This page is part of the Healthcare Associated Infection Implementation Guide (v2.0.0: STU 2) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions
JSON Format: Questionnaire-hai-questionnaire-los-event
Raw json
{
"resourceType" : "Questionnaire",
"id" : "hai-questionnaire-los-event",
"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 Event (LOS)</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) Report. It records a late onset sepsis/meningitis infection event. For Late Onset Sepsis/Meningitis Event Reports, a Medicaid beneficiary number may be present.</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-event</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-event</td>\n </tr>\n <tr>\n <td>\n <b>Identifier:</b>\n </td>\n <td>\n <span>hai-questionnaire-los-event-v2</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_event</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>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\">Facility ID</span> [<span style=\"font-style:italic\">facility</span>] (url)\n </li>\n <li>\n <span style=\"font-weight:bold\">Event Number</span> [<span style=\"font-style:italic\">event-number</span>] (url)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Event Type</span> [<span style=\"font-style:italic\">event-type</span>] (choice)\n <ul>\n <li>answerValueSet: <a href=\"http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.20\">http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.20</a>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Date of Event</span> [<span style=\"font-style:italic\">date-of-event</span>] (date)\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>] (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\">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\">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.</span> [<span style=\"font-style:italic\">inborn-outborn-observation</span>] (boolean)\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 central line present, birth weight, and gestational age. [<span style=\"font-style:italic\">risk-factors-group</span>] (display)\n </li>\n <li>\n <span style=\"font-weight:bold\">Risk Factor: Central line present prior to event, including umbilical catheter</span> [<span style=\"font-style:italic\">risk-factor-central-line</span>] (boolean)\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=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Event Details</span> [<span style=\"font-style:italic\">event-details</span>] (group)\n <ul style=\"list-style:none;\">\n <li>This group contains details aboout the late onset septis infection event. [<span style=\"font-style:italic\">event-details-group</span>] (display)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Specific Event</span> [<span style=\"font-style:italic\">infection-condition</span>] (choice)\n <ul>\n <li>answerValueSet: <a href=\"http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3196\">http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3196</a>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Laboratory Criteria Used</span> [<span style=\"font-style:italic\">criteria-used</span>] (choice)\n <ul>\n <li>answerValueSet: <a href=\"http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3195\">http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3195</a>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Died</span> [<span style=\"font-style:italic\">died</span>] (boolean)\n </li>\n <li>\n <span style=\"font-weight:bold\">Infection contributed to death</span> [<span style=\"font-style:italic\">los-contributed-to-death</span>] (boolean)\n <ul>\n <li>Enable when: <span style=\"font-style:italic\">died</span> = "true"<br/>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Discharge Date</span> [<span style=\"font-style:italic\">discharge-date</span>] (date)\n </li>\n </ul>\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Findings Group</span> [<span style=\"font-style:italic\">findings-group</span>] (group, repeats)\n <ul style=\"list-style:none;\">\n <li>This group records whether infection organisms were identified and, if so, records details about them. [<span style=\"font-style:italic\">findings-group-description</span>] (display)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Pathogen Identified</span> [<span style=\"font-style:italic\">pathogen-identified</span>] (choice)\n <ul>\n <li>answerValueSet: <a href=\"http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.16\">http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.16</a>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Pathogen Ranking</span> [<span style=\"font-style:italic\">pathogen-ranking</span>] (choice)\n <ul>\n <li>answerValueSet: <a href=\"http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking\">http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking</a>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Drug Susceptibility Test Group</span> [<span style=\"font-style:italic\">drug-susceptibility-test-group</span>] (group, repeats)\n <ul style=\"list-style:none;\">\n <li>This group contains drug-susceptibility information such as the drug and the pathogen's susceptibility to it. [<span style=\"font-style:italic\">drug-susceptibility-test-group-description</span>] (display)\n </li>\n <li>\n <span style=\"color:red\">* </span>\n <span style=\"font-weight:bold\">Drug Susceptibility Test</span> [<span style=\"font-style:italic\">drug-susceptibility-test</span>] (choice)\n <ul>\n <li>answerValueSet: <a href=\"http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.15\">http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.15</a>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Drug Susceptibility Test Interpretation</span> [<span style=\"font-style:italic\">drug-susceptibility-test-interpretation</span>] (choice)\n <ul>\n <li>answerValueSet: <a href=\"http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.13\">http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.13</a>\n </li>\n </ul>\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-event",
