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 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 - XML Representation

Active as of 2019-04-01

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<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="hai-questionnaire-opc-ssi-event"/>
  <meta>
    <versionId value="12"/>
    <lastUpdated value="2023-02-24T01:35:54.061+00:00"/>
    <source value="#tP7HDDAkX8upl5OX"/>
    <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-opc-ssi-event"/>
  <identifier>
    <value value="hai-questionnaire-opc-ssi-event-v1"/>
  </identifier>
  <name value="HAI_questionnaire_opc_ssi_event"/>
  <title
         value="Outpatient Procedure Component Surgical Site Infection (SSI) Event"/>
  <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 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.

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-id"/>
    <text value="Facility ID"/>
    <type value="url"/>
    <required value="true"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="encounter-date"/>
    <text value="Date of encounter"/>
    <type value="date"/>
    <required value="true"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="infection-details"/>
    <text value="Infection details"/>
    <type value="group"/>
    <required value="true"/>
    <repeats value="false"/>
    <item>
      <linkId value="infection-details-group-description"/>
      <text
            value="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)."/>
      <type value="display"/>
    </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="event-date"/>
      <text value="Date of event"/>
      <type value="date"/>
      <required value="true"/>
      <repeats value="false"/>
    </item>
    <item>
      <linkId value="nhsn-procedure-code-category"/>
      <text value="NHSN Procedure Code Category"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <answerValueSet
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.34"/>
    </item>
    <item>
      <linkId value="primary-cpt-procedure-code"/>
      <text value="Primary CPT Procedure Code"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <answerValueSet value="http://hl7.org/fhir/ValueSet/cpt-all"/>
    </item>
    <item>
      <linkId value="procedure-id"/>
      <text value="Procedure Id"/>
      <type value="url"/>
      <required value="true"/>
      <repeats value="false"/>
    </item>
    <item>
      <linkId value="ssi-level"/>
      <text value="Surgical Site Infection (SSI) Level"/>
      <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-of-diagnosis"/>
      <text value="Criteria of Diagnosis"/>
      <type value="group"/>
      <required value="true"/>
      <repeats value="false"/>
      <item>
        <linkId value="criteria-of-diagnosis-group-description"/>
        <text
              value="This group records the criteria used in the diagnosis of an infection."/>
        <type value="display"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-abscess"/>
        <code>
          <system value="http://snomed.info/sct"/>
          <code value="128477000"/>
          <display value="Abscess"/>
        </code>
        <text value="Criteria of Diagnosis: Abscess"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-redness"/>
        <code>
          <system value="http://snomed.info/sct"/>
          <code value="386713009"/>
          <display value="Redness"/>
        </code>
        <text value="Criteria of Diagnosis: Redness"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-fever"/>
        <code>
          <system value="http://snomed.info/sct"/>
          <code value="386661006"/>
          <display value="Fever"/>
        </code>
        <text value="Criteria of Diagnosis: Fever"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-heat"/>
        <code>
          <system value="http://snomed.info/sct"/>
          <code value="304214002"/>
          <display value="Feels warm (finding)"/>
        </code>
        <text value="Criteria of Diagnosis: Heat"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-incision-purulent-drainage"/>
        <code>
          <system value="http://snomed.info/sct"/>
          <code value="255320000"/>
          <display value="Infection - suppurative (disorder)"/>
        </code>
        <text value="Criteria of Diagnosis: Purulent drainage"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-wound-dehisced"/>
        <code>
          <system value="http://snomed.info/sct"/>
          <code value="225553008"/>
          <display value="Wound dehiscence"/>
        </code>
        <text value="Criteria of Diagnosis: Wound spontaneously dehisced"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-incision-opened"/>
        <code>
          <system
                  value="https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"/>
          <code value="1967-9"/>
          <display
                   value="Incision deliberately opened or otherwise drained by physician"/>
        </code>
        <text value="Criteria of Diagnosis: Incision deliberately opened"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-evidence-found"/>
        <code>
          <system
                  value="https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"/>
          <code value="1905-9"/>
          <display
                   value="Other evidence of infection found on direct exam, during surgery, or by diagnostic tests"/>
        </code>
        <text
              value="Criteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-localized-swelling"/>
        <code>
          <system
                  value="https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"/>
          <code value="1920-8"/>
          <display value="Localized swelling"/>
        </code>
        <text value="Criteria of Diagnosis: Localized swelling"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-pain-tenderness"/>
        <code>
          <system
                  value="https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"/>
          <code value="1960-4"/>
          <display value="Pain or tenderness"/>
        </code>
        <text value="Criteria of Diagnosis: Pain or tenderness"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-organism-identified"/>
        <code>
          <system
                  value="https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"/>
          <code value="1952-1"/>
          <display value="Positive culture"/>
        </code>
        <text value="Criteria of Diagnosis: Organism Identified"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-testing-not-performed"/>
        <code>
          <system
                  value="https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"/>
          <code value="1901-8"/>
          <display value="Not cultured"/>
        </code>
        <text
              value="Criteria of Diagnosis: Culture or non-culture based testing not performed"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-imaging-test"/>
        <code>
          <system
                  value="https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"/>
          <code value="1924-0"/>
          <display value="Radiographic evidence of infection"/>
        </code>
        <text
              value="Criteria of Diagnosis: Imaging test evidence of infection"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
      <item>
        <linkId value="criteria-of-diagnosis-physician-diagnosis"/>
        <code>
          <system
                  value="https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html"/>
          <code value="1963-8"/>
          <display value="Physician Diagnosis of this event type"/>
        </code>
        <text
              value="Criteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physician"/>
        <type value="boolean"/>
        <required value="true"/>
        <repeats value="false"/>
      </item>
    </item>
    <item>
      <linkId value="ssi-detection-method-type"/>
      <text
            value="Surveillence method type (active/passive) through which the SSI was detected"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <answerValueSet
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.31"/>
    </item>
    <item>
      <linkId value="ssi-detection-method"/>
      <text value="Surveillence method through which the SSI was detected"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <answerValueSet
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.29"/>
    </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>
  <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>