NHSN Healthcare Associated Infection (HAI) Reports
2.1.0 - STU 2.1 United States of America flag

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 in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

: Questionnaire - Outpatient Procedure Component Surgical Site Infection Event - TTL Representation

Active as of 2019-04-01

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Questionnaire ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "hai-questionnaire-opc-ssi-event"] ; # 
  fhir:meta [
fhir:versionId [ fhir:v "12" ] ;
fhir:lastUpdated [ fhir:v "2023-02-24T01:35:54.061+00:00"^^xsd:dateTime ] ;
fhir:source [ fhir:v "#tP7HDDAkX8upl5OX"^^xsd:anyURI ] ;
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire>     ] )
  ] ; # 
  fhir:language [ fhir:v "en-US"] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Placeholder</div>"
  ] ; # 
  fhir:url [ fhir:v "http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-opc-ssi-event"^^xsd:anyURI] ; # 
  fhir:identifier ( [
fhir:value [ fhir:v "hai-questionnaire-opc-ssi-event-v1" ]
  ] ) ; # 
  fhir:name [ fhir:v "HAI_questionnaire_opc_ssi_event"] ; # 
  fhir:title [ fhir:v "Outpatient Procedure Component Surgical Site Infection (SSI) Event"] ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:experimental [ fhir:v "false"^^xsd:boolean] ; # 
  fhir:subjectType ( [ fhir:v "Patient"] ) ; # 
  fhir:date [ fhir:v "2019-04-01"^^xsd:date] ; # 
  fhir:publisher [ fhir:v "HL7 International - Structured Documents Work Group"] ; # 
  fhir:contact ( [
fhir:name [ fhir:v "HL7 International - Structured Documents" ] ;
    ( fhir:telecom [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://www.hl7.org/Special/committees/structure" ]     ] )
  ] ) ; # 
  fhir:description [ fhir:v "This Questionnaire instance defines the questions and possible answers in the Outpatient Procedure Component Surgical Site Infection Event. This report is for reporting data on each patient having a SSI event related to one of the NHSN operative procedures selected for monitoring.\n\nFor 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/).\n"] ; # 
  fhir:jurisdiction ( [
    ( fhir:coding [
fhir:system [ fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ] ;
fhir:code [ fhir:v "US" ] ;
fhir:display [ fhir:v "United States of America" ]     ] ) ;
fhir:text [ fhir:v "United States of America" ]
  ] ) ; # 
  fhir:code ( [
a loinc:51897-7 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "51897-7" ] ;
fhir:display [ fhir:v "Healthcare Associated Infection report Document" ]
  ] ) ; # 
  fhir:item ( [
fhir:linkId [ fhir:v "facility-id" ] ;
fhir:text [ fhir:v "Facility ID" ] ;
fhir:type [ fhir:v "url" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]
  ] [
fhir:linkId [ fhir:v "encounter-date" ] ;
fhir:text [ fhir:v "Date of encounter" ] ;
fhir:type [ fhir:v "date" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]
  ] [
fhir:linkId [ fhir:v "infection-details" ] ;
fhir:text [ fhir:v "Infection details" ] ;
fhir:type [ fhir:v "group" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
    ( fhir:item [
fhir:linkId [ fhir:v "infection-details-group-description" ] ;
fhir:text [ fhir:v "This group records the infection type, with details. It records SSI level, all identification criteria used to identify this SSI event, and identified pathogen(s)." ] ;
fhir:type [ fhir:v "display" ]     ] [
fhir:linkId [ fhir:v "event-type" ] ;
fhir:text [ fhir:v "Event Type" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
fhir:answerValueSet [
fhir:v "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.20"^^xsd:anyURI ;
fhir:link <http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.20>       ]     ] [
fhir:linkId [ fhir:v "event-date" ] ;
fhir:text [ fhir:v "Date of event" ] ;
fhir:type [ fhir:v "date" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]     ] [
fhir:linkId [ fhir:v "nhsn-procedure-code-category" ] ;
fhir:text [ fhir:v "NHSN Procedure Code Category" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
fhir:answerValueSet [
fhir:v "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.34"^^xsd:anyURI ;
fhir:link <http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.34>       ]     ] [
fhir:linkId [ fhir:v "primary-cpt-procedure-code" ] ;
fhir:text [ fhir:v "Primary CPT Procedure Code" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
fhir:answerValueSet [
fhir:v "http://hl7.org/fhir/ValueSet/cpt-all"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/ValueSet/cpt-all>       ]     ] [
fhir:linkId [ fhir:v "procedure-id" ] ;
fhir:text [ fhir:v "Procedure Id" ] ;
fhir:type [ fhir:v "url" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]     ] [
fhir:linkId [ fhir:v "ssi-level" ] ;
fhir:text [ fhir:v "Surgical Site Infection (SSI) Level" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
fhir:answerValueSet [
fhir:v "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3196"^^xsd:anyURI ;
fhir:link <http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3196>       ]     ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis" ] ;
fhir:text [ fhir:v "Criteria of Diagnosis" ] ;
fhir:type [ fhir:v "group" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
      ( fhir:item [
fhir:linkId [ fhir:v "criteria-of-diagnosis-group-description" ] ;
fhir:text [ fhir:v "This group records the criteria used in the diagnosis of an infection." ] ;
fhir:type [ fhir:v "display" ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-abscess" ] ;
        ( fhir:code [
a sct:128477000 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "128477000" ] ;
fhir:display [ fhir:v "Abscess" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Abscess" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-redness" ] ;
        ( fhir:code [
a sct:386713009 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "386713009" ] ;
fhir:display [ fhir:v "Redness" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Redness" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-fever" ] ;
        ( fhir:code [
a sct:386661006 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "386661006" ] ;
