questionnaire-sdc-profile-example-loinc
type: Questionnaire
node role: treeRoot
id:
  v: questionnaire-sdc-profile-example-loinc
meta:
  profile:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire
    l: sdc-questionnaire
language:
  v: en
text:
  status:
    v: extensions
  div:
    v: Generated Narrative: Questionnaire questionnaire-sdc-profile-example-loinc Profile: SDC Base Questionnaire LinkID Text Cardinality Type Flags Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> MedicationorOtherSubstance Questionnaire http://hl7.org/fhir/uv/sdc/Questionnaire/questionnaire-sdc-profile-example-loinc#4.0.0 #xD; Medication/header null 0..1 group #xD; 0 Form ID: 1..1 string #xD; 74080-3/74081-1 Event ID: 1..1 string #xD; 74080-3/30947-6 Initial Report Date (HERF Q1) 1..1 string #xD; Medication/SEC00 Medication or Other Substance 0..1 group #xD; Medication/SEC00.0 Use this form to report any patient safety event or unsafe condition involving a substance such as a medications, biological products, nutritional products, expressed human breast milk, medical gases, or contrast media. Do not complete this form if the event involves appropriateness of therapeutic choice or decision making (e.g., physician decision to prescribe medication despite known drug-drug interaction). If the event involves a device, please also complete the Device or Medical/Surgical Supply including Health Information Technology (HIT) form. Narrative detail can be captured on the Healthcare Event Reporting Form (HERF). 0..1 display #xD; Medication/SEC01/74080-3 null 1..1 group #xD; 74080-3/74076-1 1.. What type of medication/substance was involved? 1..1 choice Value Set: AHRQ_Medication_Q1 #xD; 74080-3/74075-3 2.. What type of medication? 1..1 choice Enable When: 74080-3/74076-1 = Medications (LOINC#LA20271-5) Value Set: AHRQ_Medication_Q2 #xD; 74080-3/74077-9-q 3.. Please list all ingredients: 1..* string Enable When: 74080-3/74075-3 = Compounded preparations (LOINC#LA20298-8) #xD; 74080-3/74074-6 4.. What type of biological product? 0..1 choice Enable When: 74080-3/74076-1 = Biological products (LOINC#LA20335-8) Value Set: AHRQ_Medication_Q4 #xD; 74080-3/30959-1 5.. What was the lot number of the vaccine? 1..1 string Enable When: 74080-3/74074-6…
contained: ValueSet
  id:
    v: ll2654-3
  url:
    v: http://hl7.org/fhir/uv/sdc/ValueSet/LL2654-3
    l: LL2654-3
  name:
    v: AhrqMedicationQ1
  title:
    v: AHRQ_Medication_Q1
  status:
    v: active
  description:
    v: The answer list for question 1 on the AHRQ "Medication or Other Substance" form
  copyright:
    v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
  compose:
    include:
      system:
        v: http://loinc.org
        l: loinc.org
contained: ValueSet
  id:
    v: ll2655-0
  url:
    v: http://example.org/ValueSet/ll2655-0
    l: ll2655-0
  name:
    v: AhrqMedicationQ2
  title:
    v: AHRQ_Medication_Q2
  status:
    v: active
  description:
    v: The answer list for question 2 on the AHRQ "Medication or Other Substance" form
  copyright:
    v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
  compose:
    include:
      system:
        v: http://loinc.org
        l: loinc.org
contained: ValueSet
  id:
    v: ll2657-6
  name:
    v: AhrqMedicationQ4
  title:
    v: AHRQ_Medication_Q4
  status:
    v: active
  description:
    v: The answer list for question 4 on the AHRQ "Medication or Other Substance" form
  copyright:
    v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
  compose:
    include:
      system:
        v: http://loinc.org
        l: loinc.org
contained: ValueSet
  id:
    v: ll2659-2
  url:
    v: http://example.org/ValueSet/ll2659-2
    l: ll2659-2
  name:
    v: AhrqMedicationQ6
  title:
    v: AHRQ_Medication_Q6
  status:
    v: active
  description:
    v: The answer list for question 6 on the AHRQ "Medication or Other Substance" form
  copyright:
    v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
  compose:
    include:
      system:
        v: http://loinc.org
        l: loinc.org
contained: ValueSet
  id:
    v: ll2660-0
  url:
    v: http://example.org/ValueSet/ll2660-0
    l: ll2660-0
  name:
    v: AHRQMedicationQ7
  title:
    v: AHRQ_Medication_Q7
  status:
    v: active
  description:
    v: The answer list for question 7 on the AHRQ 'Medication or Other Substance' form
  copyright:
    v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
  compose:
    include:
      system:
        v: http://loinc.org
        l: loinc.org
contained: ValueSet
  id:
    v: ll2661-8
  name:
    v: AHRQMedicationQ8
  title:
    v: AHRQ_Medication_Q8
  status:
    v: active
  description:
    v: The answer list for question 8 on the AHRQ 'Medication or Other Substance' form
  copyright:
    v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
  compose:
    include:
      system:
        v: http://loinc.org
        l: loinc.org
contained: ValueSet
  id:
    v: ll2662-6
  name:
    v: AHRQMedicationQ9
  title:
    v: AHRQ_Medication_Q9
  status:
    v: active
  description:
    v: The answer list for question 9 on the AHRQ 'Medication or Other Substance' form
  copyright:
    v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
  compose:
    include:
      system:
        v: http://loinc.org
        l: loinc.org
contained: ValueSet
  id:
    v: ll2663-4
  name:
    v: AHRQMedicationQ10
  title:
    v: AHRQ_Medication_Q10
  status:
    v: active
  description:
    v: The answer list for question 10 on the AHRQ 'Medication or Other Substance' form
  copyright:
    v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
  compose:
    include:
      system:
        v: http://loinc.org
        l: loinc.org
contained: ValueSet
  id:
    v: ll2664-2
  name:
    v: AHRQMedicationQ11
  title:
    v: AHRQ_Medication_Q11
  status:
    v: active
  description:
    v: The answer list for question 11 on the AHRQ 'Medication or Other Substance' form
  copyright:
    v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
  compose:
    include:
      system:
        v: http://loinc.org
        l: loinc.org
contained: ValueSet
  id:
    v: ll2665-9
  name:
    v: AHRQMedicationQ12
  title:
    v: AHRQ_Medication_Q12
  status:
    v: active
  description:
    v: The answer list for question 12 on the AHRQ 'Medication or Other Substance' form
  copyright:
    v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
code: https://loinc.org/rdf/74080-3

