108-9: Appendix surgery</td>
          </tr>
          <tr>
            <td>CPT Procedure Code</td>
            <td>44970: Laparoscopic Procedures on the Appendix</td>
          </tr>
          <tr>
            <td>Procedure Id</td>
            <td>urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.2.1.1.5:21987654321</td>
          </tr>
          <tr>
            <td>Surgical Site Infection (SSI) Level</td>
            <td>Superficial incisional primary SSI</td>
          </tr>
          <tr>
            <td>Surveillence method type (active/passive) through which the SSI was detected</td>
            <td>Active SSI Detection Method</td>
          </tr>
          <tr>
            <td>Surveillence method through which the SSI was detected</td>
            <td>Review of patient's medical record</td>
          </tr>
        </tbody>
      </table>
      <h3>Criteria of Diagnosis</h3>
      <table border="1">
        <tbody>
          <tr>
            <td>Abscess</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Redness</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Fever</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Heat</td>
            <td>true</td>
          </tr>
          <tr>
            <td>Purulent drainage</td>
            <td>true</td>
          </tr>
          <tr>
            <td>Wound spontaneously dehisced</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Incision deliberately opened</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Localized swelling</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Pain or tenderness</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Organism Identified</td>
            <td>true</td>
          </tr>
          <tr>
            <td>Culture or non-culture based testing not performed</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Imaging test evidence of infection</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Diagnosis of superficial SSI by surgeon or attending physician</td>
            <td>false</td>
          </tr>
        </tbody>
      </table>
      <h3>Findings</h3>
      <table border="1">
        <tbody>
          <tr>
            <td>Pathogen Identified</td>
            <td>Staphylococcus, coagulase negative (organism)</td>
          </tr>
          <tr>
            <td>Pathogen Ranking</td>
            <td>First</td>
          </tr>
          <tr>
            <td>Pathogen Identified</td>
            <td>Life form of parasite (organism)</td>
          </tr>
          <tr>
            <td>Pathogen Ranking</td>
            <td>Second</td>
          </tr>
          <tr>
            <td>Pathogen Identified</td>
            <td>Acid-fast bacillus</td>
          </tr>
          <tr>
            <td>Pathogen Ranking</td>
            <td>Third</td>
          </tr>
        </tbody>
      </table>
      <h3>Comment</h3>
      <table border="1">
        <tbody>
          <tr>
            <td>Comment</td>
            <td>NHSN text comment that is less than 2000 characters.</td>
          </tr>
        </tbody>
      </table>
    </div>
  </text>
  <identifier>
    <system value="urn:oid:2.16.840.1.113883.3.117.1.1.5.2.1.1.2"/>
    <value value="20202210"/>
  </identifier>
  <questionnaire>
    <reference
               value="http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-opc-ssi-event"/>
  </questionnaire>
  <status value="completed"/>
  <subject>
    <reference value="Patient/hai-patient-1"/>
    <display value="hai-patient-1"/>
  </subject>
  <author>
    <reference value="Device/hai-authoring-device"/>
    <display value="hai-authoring-device"/>
  </author>
  <item>
    <linkId value="facility-id"/>
    <text value="Facility ID"/>
    <answer>
      <valueUri value="urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.1.1:9W"/>
    </answer>
  </item>
  <item>
    <linkId value="encounter-date"/>
    <text value="Date of encounter"/>
    <answer>
      <valueDate value="2018-08-05"/>
    </answer>
  </item>
  <item>
    <linkId value="infection-details"/>
    <text value="Infection details"/>
    <item>
      <linkId value="event-type"/>
      <text value="Event Type"/>
      <answer>
        <valueCoding>
          <system value="http://snomed.info/sct"/>
          <code value="433202001"/>
          <display value="Surgical Site Infection"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="event-date"/>
      <text value="Date of event"/>
      <answer>
        <valueDate value="2018-08-06"/>
      </answer>
    </item>
    <item>
      <linkId value="nhsn-procedure-code-category"/>
      <text value="NHSN Procedure Code Category"/>
      <answer>
        <valueCoding>
          <system
                  value="http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277"/>
          <code value="2108-9"/>
          <display value="Appendix surgery"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="cpt-procedure-code"/>
      <text value="CPT Procedure Code"/>
      <answer>
        <valueCoding>
          <system value="http://www.ama-assn.org/go/cpt"/>
          <code value="44970"/>
          <display value="Laparoscopic Procedures on the Appendix"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="procedure-id"/>
      <text value="Procedure Id"/>
      <answer>
        <valueUri
                  value="urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.2.1.1.5:21987654321"/>
      </answer>
    </item>
    <item>
      <linkId value="ssi-level"/>
      <text value="Surgical Site Infection (SSI) Level"/>
      <answer>
        <valueCoding>
          <system
                  value="http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277"/>
          <code value="1620-4"/>
          <display value="Superficial incisional primary SSI"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="criteria-of-diagnosis"/>
