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

Outpatient Procedure Component Surgical Site Infection (SSI) Event Mapping to CDA

FHIR QuestionnaireResponse elements	CDA Mapping
QuestionnaireResponse.identifier	ClinicalDocument/id
QuestionnaireResponse.code.code="51897-7"	ClinicalDocument/code
QuestionnaireResponse.subject	ClinicalDocument/recordTarget
QuestionnaireResponse.author	ClinicalDocument/author

item	item.linkId	CDA Mapping
facility-id	Facility ID	x
encounter-date	Date of encounter	ClinicalDocument/componentOf/effectiveTime/low
infection-details	Infection details	Infection Details Section in an OPC SSI Report
event-type	Event Type	Infection-Type Observation in an OPC SSI Event/value
event-date	Date of event	Infection-Type Observation in an OPC SSI Event/effectiveTime/low
nhsn-procedure-code-category	NHSN Procedure Code Category	Procedure Details in an OPC SSI Event/code
primary-cpt-procedure-code	Primary CPT Procedure Code	Procedure Details in an OPC SSI Event/code/translation
procedure-id	Procedure Id	Procedure Details in an OPC SSI Event/code/id
ssi-level	Surgical Site Infection (SSI) Level	Infection Condition Observation/value
criteria-of-diagnosis	Criteria of Diagnosis	Criteria of Diagnosis Organizer
criteria-of-diagnosis-abscess	Criteria of Diagnosis: Abscess	Criterion of Diagnosis Observation[value="128477000"]/negationInd
criteria-of-diagnosis-redness	Criteria of Diagnosis: Redness	Criterion of Diagnosis Observation[value="386713009"]/negationInd
criteria-of-diagnosis-fever	Criteria of Diagnosis: Fever	Criterion of Diagnosis Observation[value="386661006"]/negationInd
criteria-of-diagnosis-heat	Criteria of Diagnosis: Heat	Criterion of Diagnosis Observation[value="304214002"]/negationInd
criteria-of-diagnosis-incision-purulent-drainage	Criteria of Diagnosis: Purulent drainage	Criterion of Diagnosis Observation[value="255320000"]/negationInd
criteria-of-diagnosis-wound-dehisced	Criteria of Diagnosis: Wound spontaneously dehisced	Criterion of Diagnosis Observation[value="225553008"]/negationInd
criteria-of-diagnosis-incision-opened	Criteria of Diagnosis: Incision deliberately opened	Criterion of Diagnosis Observation[value="1967-9"]/negationInd
criteria-of-diagnosis-evidence-found	Criteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam	Criterion of Diagnosis Observation[value="1905-9"]/negationInd
criteria-of-diagnosis-localized-swelling	Criteria of Diagnosis: Localized swelling	Criterion of Diagnosis Observation[value="1920-8"]/negationInd
criteria-of-diagnosis-pain-tenderness	Criteria of Diagnosis: Pain or tenderness	Criterion of Diagnosis Observation[value="1960-4"]/negationInd
criteria-of-diagnosis-organism-identified	Criteria of Diagnosis: Organism Identified	Criterion of Diagnosis Observation[value="1952-1"]/negationInd
criteria-of-diagnosis-testing-not-performed	Criteria of Diagnosis: Culture or non-culture based testing not performed	Criterion of Diagnosis Observation[value="1901-8"]/negationInd
criteria-of-diagnosis-imaging-test	Criteria of Diagnosis: Imaging test evidence of infection	Criterion of Diagnosis Observation[value="1924-0"]/negationInd
criteria-of-diagnosis-physician-diagnosis	Criteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physician	Criterion of Diagnosis Observation[value="1963-8"]/negationInd
ssi-detection-method-type	Surveillence method type (active/passive) through which the SSI was detected	SSI Detection Method/code
ssi-detection-method	Surveillence method through which the SSI was detected	SSI Detection Method/value
findings-group	Findings Group	Findings Section in an OPC SSI Report
pathogen-identified	Pathogen Identified	Pathogen Identified Observation/value
pathogen-ranking	Pathogen Ranking	Pathogen Ranking Observation/value
nhsn-comment	Comments	NHSN Comment/text