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 1

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: a.

v: LA20271-5

v: Medications

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 2

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: b.

v: LA20335-8

v: Biological products

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 3

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: c.

v: LA20336-6

v: Nutritional products

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 4

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: d.

v: LA20337-4

v: Expressed human breast milk

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 5

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: e.

v: LA20338-2

v: Medical gases (e.g., oxygen, nitrogen, nitrous oxide)

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 6

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: f.

v: LA20339-0

v: Contrast media

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 7

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: g.

v: LA20340-8

v: Radiopharmaceuticals

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 8

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: h.

v: LA20341-6

v: Patient food (not suspected in drug-food interactions)

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 9

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: i.

v: LA20342-4

v: Drug-drug, drug-food, or adverse drug reaction as a result of a prescription and/or administration of a drug and/or food prior to admission

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 10

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: j.

v: LA20343-2

v: Other substance: PLEASE SPECIFY

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 1

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: a.

v: LA20278-0

v: Prescription or over-the-counter (including herbal supplements)

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 2

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: b.

v: LA20298-8

v: Compounded preparations

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 3

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: c.

v: LA20299-6

v: Investigational drugs

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 4

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: d.

v: LA4489-6

v: Unknown

v: LA20283-0

v: Vaccines

v: LA20287-1

v: Other biological products (e.g., thrombolytic)

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 1

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: a.

v: LA20273-1

v: Dietary supplements (other than vitamins or minerals)

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 2

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: b.

v: LA16117-6

v: Vitamins or minerals

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 3

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: c.

v: LA20320-0

v: Enteral nutritional products, including infant formula

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 4

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: d.

v: LA20321-8

v: Parenteral nutritional products

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-conceptOrder
  l: valueset-conceptOrder
value: Integer
  v: 5

url:
  v: http://hl7.org/fhir/StructureDefinition/valueset-label
  l: valueset-label
value: String
  v: e.

