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
XML Format: Questionnaire-hai-questionnaire-los-event
Raw xml
<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" lang="en-US"> <h1 xmlns:xsl="http://www.w3.org/1999/XSL/Transform">Late Onset Sepsis/Meningitis Event (LOS)</h1> <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> <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> <h2 xmlns:xsl="http://www.w3.org/1999/XSL/Transform">Questionnaire Details</h2> <table xmlns:xsl="http://www.w3.org/1999/XSL/Transform"> <tr> <td> <b>Id:</b> </td> <td>hai-questionnaire-los-event</td> </tr> <tr> <td> <b>Profile:</b> </td> <td>http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire</td> </tr> <tr> <td> <b>Language:</b> </td> <td>en-US</td> </tr> <tr> <td> <b>Url:</b> </td> <td>http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-event</td> </tr> <tr> <td> <b>Identifier:</b> </td> <td> <span>hai-questionnaire-los-event-v2</span> </td> </tr> <tr> <td> <b>Version:</b> </td> <td>Version: 2.0.0</td> </tr> <tr> <td> <b>Name:</b> </td> <td>HAI_questionnaire_los_event</td> </tr> <tr> <td> <b>Status:</b> </td> <td>draft</td> </tr> <tr> <td> <b>Subject Type:</b> </td> <td>Patient (Source Patient Resource (US Core Patient))</td> </tr> <tr> <td> <b>Date:</b> </td> <td>2019-04-01</td> </tr> <tr> <td> <b>Publisher:</b> </td> <td>HL7 Structured Documents Work Group</td> </tr> <tr> <td> <b>Jurisdiction:</b> </td> <td> <span title="Code system: urn:iso:std:iso:3166">Code: US</span> </td> </tr> <tr> <td> <b>Code:</b> </td> <td> <ul style="list-style:none; padding-left:0; margin:0 0;"> <li>Healthcare Associated Infection report Document</li> <li>Code system: <a href="http://loinc.org">http://loinc.org</a> </li> <li>Code: 51897-7</li> </ul> </td> </tr> </table> <br xmlns:xsl="http://www.w3.org/1999/XSL/Transform"/> <br xmlns:xsl="http://www.w3.org/1999/XSL/Transform"/> <h2 xmlns:xsl="http://www.w3.org/1999/XSL/Transform">Questionnaire Items (<span style="color:red">*</span> required)</h2> <ul xmlns:xsl="http://www.w3.org/1999/XSL/Transform" style="list-style:none;"> <li> <span style="color:red">* </span> <span style="font-weight:bold">Facility ID</span> [<span style="font-style:italic">facility</span>] (url) </li> <li> <span style="font-weight:bold">Event Number</span> [<span style="font-style:italic">event-number</span>] (url) </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Event Type</span> [<span style="font-style:italic">event-type</span>] (choice) <ul> <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> </li> </ul> </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Date of Event</span> [<span style="font-style:italic">date-of-event</span>] (date) </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Facility Location</span> [<span style="font-style:italic">facility-location</span>] (choice) <ul> <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> </li> </ul> </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Date Admitted to Facility:</span> [<span style="font-style:italic">date-admitted-to-facility</span>] (date) </li> <li> <span style="color:red">* </span> <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) </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Risk Factors</span> [<span style="font-style:italic">risk-factors</span>] (group) <ul style="list-style:none;"> <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) </li> <li> <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) </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Risk Factor: Birth weight (grams)</span> [<span style="font-style:italic">risk-factor-birth-weight</span>] (quantity) </li> <li> <span style="color:red">* </span> <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) </li> <li> <span style="font-weight:bold">Risk Factor: Gestational age (days)</span> [<span style="font-style:italic">risk-factor-gestational-age</span>] (quantity) <ul> <li>Enable when: <span style="font-style:italic">gestational-age-known</span> = "true"<br/> </li> </ul> </li> </ul> </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Event Details</span> [<span style="font-style:italic">event-details</span>] (group) <ul style="list-style:none;"> <li>This group contains details aboout the late onset septis infection event. [<span style="font-style:italic">event-details-group</span>] (display) </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Specific Event</span> [<span style="font-style:italic">infection-condition</span>] (choice) <ul> <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> </li> </ul> </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Laboratory Criteria Used</span> [<span style="font-style:italic">criteria-used</span>] (choice) <ul> <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> </li> </ul> </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Died</span> [<span style="font-style:italic">died</span>] (boolean) </li> <li> <span style="font-weight:bold">Infection contributed to death</span> [<span style="font-style:italic">los-contributed-to-death</span>] (boolean) <ul> <li>Enable when: <span style="font-style:italic">died</span> = "true"<br/> </li> </ul> </li> <li> <span style="font-weight:bold">Discharge Date</span> [<span style="font-style:italic">discharge-date</span>] (date) </li> </ul> </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Findings Group</span> [<span