Healthcare Associated Infection Reports (HL7 FHIR® IG : Trial Use v1.0.0 / US Realm)

This page is part of the Healthcare Associated Infection Implementation Guide (v2.0.0: STU 2) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions 



<Bundle xmlns="http://hl7.org/fhir">
  <id value="hai-bundle-los-event"/>
  <identifier>
    <system value="urn:ietf:rfc:3986"/>
    <value value="urn:uuid:876e4d4a-e6b6-4898-91ee-811809c3e623"/>
  </identifier>
  <type value="collection"/>
  <entry>
    <fullUrl value="urn:uuid:3ed9a2c6-02a9-41e1-9f43-52ca33ba8618"/>
    <resource>
      <QuestionnaireResponse>
        <id value="hai-questionnaireResponse-los-event"/>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire-response"/>
        </meta>
        <text>
          <status value="generated"/>
          <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>Late Onset Sepsis/Meningitis Event (LOS)</h2>
            <table border="1">
              <tbody>
                <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>Event #</td>
                  <td>urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.2.1.1.3:31</td>
                </tr>
                <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>
                <tr>
                  <td>Event Type</td>
                  <td>Late onset sepsis (LOS)</td>
                </tr>
                <tr>
                  <td>Date of Event</td>
                  <td>2018-01-02</td>
                </tr>
                <tr>
                  <td>Date Admitted to Facility</td>
                  <td>2018-01-01</td>
                </tr>
                <tr>
                  <td>Inborn/Outborn</td>
                  <td>Inborn</td>
                </tr>
                <tr>
                  <td>Location</td>
                  <td>Medical/Surgical Critical Care</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>Event Details</h2>
            <table border="1">
              <tbody>
                <tr>
                  <td>Specific Event</td>
                  <td>Neonatal Laboratory Confirmed Bloodstream Infection (NLCBI 2)</td>
                </tr>
                <tr>
                  <td>Criteria used</td>
                  <td>Recognized pathogen from one or more blood specimens</td>
                </tr>
                <tr>
                  <td>Died</td>
                  <td>Yes</td>
                </tr>
                <tr>
                  <td>LOS Contributed to Death</td>
                  <td>No</td>
                </tr>
                <tr>
                  <td>Discharge date</td>
                  <td>2018-01-12</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>First</td>
                </tr>
                <tr>
                  <td>Clarithro Susc Islt</td>
                  <td>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>
        </text>
        <identifier>
        <!--  (CDA Mapping: ClinicalDocument/id/root)  -->
          <system value="urn:oid:2.16.840.1.113883.3.117.1.1.5.2.1.1.2"/>
        <!--  (CDA Mapping: ClinicalDocument/id/extension)  -->
          <value value="20202201"/>
        </identifier>
        <questionnaire>
          <reference
                     value="http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-event"/>
        </questionnaire>
        <status value="completed"/>
      <!--   
    Patient Information 
        including:
        - Patient ID
        - Social Security #
        - Secondary ID
        - Medicaid #
        - Patient Name
        - Patient Gender
        - Patient Date of Birth
        - Patient Ethnicity
        - Patient Race
   -->
        <subject>
          <reference value="urn:uuid:e8f49540-d231-452c-abd5-16e9c6d6375b"/>
          <display value="hai-patient-1"/>
        </subject>
        <author>
          <reference value="urn:uuid:65a95666-9ba7-4107-a37b-07957c094b88"/>
          <display value="hai-authoring-device"/>
        </author>
      <!--  Facility ID
       CDA: ClinicalDocument/componentOf/encompassingEncounter/location/healthCareFacility/id  -->
        <item>
          <linkId value="facility"/>
          <text value="Facility ID"/>
          <answer>
            <valueUri value="urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.1.1:9W"/>
          </answer>
        </item>
      <!--  Event # 
       CDA: ClinicalDocument/componentOf/encompassingEncounter/id -->
        <item>
          <linkId value="event-number"/>
          <text value="Event #"/>
          <answer>
            <valueUri value="urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.2.1.1.3:31"/>
          </answer>
        </item>
      <!--  Event Type 
       (CDA Mapping: Infection-Type Observation/value)  -->
        <item>
          <linkId value="event-type"/>
          <text value="Event Type"/>
          <answer>
            <valueCoding>
              <system value="http://snomed.info/sct"/>
              <code value="765107002"/>
              <display value="Late-onset neonatal sepsis (disorder)"/>
            </valueCoding>
          </answer>
        </item>
      <!--  Date of Event 
       (CDA Mapping: Infection-Type Observation/effectiveTime  -->
        <item>
          <linkId value="date-of-event"/>
          <text value="Date of Event"/>
          <answer>
            <valueDate value="2018-01-02"/>
          </answer>
        </item>
      <!--  Facility Location 
       (CDA Mapping: encompassingEncounter/location/healthcareFacility/code) -->
        <item>
          <linkId value="facility-location"/>
          <text value="Facility Location"/>
          <answer>
            <valueCoding>