v: LA20318-4

v: Other: PLEASE SPECIFY

v: LA20275-6

v: Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication)
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/rendering-xhtml
    l: rendering-xhtml
  value: String
    v: Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication)

v: LA20314-3

v: Unsafe condition
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/rendering-style
    l: rendering-style
  value: String
    v: color:green

v: LA20315-0

v: Adverse reaction in patient to the administered substance without any apparent incorrect action

v: LA4489-6

v: Unknown

v: LA20276-4

v: Incorrect patient

v: LA20302-8

v: Incorrect medication/substance

v: LA20303-6

v: Incorrect dose(s)

v: LA20304-4

v: Incorrect route of administration

v: LA20305-1

v: Incorrect timing

v: LA20306-9

v: Incorrect rate

v: LA20307-7

v: Incorrect duration of administration or course of therapy

v: LA20308-5

v: Incorrect dosage form (e.g., sustained release instead of immediate release)

v: LA20309-3

v: Incorrect strength or concentration

v: LA20310-1

v: Incorrect preparation, including inappropriate cutting of tablets, error in compounding, mixing, etc.

v: LA20311-9

v: Expired or deteriorated medication/substance

v: LA20312-7

v: Medication/substance that is known to be an allergen to the patient

v: LA20345-7

v: Medication/substance that is known to be contraindicated for the patient

v: LA20313-5

v: Incorrect patient/family action (e.g., self-administration error)

v: LA20318-4

v: Other: PLEASE SPECIFY

v: LA20277-2

v: Overdose

v: LA20300-2

v: Underdose

v: LA20301-0

v: Missed or omitted dose

v: LA7271-5

v: Extra dose

v: LA4489-6

v: Unknown

v: LA20280-6

v: Too early

v: LA20290-5

v: Too late

v: LA4489-6

v: Unknown

v: LA20282-2

v: Too quickly

v: LA20288-9

v: Too slowly

v: LA4489-6

v: Unknown

include:
  system:
    v: http://loinc.org
    l: loinc.org
  concept:
    code:
      v: LA20281-4
    display:
      v: Too high
  concept:
    code:
      v: LA20289-7
    display:
      v: Too low
  concept:
    code:
      v: LA4489-6
    display:
      v: Unknown

ValueSet
id:
  v: ll2817-6
name:
  v: AhrqYNUnk
title:
  v: AHRQ_Y/N/UNK
status:
  v: active
description:
  v: AHRQ Common Format Answer list for Yes (A15), No (A18), Unknown (UNK)
copyright:
  v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
compose:
  include:
    system:
      v: http://loinc.org
      l: loinc.org
    concept:
      code:
        v: LA33-6
      display:
        v: Yes
    concept:
      code:
        v: LA32-8
      display:
        v: No
    concept:
      code:
        v: LA4489-6
      display:
        v: Unknown

ValueSet
id:
  v: ll2668-3
name:
  v: AHRQMedicationQ15
title:
  v: AHRQ_Medication_Q15
status:
  v: active
description:
  v: The answer list for question 15 on the AHRQ 'Medication or Other Substance' form
copyright:
  v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
compose:
  include:
    system:
      v: http://loinc.org
      l: loinc.org
    concept:
      code:
        v: LA20274-9
      display:
        v: Drug-drug
    concept:
      code:
        v: LA20316-8
      display:
        v: Drug-food
    concept:
      code:
        v: LA20317-6
      display:
        v: Drug-disease
    concept:
      code:
        v: LA20318-4
      display:
        v: Other: PLEASE SPECIFY

ValueSet
id:
  v: ll2669-1
name:
  v: AHRQMedicationQ16
title:
  v: AHRQ_Medication_Q16
status:
  v: active
description:
  v: The answer list for question 16 on the AHRQ 'Medication or Other Substance' form
copyright:
  v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
compose:
  include:
    system:
      v: http://loinc.org
      l: loinc.org
    concept:
      code:
        v: LA20279-8
      display:
        v: Purchasing
    concept:
      code:
        v: LA20291-3
      display:
        v: Storing
    concept:
      code:
        v: LA20292-1
      display:
        v: Prescribing/ordering
    concept:
      code:
        v: LA20293-9
      display:
        v: Transcribing
    concept:
      code:
        v: LA20294-7
      display:
        v: Preparing
    concept:
      code:
        v: LA20295-4
      display:
        v: Dispensing
    concept:
      code:
        v: LA20296-2
      display:
        v: Administering
    concept:
      code:
        v: LA20297-0
      display:
        v: Monitoring
    concept:
      code:
        v: LA4489-6
      display:
        v: Unknown
    concept:
      code:
        v: LA20318-4
      display:
        v: Other: PLEASE SPECIFY

