NHSN Healthcare Associated Infection (HAI) Reports
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This page is part of the Healthcare Associated Infection Implementation Guide (v2.1.0: STU2) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: Questionnaire - Late Onset Sepsis/Meningitis Event (LOS) - XML Representation

Active as of 2019-04-01

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<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="hai-questionnaire-los-event"/>
  <meta>
    <versionId value="13"/>
    <lastUpdated value="2023-02-24T01:35:54.069+00:00"/>
    <source value="#TutCpWfFornPy4FG"/>
    <profile
             value="http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">Placeholder</div>
  </text>
  <url
       value="http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-event"/>
  <identifier>
    <value value="hai-questionnaire-los-event-v2"/>
  </identifier>
  <name value="HAI_questionnaire_los_event"/>
  <title value="Late Onset Sepsis/Meningitis Event (LOS)"/>
  <status value="active"/>
  <experimental value="false"/>
  <subjectType value="Patient"/>
  <date value="2019-04-01"/>
  <publisher value="HL7 International - Structured Documents Work Group"/>
  <contact>
    <name value="HL7 International - Structured Documents"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/structure"/>
    </telecom>
  </contact>
  <description
               value="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.

For further details on reporting healthcare-associated infections see the specific protocols and data collection forms on the NHSN website [https://www.cdc.gov/nhsn/](https://www.cdc.gov/nhsn/).
"/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
      <display value="United States of America"/>
    </coding>
    <text value="United States of America"/>
  </jurisdiction>
  <code>
    <system value="http://loinc.org"/>
    <code value="51897-7"/>
    <display value="Healthcare Associated Infection report Document"/>
  </code>
  <item>
    <linkId value="facility"/>
    <text value="Facility ID"/>
    <type value="url"/>
    <required value="true"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="event-number"/>
    <text value="Event Number"/>
    <type value="url"/>
    <required value="false"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="event-type"/>
    <text value="Event Type"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerValueSet
                    value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.20"/>
  </item>
  <item>
    <linkId value="date-of-event"/>
    <text value="Date of Event"/>
    <type value="date"/>
    <required value="true"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="facility-location"/>
    <text value="Facility Location"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerValueSet
                    value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.19"/>
  </item>
  <item>
    <linkId value="date-admitted-to-facility"/>
    <text value="Date Admitted to Facility:"/>
    <type value="date"/>
    <required value="true"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="inborn-outborn-observation"/>
    <code>
      <system value="http://snomed.info/sct"/>
      <code value="445087001"/>
      <display value="Born before arrival to hospital (situation)"/>
    </code>
    <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."/>
    <type value="boolean"/>
    <required value="true"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="risk-factors"/>
    <code>
      <system value="http://loinc.org"/>
      <code value="51898-5"/>
      <display value="Risk factors Document"/>
    </code>
    <text value="Risk Factors"/>
    <type value="group"/>
    <required value="true"/>
    <repeats value="false"/>
    <item>
      <linkId value="risk-factors-group"/>
      <text
            value="This group contains risk factors such as central line present, birth weight, and gestational age."/>
      <type value="display"/>
    </item>
    <item>
      <linkId value="risk-factor-central-line"/>
      <code>
        <system
                value="https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"/>
        <code value="1006-6"/>
        <display value="central line including umbilical catheter"/>
      </code>
      <text
            value="Risk Factor: Central line present prior to event, including umbilical catheter"/>
      <type value="boolean"/>
      <required value="false"/>
      <repeats value="false"/>
    </item>
    <item>
      <linkId value="risk-factor-birth-weight"/>
      <code>
        <system value="http://snomed.info/sct"/>
        <code value="364589006"/>
        <display value="Birth Weight"/>
      </code>
      <text value="Risk Factor: Birth weight (grams)"/>
      <type value="quantity"/>
      <required value="true"/>
      <repeats value="false"/>
    </item>
    <item>
      <linkId value="gestational-age-known"/>
      <text
            value="Gestational age known: set true if known and false if unknown"/>
      <type value="boolean"/>
      <required value="true"/>
      <repeats value="false"/>
    </item>