              <system
                      value="http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.259"/>
              <code value="1029-8"/>
              <display value="Medical/Surgical Critical Care"/>
            </valueCoding>
          </answer>
        </item>
      <!--  Date Admitted to Facility
       (CDA Mapping: ClinicalDocument/componentOf/encompassingEncounter/effectiveTime/low)  -->
        <item>
          <linkId value="date-admitted-to-facility"/>
          <text value="Date Admitted to Facility:"/>
          <answer>
            <valueDate value="2018-01-01"/>
          </answer>
        </item>
      <!--  Inborn/Outborn Observation 
       (CDA Mapping: Inborn/Outborn Observation/value) -->
        <item>
          <linkId value="inborn-outborn-observation"/>
          <text
                value="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."/>
          <answer>
            <valueBoolean value="false"/>
          </answer>
        </item>
      <!--  Risk Factors
       CDA: Risk Factors Section (LOS/Men) -->
        <item>
          <linkId value="risk-factors"/>
          <text
                value="Risk Factors: Contains central line present, birth weight, gestational age"/>
        <!--  Central Line present prior to event, including umbilical catheter
         (CDA Mapping: Infection Risk Factors Observation/value="1006-6" - if present then true)  -->
          <item>
            <linkId value="risk-factor-central-line"/>
            <text
                  value="Risk Factor: Central line present prior to event, including umbilical catheter"/>
            <answer>
              <valueBoolean value="true"/>
            </answer>
          </item>
        <!--  Birth Weight (grams)
         (CDA Mapping: Infection Risk Factors Measurement Observaiton/value)  -->
          <item>
            <linkId value="risk-factor-birth-weight"/>
            <text value="Risk Factor: Birth weight (grams)"/>
            <answer>
              <valueQuantity>
                <value value="700"/>
                <unit value="g"/>
              </valueQuantity>
            </answer>
          </item>
        <!--  Gestational Age
         (CDA Mapping: Gestational Age Observation/value)  -->
          <item>
            <linkId value="risk-factor-gestational-age"/>
            <text value="Risk Factor: Gestational age (days)"/>
            <answer>
              <valueQuantity>
                <value value="276"/>
                <unit value="d"/>
              </valueQuantity>
            </answer>
          </item>
        </item>
      <!--  Event Details 
         CDA: Infection Details in Late Onset Sepsis Report -->
        <item>
          <linkId value="event-details"/>
          <text value="Event Details"/>
        <!--  Infection Condition 
         (CDA Mapping: Infection Condition Observation/value -->
          <item>
            <linkId value="infection-condition"/>
            <text value="Specific Event"/>
            <answer>
              <valueCoding>
                <system
                        value="http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277"/>
                <code value="3067-6"/>
                <display
                         value="Neonatal Laboratory Confirmed Bloodstream Infection (NLCBI 2)"/>
              </valueCoding>
            </answer>
          </item>
        <!--  Criteria Used (Lab) 
         (CDA Mapping: Criterion of Diagnosis Observation/value -->
          <item>
            <linkId value="criteria-used"/>
            <text value="Laboratory Criteria Used"/>
            <answer>
              <valueCoding>
                <system
                        value="http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277"/>
                <code value="1951-3"/>
                <display
                         value="Recognized pathogen from one or more blood cultures"/>
              </valueCoding>
            </answer>
          </item>
        <!--  Died 
         (CDA Mapping: Death Observation in an Infection-type Report/value)  -->
          <item>
            <linkId value="died"/>
            <text value="Died"/>
            <answer>
              <valueBoolean value="true"/>
            </answer>
          </item>
        <!--  LOS Contributed to Death 
         (CDA Mapping: Infection Contributed to Death Observation)  -->
        <!--  Note: This item is only enabled when the death observation is marked as "true"  -->
          <item>
            <linkId value="los-contributed-to-death"/>
            <text value="Infection contributed to death"/>
            <answer>
              <valueBoolean value="false"/>
            </answer>
          </item>
        <!--  Discharge Date 
         (CDA Mapping: ClinicalDocument/componentOf/encompassingEncounter/effectiveTime/high)  -->
          <item>
            <linkId value="discharge-date"/>
            <text value="Discharge Date"/>
            <answer>
              <valueDate value="2018-01-12"/>
            </answer>
          </item>
        </item>
      <!--  Findings Group
       CDA: Findings Section in an Infection-Type Report -->
        <item>
          <linkId value="findings-group"/>
          <text
                value="Findings Group: Records whether infection organisms were identified and, if so, records details about them."/>
        <!--  Pathogen Identified
         (CDA Mapping: Pathogen Identified Observation)  -->
          <item>
            <linkId value="pathogen-identified"/>
            <text value="Pathogen Identified"/>
            <answer>
              <valueCoding>
                <system value="http://snomed.info/sct"/>