ValueSet
id:
  v: ll2828-3
name:
  v: AhrqYN
title:
  v: AHRQ_Y/N
status:
  v: active
description:
  v: AHRQ Common Format Answer list for Yes (A15) and No (A18)
copyright:
  v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
compose:
  include:
    system:
      v: http://loinc.org
      l: loinc.org
    concept:
      code:
        v: LA33-6
      display:
        v: Yes
    concept:
      code:
        v: LA32-8
      display:
        v: No

ValueSet
id:
  v: ll2682-4
name:
  v: AHRQMedicationQ28Q29
title:
  v: AHRQ_Medication_Q28_Q29
status:
  v: active
description:
  v: The answer list for questions 28 and 29 on the AHRQ 'Medication or Other Substance' form
copyright:
  v: This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use
compose:
  include:
    system:
      v: http://loinc.org
      l: loinc.org
    concept:
      code:
        v: LA20272-3
      display:
        v: Cutaneous, topical application, including ointment, spray, patch
    concept:
      code:
        v: LA9451-1
      display:
        v: Subcutaneous
    concept:
      code:
        v: LA9444-6
      display:
        v: Ophthalmic
    concept:
      code:
        v: LA20324-2
      display:
        v: Oral, including sublingual or buccal
    concept:
      code:
        v: LA9445-3
      display:
        v: Otic
    concept:
      code:
        v: LA9263-0
      display:
        v: Nasal
    concept:
      code:
        v: LA9427-1
      display:
        v: Inhalation
    concept:
      code:
        v: LA9437-0
      display:
        v: Intravenous
    concept:
      code:
        v: LA9429-7
      display:
        v: Intramuscular
    concept:
      code:
        v: LA9435-4
      display:
        v: Intrathecal
    concept:
      code:
        v: LA9418-0
      display:
        v: Epidural
    concept:
      code:
        v: LA20332-5
      display:
        v: Gastric
    concept:
      code:
        v: LA9369-5
      display:
        v: Rectal
    concept:
      code:
        v: LA9459-4
      display:
        v: Vaginal
    concept:
      code:
        v: LA4489-6
      display:
        v: Unknown
    concept:
      code:
        v: LA20318-4
      display:
        v: Other: PLEASE SPECIFY

url:
  v: http://hl7.org/fhir/StructureDefinition/artifact-versionAlgorithm
  l: artifact-versionAlgorithm
value: Coding
  system:
    v: http://hl7.org/fhir/version-algorithm
    l: version-algorithm
  code:
    v: semver

system:
  v: urn:ietf:rfc:3986
  l: 3986
value:
  v: urn:oid:2.16.840.1.113883.4.642.40.17.35.13

v: 4.0.0

v: MedicationorOtherSubstance

v: Medication or Other Substance
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/rendering-style
    l: rendering-style
  value: String
    v: color:#0000FF

v: active

v: Patient

v: 2012-04-01

v: HL7 International / FHIR Infrastructure

name:
  v: HL7 International / FHIR Infrastructure
telecom:
  system:
    v: url
  value:
    v: http://www.hl7.org/Special/committees/fiwg

telecom:
  system:
    v: url
  value:
    v: http://www.hl7.org/Special/committees/fiwg

coding:
  system:
    v: http://unstats.un.org/unsd/methods/m49/m49.htm
    l: m49.htm
  code:
    v: 001
  display:
    v: World

https://loinc.org/rdf/74080-3
system:
  v: http://loinc.org
  l: loinc.org
code:
  v: 74080-3

