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: QuestionnaireResponse-hai-questionnaireresponse-opc-ssi-event
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{ "resourceType" : "QuestionnaireResponse", "id" : "hai-questionnaireresponse-opc-ssi-event", "meta" : { "profile" : [ "http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaireresponse" ] }, "language" : "en-US", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" lang=\"en-US\">\n <table xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\" class=\"bare\">\n <tr>\n <td>\n <b>Id:</b>\n </td>\n <td>hai-questionnaireresponse-opc-ssi-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-questionnaireresponse</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>Identifier:</b>\n </td>\n <td>\n <span title=\"Code system: urn:oid:2.16.840.1.113883.3.117.1.1.5.2.1.1.2\">20202206</span>\n </td>\n </tr>\n <tr>\n <td>\n <b>Questionnaire:</b>\n </td>\n <td>http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-opc-ssi-event</td>\n </tr>\n <tr>\n <td>\n <b>Status:</b>\n </td>\n <td>completed</td>\n </tr>\n <tr>\n <td>\n <b>Subject:</b>\n </td>\n <td>\n <a href=\"Patient-hai-patient-1.html\">hai-patient-1</a>\n </td>\n </tr>\n <tr>\n <td>\n <b>Author:</b>\n </td>\n <td>\n <a href=\"Device-hai-authoring-device.html\">hai-authoring-device</a>\n </td>\n </tr>\n </table>\n <br xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\"/>\n <h2 xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\">QuestionnaireResponse Answers</h2>\n <ul xmlns:xsl=\"http://www.w3.org/1999/XSL/Transform\" style=\"list-style:none;\">\n <li>\n <span style=\"font-weight:bold\">Facility ID</span> [<span style=\"font-style:italic\">facility-id</span>]: \n <span style=\"text-decoration:underline\">urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.1.1:9W</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Date of encounter</span> [<span style=\"font-style:italic\">encounter-date</span>]: \n <span style=\"text-decoration:underline\">2018-08-05</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Infection details</span> [<span style=\"font-style:italic\">infection-details</span>]: \n <ul style=\"list-style:none;\">\n <li>\n <span style=\"font-weight:bold\">Event Type</span> [<span style=\"font-style:italic\">event-type</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Surgical Site Infection</li>\n <li>Code system: <a href=\"http://snomed.info/sct\">http://snomed.info/sct</a>\n </li>\n <li>Code: 433202001</li>\n </span>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Date of event</span> [<span style=\"font-style:italic\">event-date</span>]: \n <span style=\"text-decoration:underline\">2018-08-06</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">NHSN Procedure Code Category</span> [<span style=\"font-style:italic\">nhsn-procedure-code-category</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Appendix surgery</li>\n <li>Code system: <a href=\"http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277\">http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277</a>\n </li>\n <li>Code: 2108-9</li>\n </span>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Primary CPT Procedure Code</span> [<span style=\"font-style:italic\">primary-cpt-procedure-code</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Laparoscopic Procedures on the Appendix</li>\n <li>Code system: <a href=\"http://www.ama-assn.org/go/cpt\">http://www.ama-assn.org/go/cpt</a>\n </li>\n <li>Code: 44970</li>\n </span>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Procedure Id</span> [<span style=\"font-style:italic\">procedure-id</span>]: \n <span style=\"text-decoration:underline\">urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.2.1.1.5:21987654321</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Surgical Site Infection (SSI) Level</span> [<span style=\"font-style:italic\">ssi-level</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Superficial incisional primary SSI</li>\n <li>Code system: <a href=\"http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277\">http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277</a>\n </li>\n <li>Code: 1620-4</li>\n </span>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis</span> [<span style=\"font-style:italic\">criteria-of-diagnosis</span>]: \n <ul style=\"list-style:none;\">\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Abscess</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-abscess</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Redness</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-redness</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Fever</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-fever</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Heat</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-heat</span>]: \n <span style=\"text-decoration:underline\">true</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Purulent drainage</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-incision-purulent-drainage</span>]: \n <span style=\"text-decoration:underline\">true</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Wound spontaneously dehisced</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-wound-dehisced</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Incision deliberately opened</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-incision-opened</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-evidence-found</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Localized