                <code value="48321006"/>
                <display value="Clostridium symbiosum (organism)"/>
              </valueCoding>
            </answer>
          </item>
        <!--  Pathogen Ranking
         (CDA Mapping: Pathogen Ranking Observation)  -->
          <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>
        <!--  Drug Susceptibility Test Group
         (CDA Mapping: Drug Susceptibility Test Observation)  -->
          <item>
            <linkId value="drug-susceptibility-test-group"/>
            <text value="Drug Susceptibility Test Group"/>
          <!--  Drug Susceptibilty Test 
           CDA: Drug-Susceptibility Test Observation/code  -->
            <item>
              <linkId value="drug-susceptibility-test"/>
              <text value="Drug Susceptibility Test"/>
              <answer>
                <valueCoding>
                  <system value="http://loinc.org"/>
                  <code value="18907-6"/>
                  <display value="Clarithro Susc Islt"/>
                </valueCoding>
              </answer>
            </item>
          <!--  Drug Susceptibilty Test Interpretation
           CDA: Drug-Susceptibility Test Observation/interpretationCode  -->
            <item>
              <linkId value="drug-susceptibility-test-interpretation"/>
              <text value="Drug Susceptibility Test Interpretation"/>
              <answer>
                <valueCoding>
                  <system
                          value="http://hl7.org/fhir/v3/ObservationInterpretation"/>
                  <code value="R"/>
                  <display value="Resistant"/>
                </valueCoding>
              </answer>
            </item>
          </item>
        </item>
      <!--  NHSN Comment
         CDA: NHSN Comment Section/NHSN Comment -->
        <item>
          <linkId value="nhsn-comment"/>
          <text value="Comments"/>
          <answer>
            <valueString
                         value="NHSN text comment that is less than 2000 characters."/>
          </answer>
        </item>
      </QuestionnaireResponse>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:e8f49540-d231-452c-abd5-16e9c6d6375b"/>
    <resource>
      <Patient>
        <meta>
          <profile
                   value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient"/>
        </meta>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
            <table>
              <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>
          </div>
        </text>
      <!--  Race  -->
        <extension
                   url="http://hl7.org/fhir/us/core/StructureDefinition/us-core-race">
          <extension url="ombCategory">
            <valueCoding>
              <system value="urn:oid:2.16.840.1.113883.6.238"/>
              <code value="2106-3"/>
              <display value="White"/>
            </valueCoding>
          </extension>
          <extension url="text">
            <valueString value="White"/>
          </extension>
        </extension>
      <!--  Ethnicity  -->
        <extension
                   url="http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity">
          <extension url="ombCategory">
            <valueCoding>
              <system value="urn:oid:2.16.840.1.113883.6.238"/>
              <code value="2186-5"/>
              <display value="Not Hispanic or Latino"/>
            </valueCoding>
          </extension>
          <extension url="text">
            <valueString value="Not Hispanic or Latino"/>
          </extension>
        </extension>
      <!--     Medicaid beneficiary number     -->
        <identifier>
          <type>
            <coding>
              <system value="http://hl7.org/fhir/v2/0203"/>
              <code value="MA"/>
            </coding>
          </type>
          <system value="urn:oid:2.16.840.1.113883.19.5"/>
          <value value="959595"/>
        </identifier>
      <!--     Social Security     -->
        <identifier>
          <type>
            <coding>
              <system value="http://hl7.org/fhir/v2/0203"/>
              <code value="SS"/>
            </coding>
          </type>
          <system value="urn:oid:2.16.840.1.113883.4.1"/>
          <value value="12345"/>
        </identifier>
      <!--  Medical Record Number  -->
        <identifier>
          <type>
            <coding>
              <system value="http://hl7.org/fhir/v2/0203"/>
              <code value="MR"/>
            </coding>
          </type>
          <system value="urn:oid:2.16.840.1.113883.4.338"/>
          <value value="12345"/>
        </identifier>
        <name>
          <use value="official"/>
          <family value="Nuclear"/>
          <given value="Ned"/>
        </name>
      <!--  use FHIR code system for male / female     -->
        <gender value="male"/>
        <birthDate value="1954-11-25"/>
      </Patient>
    </resource>
  </entry>
  <entry>
    <fullUrl value="urn:uuid:65a95666-9ba7-4107-a37b-07957c094b88"/>
    <resource>
      <Device>
        <text>
          <status value="generated"/>
          <div xmlns="http://www.w3.org/1999/xhtml">
            <p><b>id</b>: hai-authoring-device</p>
            <p><b>Id</b>: 2.16.840.1.113883.3.117.1.1.5.1.1.2:anAuthorID</p>
          </div>
        </text>
        <identifier>
        <!--  (CDA Mapping: author/assignedAuthor/id/root)  -->
          <system value="urn:oid:2.16.840.1.113883.3.117.1.1.5.1.1.2"/>
        <!--  (CDA Mapping: author/assignedAuthor/id/extension)  -->
          <value value="anAuthorId"/>
        </identifier>
      </Device>
    </resource>
  </entry>
</Bundle>