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl
    l: questionnaire-itemControl
  value: CodeableConcept
    coding:
      system:
        v: http://hl7.org/fhir/questionnaire-item-control
        l: questionnaire-item-control
      code:
        v: header
link id:
  v: Medication/header
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/questionnaire-hidden
      l: questionnaire-hidden
    value: Boolean
      v: true
  link id:
    v: 0
  text:
    v: Form ID:
  type:
    v: string
  required:
    v: true
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minLength
      l: minLength
    value: Integer
      v: 3
  link id:
    v: 74080-3/74081-1
  text:
    v: Event ID:
  type:
    v: string
  required:
    v: true
item:
  link id:
    v: 74080-3/30947-6
  text:
    v: Initial Report Date (HERF Q1)
  type:
    v: string
  required:
    v: true

link id:
  v: Medication/SEC00
text:
  v: Medication or Other Substance
type:
  v: group
item:
  link id:
    v: Medication/SEC00.0
  text:
    v: Use this form to report any patient safety event or unsafe condition involving a substance such as a medications, biological products, nutritional products, expressed human breast milk, medical gases, or contrast media. Do not complete this form if the event involves appropriateness of therapeutic choice or decision making (e.g., physician decision to prescribe medication despite known drug-drug interaction). If the event involves a device, please also complete the Device or Medical/Surgical Supply including Health Information Technology (HIT) form. Narrative detail can be captured on the Healthcare Event Reporting Form (HERF).
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/rendering-xhtml
        l: rendering-xhtml
      value: String
        v: Use this form to report any patient safety event or unsafe condition involving a substance such as a medications, biological products, nutritional products, expressed human breast milk, medical gases, or contrast media. Do not complete this form if the event involves appropriateness of therapeutic choice or decision making (e.g., physician decision to prescribe medication despite known drug-drug interaction). If the event involves a device, please also complete the Device or Medical/Surgical Supply including Health Information Technology (HIT) form. Narrative detail can be captured on the Healthcare Event Reporting Form (HERF).
  type:
    v: display
item:
  link id:
    v: Medication/SEC01/74080-3
  type:
    v: group
  required:
    v: true
  item:
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/minLength
        l: minLength
      value: Integer
        v: 1
    link id:
      v: 74080-3/74076-1
    code: https://loinc.org/rdf/74076-1
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 74076-1
    prefix:
      v: 1.
    text:
      v: What type of medication/substance was involved?
    type:
      v: choice
    required:
      v: true
    answer value set:
      v: #ll2654-3
      l: ll2654-3
    item:
      extension:
        value: Integer
      link id:
        v: 74080-3/74075-3
      code: https://loinc.org/rdf/74075-3
      prefix:
        v: 2.
      text:
        v: What type of medication?
      type:
        v: choice
      enable when:
        answer: Coding
      required:
        v: true
      answer value set:
        v: #ll2655-0
        l: ll2655-0
      item:
        code: https://loinc.org/rdf/74077-9
    item:
      extension:
        value: Integer
      link id:
        v: 74080-3/74074-6
      prefix:
        v: 4.
      text:
        v: What type of biological product?
      type:
        v: choice
      enable when:
        answer: Coding
      answer value set:
        v: #ll2657-6
        l: ll2657-6
    item:
      link id:
        v: 74080-3/74073-8
      prefix:
        v: 6.
      text:
        v: What type of nutritional product?
      type:
        v: choice
      enable when:
        answer: Coding
      required:
        v: true
      answer value set:
        v: #ll2659-2
        l: ll2659-2
    item:
      link id:
        v: 74080-3/74076-1/Other/Specify
      type:
        v: string
      enable when:
        answer: Coding
      required:
        v: true
  item:
    link id:
      v: 74080-3/74072-0
    prefix:
      v: 7.
    text:
      v: Which of the following best characterizes the event?
    type:
      v: choice
    enable when:
      question:
        v: 74080-3/74076-1
      operator:
        v: !=
      answer: Coding
        type: LA20340-8
    enable when:
      question:
        v: 74080-3/74076-1
      operator:
        v: !=
      answer: Coding
        type: LA20341-6
    enable when:
      question:
        v: 74080-3/74076-1
      operator:
        v: !=
      answer: Coding
        type: LA20342-4
    enable behavior:
      v: all
    required:
      v: true
    answer value set:
      v: #ll2660-0
      l: ll2660-0
  item:
    link id:
      v: 74080-3/74071-2
    prefix:
      v: 8.
    text:
      v: What was the incorrect action?
    type:
      v: choice
    enable when:
      question:
        v: 74080-3/74072-0
      operator:
        v: =
      answer: Coding
        type: LA20275-6
    answer value set:
      v: #ll2661-8
      l: ll2661-8
    item:
      link id:
        v: 74080-3/74070-4
      prefix:
        v: 9.
      text:
        v: Which best describes the incorrect dose(s)?
      type:
        v: choice
      enable when:
        answer: Coding
      required:
        v: true
      answer value set:
        v: #ll2662-6
        l: ll2662-6
    item:
      link id:
        v: Medication/74069-6
      prefix:
        v: 10.
      text:
        v: Which best describes the incorrect timing?
      type:
        v: choice
      enable when:
        answer: Coding
      required:
        v: true
      answer value set:
        v: #ll2663-4
        l: ll2663-4

