This page is part of the Healthcare Associated Infection Implementation Guide (v1.0.0: STU 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

• Questionnaire Content
• Questionnaire XML
• Questionnaire JSON

<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="hai-questionnaire-los-event"/>
  <meta>
    <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">
      <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.<br/>For Late Onset Sepsis/Meningitis Event Reports, a Medicaid beneficiary number may be present.</p>

      <h2>Late Onset Sepsis/Meningitis Event (LOS) Instance Details</h2>
      <table border="1">
        <tbody>
          <tr>
            <td>url</td>
            <td>http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-event</td>
          </tr>

          <tr>
            <td>Version</td>
            <td>R1</td>
          </tr>
          <tr>
            <td>title</td>
            <td>Late Onset Sepsis/Meningitis Event (LOS)</td>
          </tr>
          <tr>
            <td>Publish date</td>
            <td>2018-09-30</td>
          </tr>
          <tr>
            <td>Realm</td>
            <td>US</td>
          </tr>
          <tr>
            <td>Code</td>
            <td>LOINC 51897-7: Healthcare Associated Infection report Document</td>
          </tr>
          <tr>
            <td>Subject type</td>
            <td>Patient</td>
          </tr>
        </tbody>
      </table>
      <h2>Questionnaire Items</h2>
      <table border="1">
        <thead>
          <tr>
            <th>Group</th>
            <th>Item</th>
            <th>Type</th>
            <th>Required</th>
            <th>Repeats</th>
          </tr>
        </thead>
        <tbody>
          <tr>
            <td/>
            <td>Facility ID</td>
            <td>url</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td/>
            <td>Event #</td>
            <td>url</td>
            <td>false</td>
            <td>false</td>
          </tr>
          <tr>
            <td/>
            <td>Event Type</td>
            <td>choice</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td/>
            <td>Date of Event</td>
            <td>date</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td/>
            <td>Facility Location</td>
            <td>choice</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td/>
            <td>Date Admitted to Facility</td>
            <td>date</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td/>
            <td>Inborn/Outborn</td>
            <td>boolean</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td/>
            <td>Risk Factors</td>
            <td>group</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Risk Factors</td>
            <td>Central line present prior to event, including umbilical catheter</td>
            <td>boolean</td>
            <td>false</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Risk Factors</td>
            <td>Birth weight (grams)</td>
            <td>quantity</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Risk Factors</td>
            <td>Gestational Age at Birth</td>
            <td>quantity</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td/>
            <td>Event Details</td>
            <td>group</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Event Details</td>
            <td>Specific Event</td>
            <td>choice</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Event Details</td>
            <td>Laboratory Criteria Used</td>
            <td>choice</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Event Details</td>
            <td>Died</td>
            <td>boolean</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Event Details</td>
            <td>Infection contributed to death</td>
            <td>boolean</td>
            <td>true if died='true'</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Event Details</td>
            <td>Discharge date</td>
            <td>date</td>
            <td>false</td>
            <td>false</td>
          </tr>
          <tr>
            <td/>
            <td>Findings Group</td>
            <td>group</td>
            <td>false</td>
            <td>true</td>
          </tr>
          <tr>
            <td>Findings Group</td>
            <td>Pathogen Identified</td>
            <td>choice</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Findings Group</td>
            <td>Pathogen Ranking</td>
            <td>choice</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Findings Group</td>
            <td>Drug Susceptibility Test Group</td>
            <td>group</td>
            <td>false</td>
            <td>true</td>
          </tr>
          <tr>
            <td>Drug Susceptibility Test Group</td>
            <td>Drug Susceptibility Test</td>
            <td>choice</td>
            <td>true</td>
            <td>false</td>
          </tr>
          <tr>
            <td>Drug Susceptibility Test Group</td>
            <td>Drug Susceptibility Test Interpretation</td> 
            <td>choice</td>
            <td>false</td>
            <td>false</td>
          </tr>
          
          <tr>
            <td/>
            <td>Comments</td>
            <td>text</td>
            <td>false</td>
            <td>false</td>
          </tr>
        </tbody>
      </table>
    </div>
  </text>
  <url
       value="http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-event"/>
  <identifier>
    <value value="hai-questionnaire-los-event-v1"/>
  </identifier>
  <version value="1.0.0"/>
  <title value="Late Onset Sepsis/Meningitis Event (LOS)"/>
  <status value="draft"/>
  <date value="2018-09-30T00:00:00+10:00"/>
  <publisher value="HL7"/>
  <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."/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
      <display value="United States of America"/>
    </coding>
  </jurisdiction>
  <code>
    <system value="http://loinc.org"/>
    <code value="51897-7"/>
    <display value="Healthcare Associated Infection report Document"/>
  </code>
  <subjectType value="Patient"/>
  <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 #"/>
    <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"/>
    <options>
      <reference
                 value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.20"/>
    </options>
  </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"/>
    <options>
      <reference
                 value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.19"/>
    </options>
  </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: Contains central line present, birth weight, gestational age"/>
    <type value="group"/>
    <repeats value="false"/>
    <item>
      <linkId value="risk-factor-central-line"/>
      <code>
        <system value="urn:oid:2.16.840.1.113883.6.277"/>
        <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>
      <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"/>
      <required value="true"/>
      <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"/>
    <repeats value="false"/>
    <item>
      <linkId value="infection-condition"/>
      <text value="Specific Event"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <options>
        <reference
                   value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3196"/>
      </options>
    </item>
    <item>
      <linkId value="criteria-used"/>
      <text value="Laboratory Criteria Used"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <options>
        <reference
                   value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3195"/>
      </options>
    </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"/>
        <answerBoolean value="true"/>
      </enableWhen>
      <required value="true"/>
      <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: Records whether infection organisms were identified and, if so, records details about them."/>
    <type value="group"/>
    <repeats value="true"/>
    <item>
      <linkId value="pathogen-identified"/>
      <text value="Pathogen Identified"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <options>
        <reference
                   value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.16"/>
      </options>
    </item>
    <item>
      <linkId value="pathogen-ranking"/>
      <text value="Pathogen Ranking"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <options>
        <reference
                   value="http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking"/>
      </options>
    </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"/>
        <text value="Drug Susceptibility Test"/>
        <type value="choice"/>
        <required value="true"/>
        <repeats value="false"/>
        <options>
          <reference
                     value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.15"/>
        </options>
      </item>
      <item>
        <linkId value="drug-susceptibility-test-interpretation"/>
        <text value="Drug Susceptibility Test Interpretation"/>
        <type value="choice"/>
        <required value="false"/>
        <repeats value="false"/>
        <options>
          <reference
                     value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.13"/>
        </options>
      </item>
    </item>
  </item>
  <item>
    <linkId value="nhsn-comment"/>
    <code>
      <system value="http://www.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>