fhir:display [ fhir:v "Fever" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Fever" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-heat" ] ;
        ( fhir:code [
a sct:304214002 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "304214002" ] ;
fhir:display [ fhir:v "Feels warm (finding)" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Heat" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-incision-purulent-drainage" ] ;
        ( fhir:code [
a sct:255320000 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "255320000" ] ;
fhir:display [ fhir:v "Infection - suppurative (disorder)" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Purulent drainage" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-wound-dehisced" ] ;
        ( fhir:code [
a sct:225553008 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "225553008" ] ;
fhir:display [ fhir:v "Wound dehiscence" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Wound spontaneously dehisced" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-incision-opened" ] ;
        ( fhir:code [
fhir:system [ fhir:v "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1967-9" ] ;
fhir:display [ fhir:v "Incision deliberately opened or otherwise drained by physician" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Incision deliberately opened" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-evidence-found" ] ;
        ( fhir:code [
fhir:system [ fhir:v "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1905-9" ] ;
fhir:display [ fhir:v "Other evidence of infection found on direct exam, during surgery, or by diagnostic tests" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-localized-swelling" ] ;
        ( fhir:code [
fhir:system [ fhir:v "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1920-8" ] ;
fhir:display [ fhir:v "Localized swelling" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Localized swelling" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-pain-tenderness" ] ;
        ( fhir:code [
fhir:system [ fhir:v "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1960-4" ] ;
fhir:display [ fhir:v "Pain or tenderness" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Pain or tenderness" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-organism-identified" ] ;
        ( fhir:code [
fhir:system [ fhir:v "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1952-1" ] ;
fhir:display [ fhir:v "Positive culture" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Organism Identified" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-testing-not-performed" ] ;
        ( fhir:code [
fhir:system [ fhir:v "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1901-8" ] ;
fhir:display [ fhir:v "Not cultured" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Culture or non-culture based testing not performed" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-imaging-test" ] ;
        ( fhir:code [
fhir:system [ fhir:v "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1924-0" ] ;
fhir:display [ fhir:v "Radiographic evidence of infection" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Imaging test evidence of infection" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] [
fhir:linkId [ fhir:v "criteria-of-diagnosis-physician-diagnosis" ] ;
        ( fhir:code [
fhir:system [ fhir:v "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"^^xsd:anyURI ] ;
fhir:code [ fhir:v "1963-8" ] ;
fhir:display [ fhir:v "Physician Diagnosis of this event type" ]         ] ) ;
fhir:text [ fhir:v "Criteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physician" ] ;
fhir:type [ fhir:v "boolean" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ]       ] )     ] [
fhir:linkId [ fhir:v "ssi-detection-method-type" ] ;
fhir:text [ fhir:v "Surveillence method type (active/passive) through which the SSI was detected" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
fhir:answerValueSet [
fhir:v "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.31"^^xsd:anyURI ;
fhir:link <http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.31>       ]     ] [
fhir:linkId [ fhir:v "ssi-detection-method" ] ;
fhir:text [ fhir:v "Surveillence method through which the SSI was detected" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
fhir:answerValueSet [
fhir:v "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.29"^^xsd:anyURI ;
fhir:link <http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.29>       ]     ] )
  ] [
fhir:linkId [ fhir:v "findings-group" ] ;
    ( fhir:code [
a loinc:18769-0 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "18769-0" ] ;
fhir:display [ fhir:v "Microbial susceptibility tests Set" ]     ] ) ;
fhir:text [ fhir:v "Findings Group" ] ;
fhir:type [ fhir:v "group" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "true"^^xsd:boolean ] ;
    ( fhir:item [
fhir:linkId [ fhir:v "findings-group-description" ] ;
fhir:text [ fhir:v "This group records whether infection organisms were identified and, if so, records details about them." ] ;
fhir:type [ fhir:v "display" ]     ] [
fhir:linkId [ fhir:v "pathogen-identified" ] ;
fhir:text [ fhir:v "Pathogen Identified" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
fhir:answerValueSet [
fhir:v "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.16"^^xsd:anyURI ;
fhir:link <http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.16>       ]     ] [
fhir:linkId [ fhir:v "pathogen-ranking" ] ;
fhir:text [ fhir:v "Pathogen Ranking" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
fhir:answerValueSet [
fhir:v "http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking>       ]     ] )
  ] [
fhir:linkId [ fhir:v "nhsn-comment" ] ;
    ( fhir:code [
a loinc:86468-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "86468-6" ] ;
fhir:display [ fhir:v "Report Comment Section" ]     ] ) ;
fhir:text [ fhir:v "Comments" ] ;
fhir:type [ fhir:v "text" ] ;
fhir:required [ fhir:v "false"^^xsd:boolean ] ;
fhir:repeats [ fhir:v "false"^^xsd:boolean ] ;
fhir:maxLength [ fhir:v "2000"^^xsd:integer ]
  ] ) . #