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
QuestionnaireResponse: hai-questionnaireresponse-opc-ssi-event
Id: | hai-questionnaireresponse-opc-ssi-event |
Profile: | http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaireresponse |
Language: | en-US |
Identifier: | 20202206 |
Questionnaire: | http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-opc-ssi-event |
Status: | completed |
Subject: | hai-patient-1 |
Author: | hai-authoring-device |
QuestionnaireResponse Answers
- Facility ID [facility-id]: urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.1.1:9W
- Date of encounter [encounter-date]: 2018-08-05
-
Infection details [infection-details]:
-
Event Type [event-type]:
- Surgical Site Infection
- Code system: http://snomed.info/sct
- Code: 433202001
- Date of event [event-date]: 2018-08-06
-
NHSN Procedure Code Category [nhsn-procedure-code-category]:
- Appendix surgery
- Code system: http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277
- Code: 2108-9
-
Primary CPT Procedure Code [primary-cpt-procedure-code]:
- Laparoscopic Procedures on the Appendix
- Code system: http://www.ama-assn.org/go/cpt
- Code: 44970
- Procedure Id [procedure-id]: urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.2.1.1.5:21987654321
-
Surgical Site Infection (SSI) Level [ssi-level]:
- Superficial incisional primary SSI
- Code system: http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277
- Code: 1620-4
-
Criteria of Diagnosis [criteria-of-diagnosis]:
- Criteria of Diagnosis: Abscess [criteria-of-diagnosis-abscess]: false
- Criteria of Diagnosis: Redness [criteria-of-diagnosis-redness]: false
- Criteria of Diagnosis: Fever [criteria-of-diagnosis-fever]: false
- Criteria of Diagnosis: Heat [criteria-of-diagnosis-heat]: true
- Criteria of Diagnosis: Purulent drainage [criteria-of-diagnosis-incision-purulent-drainage]: true
- Criteria of Diagnosis: Wound spontaneously dehisced [criteria-of-diagnosis-wound-dehisced]: false
- Criteria of Diagnosis: Incision deliberately opened [criteria-of-diagnosis-incision-opened]: false
- Criteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam [criteria-of-diagnosis-evidence-found]: false
- Criteria of Diagnosis: Localized swelling [criteria-of-diagnosis-localized-swelling]: false
- Criteria of Diagnosis: Pain or tenderness [criteria-of-diagnosis-pain-tenderness]: false
- Criteria of Diagnosis: Organism Identified [criteria-of-diagnosis-organism-identified]: true
- Criteria of Diagnosis: Culture or non-culture based testing not performed [criteria-of-diagnosis-testing-not-performed]: false
- Criteria of Diagnosis: Imaging test evidence of infection [criteria-of-diagnosis-imaging-test]: false
- Criteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physician [criteria-of-diagnosis-physician-diagnosis]: false
-
Surveillence method type (active/passive) through which the SSI was detected [ssi-detection-method-type]:
- Active SSI Detection Method
- Code system: http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277
- Code: 1309-4
-
Surveillence method through which the SSI was detected [ssi-detection-method]:
- Review of patient's medical record
- Code system: http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277
- Code: 1321-9
-
Event Type [event-type]:
-
Findings Group [findings-group]:
-
Pathogen Identified [pathogen-identified]:
- Staphylococcus, coagulase negative (organism)
- Code system: http://snomed.info/sct
- Code: 116197008
-
Pathogen Ranking [pathogen-ranking]:
- First
- Code system: http://snomed.info/sct
- Code: 255216001
-
Pathogen Identified [pathogen-identified]:
-
Findings Group [findings-group]:
-
Pathogen Identified [pathogen-identified]:
- Life form of parasite (organism)
- Code system: http://snomed.info/sct
- Code: 103535006
-
Pathogen Ranking [pathogen-ranking]:
- Second
- Code system: http://snomed.info/sct
- Code: 81170007
-
Pathogen Identified [pathogen-identified]:
-
Findings Group [findings-group]:
-
Pathogen Identified [pathogen-identified]:
- Acid-fast bacillus
- Code system: http://snomed.info/sct
- Code: 243365003
-
Pathogen Ranking [pathogen-ranking]:
- Third
- Code system: http://snomed.info/sct
- Code: 70905002
-
Pathogen Identified [pathogen-identified]:
- Comments [nhsn-comment]: NHSN text comment that is less than 2000 characters.