Integer
v: 7

v: 74075-3

v: 74080-3/74076-1

v: =

Coding
type: LA20271-5
system:
  v: http://loinc.org
  l: loinc.org
code:
  v: LA20271-5
display:
  v: Medications

url:
  v: http://hl7.org/fhir/StructureDefinition/minLength
  l: minLength
value: Integer
  v: 0

v: 74080-3/74077-9-q

https://loinc.org/rdf/74077-9
system:
  v: http://loinc.org
  l: loinc.org
code:
  v: 74077-9

v: 3.

v: Please list all ingredients:

v: string

question:
  v: 74080-3/74075-3
operator:
  v: =
answer: Coding
  type: LA20298-8
  system:
    v: http://loinc.org
    l: loinc.org
  code:
    v: LA20298-8
  display:
    v: Compounded preparations

v: true

v: true

Integer
v: 8

v: 74080-3/74076-1

v: =

Coding
type: LA20335-8
system:
  v: http://loinc.org
  l: loinc.org
code:
  v: LA20335-8
display:
  v: Biological products

v: 74080-3/30959-1

v: 5.

v: What was the lot number of the vaccine?

v: string

question:
  v: 74080-3/74074-6
operator:
  v: =
answer: Coding
  type: LA20283-0
  system:
    v: http://loinc.org
    l: loinc.org
  code:
    v: LA20283-0
  display:
    v: Vaccines

v: true

v: 74080-3/74076-1

v: =

Coding
type: LA20336-6
system:
  v: http://loinc.org
  l: loinc.org
code:
  v: LA20336-6
display:
  v: Nutritional products

v: 74080-3/74073-8/Other/Specify

v: string

question:
  v: 74080-3/74073-8
operator:
  v: =
answer: Coding
  type: LA20318-4
  system:
    v: http://loinc.org
    l: loinc.org
  code:
    v: LA20318-4
  display:
    v: Other: PLEASE SPECIFY

v: true

v: 74080-3/74076-1

v: =

Coding
type: LA20343-2
system:
  v: http://loinc.org
  l: loinc.org
code:
  v: LA20343-2
display:
  v: Other substance: PLEASE SPECIFY

v: LA20340-8

v: Radiopharmaceuticals

v: LA20341-6

v: Patient food (not suspected in drug-food interactions)

v: LA20342-4

v: Drug-drug, drug-food, or adverse drug reaction as a result of a prescription and/or administration of a drug and/or food prior to admission

v: LA20275-6

v: Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication)

v: 74080-3/74071-2

v: =

Coding
type: LA20303-6
system:
  v: http://loinc.org
  l: loinc.org
code:
  v: LA20303-6
display:
  v: Incorrect dose(s)

v: 74080-3/74071-2

v: =

Coding
type: LA20305-1
system:
  v: http://loinc.org
  l: loinc.org
code:
  v: LA20305-1
display:
  v: Incorrect timing

link id:
  v: 74080-3/74068-8
prefix:
  v: 11.
text:
  v: Which best describes the incorrect rate?
type:
  v: choice
enable when:
  question:
    v: 74080-3/74071-2
  operator:
    v: =
  answer: Coding
    type: LA20306-9
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20306-9
    display:
      v: Incorrect rate
required:
  v: true
answer value set:
  v: #ll2664-2
  l: ll2664-2

