NHSN Healthcare Associated Infection (HAI) Reports
2.1.0 - STU 2.1 United States of America flag

This page is part of the Healthcare Associated Infection Implementation Guide (v2.1.0: STU2) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

mapping-opc-ssi-event

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