    <item>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/questionnaire-unit">
        <valueCoding>
          <system value="http://unitsofmeasure.org"/>
          <code value="d"/>
          <display value="d"/>
        </valueCoding>
      </extension>
      <linkId value="risk-factor-gestational-age"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="76516-4"/>
        <display value="Gestational age--at birth"/>
      </code>
      <text value="Risk Factor: Gestational age (days)"/>
      <type value="quantity"/>
      <enableWhen>
        <question value="gestational-age-known"/>
        <operator value="="/>
        <answerBoolean value="true"/>
      </enableWhen>
      <required value="false"/>
      <repeats value="false"/>
    </item>
  </item>
  <item>
    <linkId value="event-details"/>
    <code>
      <system value="http://loinc.org"/>
      <code value="51899-3"/>
      <display value="Details Document"/>
    </code>
    <text value="Event Details"/>
    <type value="group"/>
    <required value="true"/>
    <repeats value="false"/>
    <item>
      <linkId value="event-details-group"/>
      <text
            value="This group contains details aboout the late onset septis infection event."/>
      <type value="display"/>
    </item>
    <item>
      <linkId value="infection-condition"/>
      <text value="Specific Event"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <answerValueSet
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3196"/>
    </item>
    <item>
      <linkId value="criteria-used"/>
      <text value="Laboratory Criteria Used"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <answerValueSet
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3195"/>
    </item>
    <item>
      <linkId value="died"/>
      <code>
        <system value="http://snomed.info/sct"/>
        <code value="419099009"/>
        <display value="dead"/>
      </code>
      <text value="Died"/>
      <type value="boolean"/>
      <required value="true"/>
      <repeats value="false"/>
    </item>
    <item>
      <linkId value="los-contributed-to-death"/>
      <text value="Infection contributed to death"/>
      <type value="boolean"/>
      <enableWhen>
        <question value="died"/>
        <operator value="="/>
        <answerBoolean value="true"/>
      </enableWhen>
      <required value="false"/>
      <repeats value="false"/>
    </item>
    <item>
      <linkId value="discharge-date"/>
      <text value="Discharge Date"/>
      <type value="date"/>
      <required value="false"/>
      <repeats value="false"/>
    </item>
  </item>
  <item>
    <linkId value="findings-group"/>
    <code>
      <system value="http://loinc.org"/>
      <code value="18769-0"/>
      <display value="Microbial susceptibility tests Set"/>
    </code>
    <text value="Findings Group"/>
    <type value="group"/>
    <required value="true"/>
    <repeats value="true"/>
    <item>
      <linkId value="findings-group-description"/>
      <text
            value="This group records whether infection organisms were identified and, if so, records details about them."/>
      <type value="display"/>
    </item>
    <item>
      <linkId value="pathogen-identified"/>
      <text value="Pathogen Identified"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <answerValueSet
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.16"/>
    </item>
    <item>
      <linkId value="pathogen-ranking"/>
      <text value="Pathogen Ranking"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <answerValueSet
                      value="http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking"/>
    </item>
    <item>
      <linkId value="drug-susceptibility-test-group"/>
      <text value="Drug Susceptibility Test Group"/>
      <type value="group"/>
      <repeats value="true"/>
      <item>
        <linkId value="drug-susceptibility-test-group-description"/>
        <text
              value="This group contains drug-susceptibility information such as the drug and the pathogen's susceptibility to it."/>
        <type value="display"/>
      </item>
      <item>
        <linkId value="drug-susceptibility-test"/>
        <text value="Drug Susceptibility Test"/>
        <type value="choice"/>
        <required value="true"/>
        <repeats value="false"/>
        <answerValueSet
                        value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.15"/>
      </item>
      <item>
        <linkId value="drug-susceptibility-test-interpretation"/>
        <text value="Drug Susceptibility Test Interpretation"/>
        <type value="choice"/>
        <required value="false"/>
        <repeats value="false"/>
        <answerValueSet
                        value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.13"/>
      </item>
    </item>
  </item>
  <item>
    <linkId value="nhsn-comment"/>
    <code>
      <system value="http://loinc.org"/>
      <code value="86468-6"/>
      <display value="Report Comment Section"/>
    </code>
    <text value="Comments"/>
    <type value="text"/>
    <required value="false"/>
    <repeats value="false"/>
    <maxLength value="2000"/>
  </item>
</Questionnaire>