HealthcareAssociatedInfectionReports Implementation Guide CI Build

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

Questionnaire: hai-questionnaire-opc-ssi-event

Outpatient Procedure Component Surgical Site Infection (SSI) Event

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/.

Questionnaire Details

Id: hai-questionnaire-opc-ssi-event
Profile: http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire
Language: en-US
Url: http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-opc-ssi-event
Identifier: hai-questionnaire-opc-ssi-event-v1
Version: Version: 2.0.0
Name: HAI_questionnaire_opc_ssi_event
Status: draft
Experimental: false
Subject Type: Patient (Source Patient Resource (US Core Patient))
Date: 2019-04-01
Publisher: HL7 Structured Documents Work Group
Jurisdiction: Code: US
Code:
  • Healthcare Associated Infection report Document
  • Code system: http://loinc.org
  • Code: 51897-7


Questionnaire Items (* required)

  • * Facility ID [facility-id] (url)
  • * Date of encounter [encounter-date] (date)
  • * Infection details [infection-details] (group)
    • 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). [infection-details-group-description] (display)
    • * Event Type [event-type] (choice)
    • * Date of event [event-date] (date)
    • * NHSN Procedure Code Category [nhsn-procedure-code-category] (choice)
    • * Primary CPT Procedure Code [primary-cpt-procedure-code] (choice)
    • * Procedure Id [procedure-id] (url)
    • * Surgical Site Infection (SSI) Level [ssi-level] (choice)
    • * Criteria of Diagnosis [criteria-of-diagnosis] (group)
      • This group records the criteria used in the diagnosis of an infection. [criteria-of-diagnosis-group-description] (display)
      • * Criteria of Diagnosis: Abscess [criteria-of-diagnosis-abscess] (boolean)
      • * Criteria of Diagnosis: Redness [criteria-of-diagnosis-redness] (boolean)
      • * Criteria of Diagnosis: Fever [criteria-of-diagnosis-fever] (boolean)
      • * Criteria of Diagnosis: Heat [criteria-of-diagnosis-heat] (boolean)
      • * Criteria of Diagnosis: Purulent drainage [criteria-of-diagnosis-incision-purulent-drainage] (boolean)
      • * Criteria of Diagnosis: Wound spontaneously dehisced [criteria-of-diagnosis-wound-dehisced] (boolean)
      • * Criteria of Diagnosis: Incision deliberately opened [criteria-of-diagnosis-incision-opened] (boolean)
      • * Criteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam [criteria-of-diagnosis-evidence-found] (boolean)
      • * Criteria of Diagnosis: Localized swelling [criteria-of-diagnosis-localized-swelling] (boolean)
      • * Criteria of Diagnosis: Pain or tenderness [criteria-of-diagnosis-pain-tenderness] (boolean)
      • * Criteria of Diagnosis: Organism Identified [criteria-of-diagnosis-organism-identified] (boolean)
      • * Criteria of Diagnosis: Culture or non-culture based testing not performed [criteria-of-diagnosis-testing-not-performed] (boolean)
      • * Criteria of Diagnosis: Imaging test evidence of infection [criteria-of-diagnosis-imaging-test] (boolean)
      • * Criteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physician [criteria-of-diagnosis-physician-diagnosis] (boolean)
    • * Surveillence method type (active/passive) through which the SSI was detected [ssi-detection-method-type] (choice)
    • * Surveillence method through which the SSI was detected [ssi-detection-method] (choice)
  • * Findings Group [findings-group] (group, repeats)
  • Comments [nhsn-comment] (text)