link id:
  v: Medication/74067-0
prefix:
  v: 12.
text:
  v: Which best describes the incorrect strength or concentration?
type:
  v: choice
enable when:
  question:
    v: 74080-3/74071-2
  operator:
    v: =
  answer: Coding
    type: LA20309-3
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20309-3
    display:
      v: Incorrect strength or concentration
required:
  v: true
answer value set:
  v: #ll2665-9
  l: ll2665-9

link id:
  v: Medication/74066-2
prefix:
  v: 13.
text:
  v: What was the expiration date?
type:
  v: string
enable when:
  question:
    v: 74080-3/74071-2
  operator:
    v: =
  answer: Coding
    type: LA20311-9
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20311-9
    display:
      v: Expired or deteriorated medication/substance
required:
  v: true

link id:
  v: Medication/74065-4
prefix:
  v: 14.
text:
  v: Was there a documented history of allergies or sensitivities to the medication/substance administered?
type:
  v: choice
enable when:
  question:
    v: 74080-3/74071-2
  operator:
    v: =
  answer: Coding
    type: LA20312-7
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20312-7
    display:
      v: Medication/substance that is known to be an allergen to the patient
required:
  v: true
answer value set:
  v: #ll2817-6
  l: ll2817-6

link id:
  v: Medication/74064-7
prefix:
  v: 15.
text:
  v: What was the contraindication (potential or actual interaction)?
type:
  v: choice
enable when:
  question:
    v: 74080-3/74071-2
  operator:
    v: =
  answer: Coding
    type: LA20345-7
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20345-7
    display:
      v: Medication/substance that is known to be contraindicated for the patient
required:
  v: true
answer value set:
  v: #ll2668-3
  l: ll2668-3
item:
  link id:
    v: Medication/74064-7/Other/Specify
  type:
    v: string
  enable when:
    question:
      v: Medication/74064-7
    operator:
      v: =
    answer: Coding
      type: LA20318-4
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: LA20318-4
      display:
        v: Other: PLEASE SPECIFY
  required:
    v: true

link id:
  v: 74080-3/74071-2/Other/Specify
type:
  v: string
enable when:
  question:
    v: 74080-3/74071-2
  operator:
    v: =
  answer: Coding
    type: LA20318-4
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20318-4
    display:
      v: Other: PLEASE SPECIFY
required:
  v: true

link id:
  v: 74080-3/74063-9
prefix:
  v: 16.
text:
  v: At what stage in the process did the event originate, regardless of the stage at which it was discovered?
type:
  v: choice
enable when:
  question:
    v: 74080-3/74072-0
  operator:
    v: =
  answer: Coding
    type: LA20275-6
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20275-6
    display:
      v: Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication)
required:
  v: true
answer value set:
  v: #ll2669-1
  l: ll2669-1
item:
  link id:
    v: 74080-3/74063-9/Other/Specify
  type:
    v: string
  enable when:
    question:
      v: 74080-3/74063-9
    operator:
      v: =
    answer: Coding
      type: LA20318-4
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: LA20318-4
      display:
        v: Other: PLEASE SPECIFY
  required:
    v: true

link id:
  v: 74080-3/74078-7.0
text:
  v: Please provide the following medication details for any medications or other substances directly involved in the event.
type:
  v: display

link id:
  v: 74080-3/74078-x
text:
  v: For an near miss, omit question 27
type:
  v: display
enable when:
  question:
    v: 74080-3/74072-0
  operator:
    v: !=
  answer: Coding
    type: LA20314-3
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20314-3
    display:
      v: Unsafe condition

