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 in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
JSON Format: Questionnaire-hai-questionnaire-los-denom
Raw json
{
"resourceType" : "Questionnaire",
"id" : "hai-questionnaire-los-denom",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire"
]
},
"language" : "en-US",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" lang=\"en-US\">\n <h1 xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">Late Onset Sepsis/Meningitis Denominator</h1>\n <p xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">This Questionnaire instance defines the questions and possible answers in the Late Onset Sepsis/Meningitis Event (LOS) Denominator. This report records the denominator information for neonatal component late onset sepsis and meningitis (LOS/Men).</p>\n <p xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">For further details on reporting healthcare-associated infections see the specific protocols and data collection forms on the NHSN website <a href=\"https://www.cdc.gov/nhsn/\">https://www.cdc.gov/nhsn/</a>.</p>\n <h2 xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">Questionnaire Details</h2>\n <table xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">\n <tr>\n <td>\n <b>Id:</b>\n </td>\n <td>hai-questionnaire-los-denom</td>\n </tr>\n <tr>\n <td>\n <b>Profile:</b>\n </td>\n <td>http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire</td>\n </tr>\n <tr>\n <td>\n <b>Language:</b>\n </td>\n <td>en-US</td>\n </tr>\n <tr>\n <td>\n <b>Url:</b>\n </td>\n <td>http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-denom</td>\n </tr>\n <tr>\n <td>\n <b>Identifier:</b>\n </td>\n <td>\n <span>hai-questionnaire-los-denom-v1</span>\n </td>\n </tr>\n <tr>\n <td>\n <b>Version:</b>\n </td>\n <td>Version: 2.0.0</td>\n </tr>\n <tr>\n <td>\n <b>Name:</b>\n </td>\n <td>HAI_questionnaire_los_denom</td>\n </tr>\n <tr>\n <td>\n <b>Status:</b>\n </td>\n <td>draft</td>\n </tr>\n <tr>\n <td>\n <b>Experimental:</b>\n </td>\n <td>false</td>\n </tr>\n <tr>\n <td>\n <b>Subject Type:</b>\n </td>\n <td>Patient (Source Patient Resource (US Core Patient))</td>\n </tr>\n <tr>\n <td>\n <b>Date:</b>\n </td>\n <td>2019-04-01</td>\n </tr>\n <tr>\n <td>\n <b>Publisher:</b>\n </td>\n <td>HL7 Structured Documents Work Group</td>\n </tr>\n <tr>\n <td>\n <b>Jurisdiction:</b>\n </td>\n <td>\n <span title=\"Code system: urn:iso:std:iso:3166\">Code: US</span>\n </td>\n </tr>\n <tr>\n <td>\n <b>Code:</b>\n </td>\n <td>\n <ul style=\"list-style:none; padding-left:0; margin:0 0;\">\n <li>Healthcare Associated Infection report Document</li>\n <li>Code system: <a href=\"http://loinc.org\">http://loinc.org</a>\n </li>\n <li>Code: 51897-7</li>\n </ul>\n </td>\n </tr>\n </table>\n <br xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\"/>\n <br xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\"/>\n <h2 xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">Questionnaire Items (<span style=\"color:red\">*</span> required)</h2>\n <ul xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\" style=\"list-style:none;\">\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Year and month data collected for this location</span> [<span style=\"font-style:italic\">date-collected</span>] (date)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Facility ID</span> [<span style=\"font-style:italic\">facility</span>] (url)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Date Admitted to Facility</span> [<span style=\"font-style:italic\">date-admitted-to-facility</span>] (date)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Location Within Facility Encounter</span> [<span style=\"font-style:italic\">location-within-facility-encounter-group</span>] (group)\n <ul style=\"list-style:none;\">\n <li>This group contains information detailing an encounter at a location within the facility. It contains the patient's location within the facility, the date admitted or transferred to that location, the disposition of the infant and, if the infant was discharged, transferred, or expired, the date on which this occurred is recorded. If the infant had no location change, no date is recorded. [<span style=\"font-style:italic\">location-within-facility-encounter-group-description</span>] (display)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Facility Location Type</span> [<span style=\"font-style:italic\">facility-location-type</span>] (choice)\n <ul>\n <li>answerValueSet: <a href=\"http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.19\">http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.19</a>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Facility Location</span> [<span style=\"font-style:italic\">facility-location</span>] (url)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Date admitted or transferred to location</span> [<span style=\"font-style:italic\">location-admit-transfer-date</span>] (date)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Disposition of infant</span> [<span style=\"font-style:italic\">infant-disposition</span>] (choice)\n <ul>\n <li>answerValueSet: <a href=\"http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.10.20.5.9.30\">http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.10.20.5.9.30</a>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Disposition date if discharged, transferred, or expired</span> [<span style=\"font-style:italic\">disposition-date</span>] (date)\n <ul>\n <li>Enable when: <span style=\"font-style:italic\">infant-disposition</span> = "183665006" or <br/>\n <span style=\"font-style:italic\">infant-disposition</span> = "266751003" or <br/>\n <span style=\"font-style:italic\">infant-disposition</span> = "371828006"<br/>\n </li>\n </ul>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Risk Factors</span> [<span style=\"font-style:italic\">risk-factors</span>] (group)\n <ul