swelling</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-localized-swelling</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Pain or tenderness</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-pain-tenderness</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Organism Identified</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-organism-identified</span>]: \n <span style=\"text-decoration:underline\">true</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Culture or non-culture based testing not performed</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-testing-not-performed</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Imaging test evidence of infection</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-imaging-test</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n <li>\n <span style=\"font-weight:bold\">Criteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physician</span> [<span style=\"font-style:italic\">criteria-of-diagnosis-physician-diagnosis</span>]: \n <span style=\"text-decoration:underline\">false</span>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Surveillence method type (active/passive) through which the SSI was detected</span> [<span style=\"font-style:italic\">ssi-detection-method-type</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Active SSI Detection Method</li>\n <li>Code system: <a href=\"http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277\">http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277</a>\n </li>\n <li>Code: 1309-4</li>\n </span>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Surveillence method through which the SSI was detected</span> [<span style=\"font-style:italic\">ssi-detection-method</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Review of patient's medical record</li>\n <li>Code system: <a href=\"http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277\">http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277</a>\n </li>\n <li>Code: 1321-9</li>\n </span>\n </ul>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Findings Group</span> [<span style=\"font-style:italic\">findings-group</span>]: \n <ul style=\"list-style:none;\">\n <li>\n <span style=\"font-weight:bold\">Pathogen Identified</span> [<span style=\"font-style:italic\">pathogen-identified</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Staphylococcus, coagulase negative (organism)</li>\n <li>Code system: <a href=\"http://snomed.info/sct\">http://snomed.info/sct</a>\n </li>\n <li>Code: 116197008</li>\n </span>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Pathogen Ranking</span> [<span style=\"font-style:italic\">pathogen-ranking</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>First</li>\n <li>Code system: <a href=\"http://snomed.info/sct\">http://snomed.info/sct</a>\n </li>\n <li>Code: 255216001</li>\n </span>\n </ul>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Findings Group</span> [<span style=\"font-style:italic\">findings-group</span>]: \n <ul style=\"list-style:none;\">\n <li>\n <span style=\"font-weight:bold\">Pathogen Identified</span> [<span style=\"font-style:italic\">pathogen-identified</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Life form of parasite (organism)</li>\n <li>Code system: <a href=\"http://snomed.info/sct\">http://snomed.info/sct</a>\n </li>\n <li>Code: 103535006</li>\n </span>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Pathogen Ranking</span> [<span style=\"font-style:italic\">pathogen-ranking</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Second</li>\n <li>Code system: <a href=\"http://snomed.info/sct\">http://snomed.info/sct</a>\n </li>\n <li>Code: 81170007</li>\n </span>\n </ul>\n </li>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Findings Group</span> [<span style=\"font-style:italic\">findings-group</span>]: \n <ul style=\"list-style:none;\">\n <li>\n <span style=\"font-weight:bold\">Pathogen Identified</span> [<span style=\"font-style:italic\">pathogen-identified</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Acid-fast bacillus</li>\n <li>Code system: <a href=\"http://snomed.info/sct\">http://snomed.info/sct</a>\n </li>\n <li>Code: 243365003</li>\n </span>\n </ul>\n </li>\n <li>\n <span style=\"font-weight:bold\">Pathogen Ranking</span> [<span style=\"font-style:italic\">pathogen-ranking</span>]: \n <ul>\n <span style=\"text-decoration:underline\">\n <li>Third</li>\n <li>Code system: <a href=\"http://snomed.info/sct\">http://snomed.info/sct</a>\n </li>\n <li>Code: 70905002</li>\n </span>\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>]: \n <span style=\"text-decoration:underline\">NHSN text comment that is less than 2000 characters.