      <text value="Criteria of Diagnosis"/>
      <item>
        <linkId value="criteria-of-diagnosis-abscess"/>
        <text value="Criteria of Diagnosis: Abscess"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-redness"/>
        <text value="Criteria of Diagnosis: Redness"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-fever"/>
        <text value="Criteria of Diagnosis: Fever"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-heat"/>
        <text value="Criteria of Diagnosis: Heat"/>
        <answer>
          <valueBoolean value="true"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-incision-purulent-drainage"/>
        <text value="Criteria of Diagnosis: Purulent drainage"/>
        <answer>
          <valueBoolean value="true"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-wound-dehisced"/>
        <text value="Criteria of Diagnosis: Wound spontaneously dehisced"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-incision-opened"/>
        <text value="Criteria of Diagnosis: Incision deliberately opened"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-evidence-found"/>
        <text
              value="Criteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-localized-swelling"/>
        <text value="Criteria of Diagnosis: Localized swelling"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-pain-tenderness"/>
        <text value="Criteria of Diagnosis: Pain or tenderness"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-organism-identified"/>
        <text value="Criteria of Diagnosis: Organism Identified"/>
        <answer>
          <valueBoolean value="true"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-testing-not-performed"/>
        <text
              value="Criteria of Diagnosis: Culture or non-culture based testing not performed"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-imaging-test"/>
        <text value="Criteria of Diagnosis: Imaging test evidence of infection"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-physician-diagnosis"/>
        <text
              value="Criteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physician"/>
        <answer>
          <valueBoolean value="false"/>
        </answer>
      </item>
    </item>
    <item>
      <linkId value="ssi-detection-method-type"/>
      <text
            value="Surveillence method type (active/passive) through which the SSI was detected"/>
      <answer>
        <valueCoding>
          <system
                  value="http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277"/>
          <code value="1309-4"/>
          <display value="Active SSI Detection Method"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="ssi-detection-method"/>
      <text value="Surveillence method through which the SSI was detected"/>
      <answer>
        <valueCoding>
          <system
                  value="http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277"/>
          <code value="1321-9"/>
          <display value="Review of patient&#39;s medical record"/>
        </valueCoding>
      </answer>
    </item>
  </item>
  <item>
    <linkId value="findings-group"/>
    <text
          value="Findings Group: Records whether infection organisms were identified and, if so, records details about them."/>
    <item>
      <linkId value="pathogen-identified"/>
      <text value="Pathogen Identified"/>
      <answer>
        <valueCoding>
          <system value="http://snomed.info/sct"/>
          <code value="116197008"/>
          <display value="Staphylococcus, coagulase negative (organism)"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="pathogen-ranking"/>
      <text value="Pathogen Ranking"/>
      <answer>
        <valueCoding>
          <system value="http://snomed.info/sct"/>
          <code value="255216001"/>
          <display value="First"/>
        </valueCoding>
      </answer>
    </item>
  </item>
  <item>
    <linkId value="findings-group"/>
    <text
          value="Findings Group: Records whether infection organisms were identified and, if so, records details about them."/>
    <item>
      <linkId value="pathogen-identified"/>
      <text value="Pathogen Identified"/>
      <answer>
        <valueCoding>
          <system value="http://snomed.info/sct"/>
          <code value="103535006"/>
          <display value="Life form of parasite (organism)"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="pathogen-ranking"/>
      <text value="Pathogen Ranking"/>
      <answer>
        <valueCoding>
          <system value="http://snomed.info/sct"/>
          <code value="81170007"/>
          <display value="Second"/>
        </valueCoding>
      </answer>
    </item>
  </item>
  <item>
    <linkId value="findings-group"/>
    <text
          value="Findings Group: Records whether infection organisms were identified and, if so, records details about them."/>
    <item>
      <linkId value="pathogen-identified"/>
      <text value="Pathogen Identified"/>
      <answer>
        <valueCoding>
          <system value="http://snomed.info/sct"/>
          <code value="243365003"/>
          <display value="Acid-fast bacillus"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="pathogen-ranking"/>
      <text value="Pathogen Ranking"/>
      <answer>
        <valueCoding>
          <system value="http://snomed.info/sct"/>
          <code value="70905002"/>
          <display value="Third"/>
        </valueCoding>
      </answer>
    </item>
  </item>
  <item>
    <linkId value="nhsn-comment"/>
    <text value="Comments"/>
    <answer>
      <valueString value="NHSN text comment that is less than 2000 characters."/>
    </answer>
  </item>
</QuestionnaireResponse>