style="font-style:italic">findings-group</span>] (group, repeats) <ul style="list-style:none;"> <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) </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Pathogen Identified</span> [<span style="font-style:italic">pathogen-identified</span>] (choice) <ul> <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> </li> </ul> </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Pathogen Ranking</span> [<span style="font-style:italic">pathogen-ranking</span>] (choice) <ul> <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> </li> </ul> </li> <li> <span style="font-weight:bold">Drug Susceptibility Test Group</span> [<span style="font-style:italic">drug-susceptibility-test-group</span>] (group, repeats) <ul style="list-style:none;"> <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) </li> <li> <span style="color:red">* </span> <span style="font-weight:bold">Drug Susceptibility Test</span> [<span style="font-style:italic">drug-susceptibility-test</span>] (choice) <ul> <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> </li> </ul> </li> <li> <span style="font-weight:bold">Drug Susceptibility Test Interpretation</span> [<span style="font-style:italic">drug-susceptibility-test-interpretation</span>] (choice) <ul> <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> </li> </ul> </li> </ul> </li> </ul> </li> <li> <span style="font-weight:bold">Comments</span> [<span style="font-style:italic">nhsn-comment</span>] (text) </li> </ul> </div> </text> <url value="http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-event"/> <identifier> <value value="hai-questionnaire-los-event-v2"/> </identifier> <version value="2.0.0"/> <name value="HAI_questionnaire_los_event"/> <title value="Late Onset Sepsis/Meningitis Event (LOS)"/> <status value="draft"/> <subjectType value="Patient"/> <date value="2019-04-01"/> <publisher value="HL7 Structured Documents Work Group"/> <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. 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"/> </coding> </jurisdiction> <code> <system value="http://loinc.org"/> <code value="51897-7"/> <display value="Healthcare Associated Infection report Document"/> </code> <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 Number"/> <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"/> <answerValueSet value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.20"/> </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"/> <answerValueSet value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.19"/> </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"/> <type value="group"/> <required value="true"/> <repeats value="false"/> <item> <linkId value="risk-factors-group"/> <text value="This group contains risk factors such as central line present, birth weight, and gestational age."/> <type value="display"/> </item> <item> <linkId value="risk-factor-central-line"/> <code> <system value="http://hl7.org/fhir/us/hai/CodeSystem/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> <linkId value="gestational-age-known"/> <text value="Gestational age known: set true if known and false if unknown"/> <type value="boolean"/> <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"/> <enableWhen> <question value="gestational-age-known"/> <operator value="="/> <answerBoolean value="true"/> </enableWhen> <required value="false"/> <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"/> <required value="true"/> <repeats value="false"/> <item> <linkId value="event-details-group"/> <text value="This group contains details aboout the late onset septis infection event."/> <type value="display"/> </item> <item> <linkId value="infection-condition"/> <text value="Specific Event"/> <type value="choice"/> <required value="true"/> <repeats value="false"/> <answerValueSet value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3196"/> </item> <item> <linkId value="criteria-used"/> <text value="Laboratory Criteria Used"/> <type value="choice"/> <required value="true"/> <repeats value="false"/> <answerValueSet value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3195"/> </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"/> <operator value="="/> <answerBoolean value="true"/> </enableWhen> <required value="false"/> <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"/> <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://hl7.org/fhir/us/hai/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> <linkId value="drug-susceptibility-test-group"/> <text value="Drug Susceptibility Test Group"/> <type value="group"/> <repeats value="true"/> <item> <linkId value="drug-susceptibility-test-group-description"/> <text value="This group contains drug-susceptibility information such as the drug and the pathogen's susceptibility to it."/> <type value="display"/> </item> <item> <linkId value="drug-susceptibility-test"/> <text value="Drug Susceptibility Test"/> <type value="choice"/> <required value="true"/> <repeats value="false"/> <answerValueSet value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.15"/> </item> <item> <linkId value="drug-susceptibility-test-interpretation"/> <text value="Drug Susceptibility Test Interpretation"/> <type value="choice"/> <required value="false"/> <repeats value="false"/> <answerValueSet value="http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.13"/> </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>