style=\"list-style:none;\">\n <li>This group contains risk factors such as birth weight and gestational age. [<span style=\"font-style:italic\">risk-factors-group-description</span>] (display)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Risk Factor: Birth weight (grams)</span> [<span style=\"font-style:italic\">risk-factor-birth-weight</span>] (quantity)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Gestational age known: set true if known and false if unknown</span> [<span style=\"font-style:italic\">gestational-age-known</span>] (boolean)\n </li>\n <li>\n <span style=\"font-weight:bold\">Risk Factor: Gestational age (days)</span> [<span style=\"font-style:italic\">risk-factor-gestational-age</span>] (quantity)\n <ul>\n <li>Enable when: <span style=\"font-style:italic\">gestational-age-known</span> = "true"<br/>\n </li>\n </ul>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Comments</span> [<span style=\"font-style:italic\">nhsn-comment</span>] (text)\n </li>\n </ul>\n </div>"
},
"url" : "http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-denom",
"identifier" : [
{
"value" : "hai-questionnaire-los-denom-v1"
}
],
"version" : "2.0.0",
"name" : "HAI_questionnaire_los_denom",
"title" : "Late Onset Sepsis/Meningitis Denominator",
"status" : "draft",
"experimental" : false,
"subjectType" : [
"Patient"
],
"date" : "2019-04-01",
"publisher" : "HL7 Structured Documents Work Group",
"description" : "This Questionnaire instance defines the questions and possible answers in the Late Onset Sepsis/Meningitis Event (LOS) Denominator. This report records the denominator information for neonatal component late onset sepsis and meningitis (LOS/Men).\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",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US"
}
]
}
],
"code" : [
{
"system" : "http://loinc.org",
"code" : "51897-7",
"display" : "Healthcare Associated Infection report Document"
}
],
"item" : [
{
"linkId" : "date-collected",
"text" : "Year and month data collected for this location",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "facility",
"text" : "Facility ID",
"type" : "url",
"required" : true,
"repeats" : false
},
{
"linkId" : "date-admitted-to-facility",
"text" : "Date Admitted to Facility",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "location-within-facility-encounter-group",
"code" : [
{
"system" : "http://loinc.org",
"code" : "46240-8",
"display" : "History of Hospitalizations+Outpatient visits Narrative"
}
],
"text" : "Location Within Facility Encounter",
"type" : "group",
"required" : true,
"repeats" : false,
"item" : [
{
"linkId" : "location-within-facility-encounter-group-description",
"text" : "This group contains information detailing an encounter at a location within the facility. It contains the patient's location within the facility, the date admitted or transferred to that location, the disposition of the infant and, if the infant was discharged, transferred, or expired, the date on which this occurred is recorded. If the infant had no location change, no date is recorded.",
"type" : "display"
},
{
"linkId" : "facility-location-type",
"text" : "Facility Location Type",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.19"
},
{
"linkId" : "facility-location",
"text" : "Facility Location",
"type" : "url",
"required" : true,
"repeats" : false
},
{
"linkId" : "location-admit-transfer-date",
"text" : "Date admitted or transferred to location",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "infant-disposition",
"text" : "Disposition of infant",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.10.20.5.9.30"
},
{
"linkId" : "disposition-date",
"text" : "Disposition date if discharged, transferred, or expired",
"type" : "date",
"enableWhen" : [
{
"question" : "infant-disposition",
"operator" : "=",
"answerCoding" : {
"system" : "http://snomed.info/sct",
"code" : "183665006"
}
},
{
"question" : "infant-disposition",
"operator" : "=",
"answerCoding" : {
"system" : "http://snomed.info/sct",
"code" : "266751003"
}
},
{
"question" : "infant-disposition",
"operator" : "=",
"answerCoding" : {
"system" : "http://snomed.info/sct",
"code" : "371828006"
}
}
],
"required" : false,
"repeats" : false
}
]
},
{
"linkId" : "risk-factors",
"code" : [
{
"system" : "http://loinc.org",
"code" : "51898-5",
"display" : "Risk factors Document"
}
],
"text" : "Risk Factors",
"type" : "group",
"required" : true,
"repeats" : false,
"item" : [
{
"linkId" : "risk-factors-group-description",
"text" : "This group contains risk factors such as birth weight and gestational age.",
"type" : "display"
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding" : {
"system" : "http://unitsofmeasure.org",
"code" : "g",
"display" : "g"
}
}
],
"linkId" : "risk-factor-birth-weight",
"code" : [
{
"system" : "http://snomed.info/sct",
"code" : "364589006",
"display" : "Birth Weight"
}
],
"text" : "Risk Factor: Birth weight (grams)",
"type" : "quantity",
"required" : true,
"repeats" : false
},
{
"linkId" : "gestational-age-known",
"text" : "Gestational age known: set true if known and false if unknown",
"type" : "boolean",
"required" : true,
"repeats" : false
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding" : {
"system" : "http://unitsofmeasure.org",
"code" : "d",
"display" : "d"
}
}
],
"linkId" : "risk-factor-gestational-age",
"code" : [
{
"system" : "http://loinc.org",
"code" : "76516-4",
"display" : "Gestational age--at birth"
}
],
"text" : "Risk Factor: Gestational age (days)",
"type" : "quantity",
"enableWhen" : [
{
"question" : "gestational-age-known",
"operator" : "=",
"answerBoolean" : true
}
],
"required" : false,
"repeats" : false
}
]
},
{
"linkId" : "nhsn-comment",
"code" : [
{
"system" : "http://www.loinc.org",
"code" : "86468-6",
"display" : "Report Comment Section"
}
],
"text" : "Comments",
"type" : "text",
"required" : false,
"repeats" : false,
"maxLength" : 2000
}
]
}