</span>\n </li>\n </ul>\n </div>" }, "identifier" : { "system" : "urn:oid:2.16.840.1.113883.3.117.1.1.5.2.1.1.2", "value" : "20202206" }, "questionnaire" : "http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-opc-ssi-event", "status" : "completed", "subject" : { "reference" : "Patient/hai-patient-1", "display" : "hai-patient-1" }, "author" : { "reference" : "Device/hai-authoring-device", "display" : "hai-authoring-device" }, "item" : [ { "linkId" : "facility-id", "text" : "Facility ID", "answer" : [ { "valueUri" : "urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.1.1:9W" } ] }, { "linkId" : "encounter-date", "text" : "Date of encounter", "answer" : [ { "valueDate" : "2018-08-05" } ] }, { "linkId" : "infection-details", "text" : "Infection details", "item" : [ { "linkId" : "event-type", "text" : "Event Type", "answer" : [ { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "433202001", "display" : "Surgical Site Infection" } } ] }, { "linkId" : "event-date", "text" : "Date of event", "answer" : [ { "valueDate" : "2018-08-06" } ] }, { "linkId" : "nhsn-procedure-code-category", "text" : "NHSN Procedure Code Category", "answer" : [ { "valueCoding" : { "system" : "http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277", "code" : "2108-9", "display" : "Appendix surgery" } } ] }, { "linkId" : "primary-cpt-procedure-code", "text" : "Primary CPT Procedure Code", "answer" : [ { "valueCoding" : { "system" : "http://www.ama-assn.org/go/cpt", "code" : "44970", "display" : "Laparoscopic Procedures on the Appendix" } } ] }, { "linkId" : "procedure-id", "text" : "Procedure Id", "answer" : [ { "valueUri" : "urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.2.1.1.5:21987654321" } ] }, { "linkId" : "ssi-level", "text" : "Surgical Site Infection (SSI) Level", "answer" : [ { "valueCoding" : { "system" : "http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277", "code" : "1620-4", "display" : "Superficial incisional primary SSI" } } ] }, { "linkId" : "criteria-of-diagnosis", "text" : "Criteria of Diagnosis", "item" : [ { "linkId" : "criteria-of-diagnosis-abscess", "text" : "Criteria of Diagnosis: Abscess", "answer" : [ { "valueBoolean" : false } ] }, { "linkId" : "criteria-of-diagnosis-redness", "text" : "Criteria of Diagnosis: Redness", "answer" : [ { "valueBoolean" : false } ] }, { "linkId" : "criteria-of-diagnosis-fever", "text" : "Criteria of Diagnosis: Fever", "answer" : [ { "valueBoolean" : false } ] }, { "linkId" : "criteria-of-diagnosis-heat", "text" : "Criteria of Diagnosis: Heat", "answer" : [ { "valueBoolean" : true } ] }, { "linkId" : "criteria-of-diagnosis-incision-purulent-drainage", "text" : "Criteria of Diagnosis: Purulent drainage", "answer" : [ { "valueBoolean" : true } ] }, { "linkId" : "criteria-of-diagnosis-wound-dehisced", "text" : "Criteria of Diagnosis: Wound spontaneously dehisced", "answer" : [ { "valueBoolean" : false } ] }, { "linkId" : "criteria-of-diagnosis-incision-opened", "text" : "Criteria of Diagnosis: Incision deliberately opened", "answer" : [ { "valueBoolean" : false } ] }, { "linkId" : "criteria-of-diagnosis-evidence-found", "text" : "Criteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam", "answer" : [ { "valueBoolean" : false } ] }, { "linkId" : "criteria-of-diagnosis-localized-swelling", "text" : "Criteria of Diagnosis: Localized swelling", "answer" : [ { "valueBoolean" : false } ] }, { "linkId" : "criteria-of-diagnosis-pain-tenderness", "text" : "Criteria of Diagnosis: Pain or tenderness", "answer" : [ { "valueBoolean" : false } ] }, { "linkId" : "criteria-of-diagnosis-organism-identified", "text" : "Criteria of Diagnosis: Organism Identified", "answer" : [ { "valueBoolean" : true } ] }, { "linkId" : "criteria-of-diagnosis-testing-not-performed", "text" : "Criteria of Diagnosis: Culture or non-culture based testing not performed", "answer" : [ { "valueBoolean" : false } ] }, { "linkId" : "criteria-of-diagnosis-imaging-test", "text" : "Criteria of Diagnosis: Imaging test evidence of infection", "answer" : [ { "valueBoolean" : false } ] }, { "linkId" : "criteria-of-diagnosis-physician-diagnosis", "text" : "Criteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physician", "answer" : [ { "valueBoolean" : false } ] } ] }, { "linkId" : "ssi-detection-method-type", "text" : "Surveillence method type (active/passive) through which the SSI was detected", "answer" : [ { "valueCoding" : { "system" : "http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277", "code" : "1309-4", "display" : "Active SSI Detection Method" } } ] }, { "linkId" : "ssi-detection-method", "text" : "Surveillence method through which the SSI was detected", "answer" : [ { "valueCoding" : { "system" : "http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277", "code" : "1321-9", "display" : "Review of patient's medical record" } } ] } ] }, { "linkId" : "findings-group", "text" : "Findings Group", "item" : [ { "linkId" : "pathogen-identified", "text" : "Pathogen Identified", "answer" : [ { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "116197008", "display" : "Staphylococcus, coagulase negative (organism)" } } ] }, { "linkId" : "pathogen-ranking", "text" : "Pathogen Ranking", "answer" : [ { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "255216001", "display" : "First" } } ] } ] }, { "linkId" : "findings-group", "text" : "Findings Group", "item" : [ { "linkId" : "pathogen-identified", "text" : "Pathogen Identified", "answer" : [ { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "103535006", "display" : "Life form of parasite (organism)" } } ] }, { "linkId" : "pathogen-ranking", "text" : "Pathogen Ranking", "answer" : [ { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "81170007", "display" : "Second" } } ] } ] }, { "linkId" : "findings-group", "text" : "Findings Group", "item" : [ { "linkId" : "pathogen-identified", "text" : "Pathogen Identified", "answer" : [ { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "243365003", "display" : "Acid-fast bacillus" } } ] }, { "linkId" : "pathogen-ranking", "text" : "Pathogen Ranking", "answer" : [ { "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "70905002", "display" : "Third" } } ] } ] }, { "linkId" : "nhsn-comment", "text" : "Comments", "answer" : [ { "valueString" : "NHSN text comment that is less than 2000 characters." } ] } ] }