"identifier" : [
{
"value" : "hai-questionnaire-los-event-v2"
}
],
"version" : "2.0.0",
"name" : "HAI_questionnaire_los_event",
"title" : "Late Onset Sepsis/Meningitis Event (LOS)",
"status" : "draft",
"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) Report. It records a late onset sepsis/meningitis infection event. For Late Onset Sepsis/Meningitis Event Reports, a Medicaid beneficiary number may be present.\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" : "facility",
"text" : "Facility ID",
"type" : "url",
"required" : true,
"repeats" : false
},
{
"linkId" : "event-number",
"text" : "Event Number",
"type" : "url",
"required" : false,
"repeats" : false
},
{
"linkId" : "event-type",
"text" : "Event Type",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.20"
},
{
"linkId" : "date-of-event",
"text" : "Date of Event",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "facility-location",
"text" : "Facility Location",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.19"
},
{
"linkId" : "date-admitted-to-facility",
"text" : "Date Admitted to Facility:",
"type" : "date",
"required" : true,
"repeats" : false
},
{
"linkId" : "inborn-outborn-observation",
"code" : [
{
"system" : "http://snomed.info/sct",
"code" : "445087001",
"display" : "Born before arrival to hospital (situation)"
}
],
"text" : "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" : "boolean",
"required" : true,
"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",
"text" : "This group contains risk factors such as central line present, birth weight, and gestational age.",
"type" : "display"
},
{
"linkId" : "risk-factor-central-line",
"code" : [
{
"system" : "http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277",
"code" : "1006-6",
"display" : "central line including umbilical catheter"
}
],
"text" : "Risk Factor: Central line present prior to event, including umbilical catheter",
"type" : "boolean",
"required" : false,
"repeats" : false
},
{
"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" : "event-details",
"code" : [
{
"system" : "http://loinc.org",
"code" : "51899-3",
"display" : "Details Document"
}
],
"text" : "Event Details",
"type" : "group",
"required" : true,
"repeats" : false,
"item" : [
{
"linkId" : "event-details-group",
"text" : "This group contains details aboout the late onset septis infection event.",
"type" : "display"
},
{
"linkId" : "infection-condition",
"text" : "Specific Event",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3196"
},
{
"linkId" : "criteria-used",
"text" : "Laboratory Criteria Used",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3195"
},
{
"linkId" : "died",
"code" : [
{
"system" : "http://snomed.info/sct",
"code" : "419099009",
"display" : "dead"
}
],
"text" : "Died",
"type" : "boolean",
"required" : true,
"repeats" : false
},
{
"linkId" : "los-contributed-to-death",
"text" : "Infection contributed to death",
"type" : "boolean",
"enableWhen" : [
{
"question" : "died",
"operator" : "=",
"answerBoolean" : true
}
],
"required" : false,
"repeats" : false
},
{
"linkId" : "discharge-date",
"text" : "Discharge Date",
"type" : "date",
"required" : false,
"repeats" : false
}
]
},
{
"linkId" : "findings-group",
"code" : [
{
"system" : "http://loinc.org",
"code" : "18769-0",
"display" : "Microbial susceptibility tests Set"
}
],
"text" : "Findings Group",
"type" : "group",
"required" : true,
"repeats" : true,
"item" : [
{
"linkId" : "findings-group-description",
"text" : "This group records whether infection organisms were identified and, if so, records details about them.",
"type" : "display"
},
{
"linkId" : "pathogen-identified",
"text" : "Pathogen Identified",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.16"
},
{
"linkId" : "pathogen-ranking",
"text" : "Pathogen Ranking",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking"
},
{
"linkId" : "drug-susceptibility-test-group",
"text" : "Drug Susceptibility Test Group",
"type" : "group",
"repeats" : true,
"item" : [
{
"linkId" : "drug-susceptibility-test-group-description",
"text" : "This group contains drug-susceptibility information such as the drug and the pathogen's susceptibility to it.",
"type" : "display"
},
{
"linkId" : "drug-susceptibility-test",
"text" : "Drug Susceptibility Test",
"type" : "choice",
"required" : true,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.15"
},
{
"linkId" : "drug-susceptibility-test-interpretation",
"text" : "Drug Susceptibility Test Interpretation",
"type" : "choice",
"required" : false,
"repeats" : false,
"answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.13"
}
]
}
]
},
{
"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
}
]
}