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-maxOccurs
    l: questionnaire-maxOccurs
  value: Integer
    v: 5
link id:
  v: 74080-3/74078-7
type:
  v: group
enable when:
  question:
    v: 74080-3/74072-0
  operator:
    v: !=
  answer: Coding
    type: LA20315-0
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20315-0
    display:
      v: Adverse reaction in patient to the administered substance without any apparent incorrect action
enable when:
  question:
    v: 74080-3/74072-0
  operator:
    v: !=
  answer: Coding
    type: LA4489-6
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA4489-6
    display:
      v: Unknown
enable when:
  question:
    v: 74080-3/74076-1
  operator:
    v: !=
  answer: Coding
    type: LA20337-4
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20337-4
    display:
      v: Expressed human breast milk
enable when:
  question:
    v: 74080-3/74075-3
  operator:
    v: !=
  answer: Coding
    type: LA20298-8
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20298-8
    display:
      v: Compounded preparations
enable behavior:
  v: all
required:
  v: true
repeats:
  v: true
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minLength
      l: minLength
    value: Integer
      v: 0
  link id:
    v: 74080-3/74078-7/74062-1
  prefix:
    v: 17.
  text:
    v: Generic name or investigational drug name
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minLength
      l: minLength
    value: Integer
      v: 0
  link id:
    v: 74080-3/74078-7/74061-3
  prefix:
    v: 18.
  text:
    v: Ingredient RXCUI (if known)
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minLength
      l: minLength
    value: Integer
      v: 0
  link id:
    v: 74080-3/74078-7/74060-5
  prefix:
    v: 19.
  text:
    v: Brand name (if known)
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minLength
      l: minLength
    value: Integer
      v: 0
  link id:
    v: 74080-3/74078-7/74059-7
  prefix:
    v: 20.
  text:
    v: Brand name RXCUI (if known)
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minLength
      l: minLength
    value: Integer
      v: 0
  link id:
    v: 74080-3/74078-7/74058-9
  prefix:
    v: 21.
  text:
    v: Manufacturer (if known)
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minLength
      l: minLength
    value: Integer
      v: 0
  link id:
    v: 74080-3/74078-7/74057-1
  prefix:
    v: 22.
  text:
    v: Strength or concentration of product
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minLength
      l: minLength
    value: Integer
      v: 0
  link id:
    v: 74080-3/74078-7/74056-3
  prefix:
    v: 23.
  text:
    v: Clinical drug component RXCUI (if known)
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minLength
      l: minLength
    value: Integer
      v: 0
  link id:
    v: 74080-3/74078-7/74055-5
  prefix:
    v: 24.
  text:
    v: Dosage form of Product
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minLength
      l: minLength
    value: Integer
      v: 0
  link id:
    v: 74080-3/74078-7/74054-8

v: 25.

v: Dose form RXCUI (if known)

v: string

link id:
  v: 74080-3/74078-7/74053-0
prefix:
  v: 26.
text:
  v: Was this medication/substance prescribed for this patient?
type:
  v: choice
enable when:
  question:
    v: 74080-3/74072-0
  operator:
    v: !=
  answer: Coding
    type: LA20314-3
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20314-3
    display:
      v: Unsafe condition
required:
  v: true
answer value set:
  v: #ll2828-3
  l: ll2828-3

link id:
  v: Medication/74052-2
prefix:
  v: 27.
text:
  v: Was this medication/substance given to this patient?
type:
  v: choice
enable when:
  question:
    v: 74080-3/74072-0
  operator:
    v: !=
  answer: Coding
    type: LA20314-3
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20314-3
    display:
      v: Unsafe condition
required:
  v: true
answer value set:
  v: #ll2828-3
  l: ll2828-3

link id:
  v: Medication/SEC03
type:
  v: group
enable when:
  question:
    v: 74080-3/74072-0
  operator:
    v: =
  answer: Coding
    type: LA20304-4
    system:
      v: http://loinc.org
      l: loinc.org
    code:
      v: LA20304-4
    display:
      v: Incorrect route of administration
item:
  link id:
    v: 74080-3/74051-4
  prefix:
    v: 28.
  text:
    v: What was the intended route of administration?
  type:
    v: choice
  required:
    v: true
  answer value set:
    v: #ll2682-4
    l: ll2682-4
  item:
    link id:
      v: 74080-3/74051-4/Other/Specify
    type:
      v: string
    enable when:
      question:
        v: 74080-3/74051-4
      operator:
        v: =
      answer: Coding
        type: LA20318-4
    required:
      v: true
item:
  link id:
    v: 74080-3/74050-6
  prefix:
    v: 29.
  text:
    v: What was the actual route of administration (attempted or completed)?
  type:
    v: choice
  required:
    v: true
  answer value set:
    v: #ll2682-4
    l: ll2682-4
  item:
    link id:
      v: 74080-3/74050-6/Other/Specify
    type:
      v: string
    enable when:
      question:
        v: 74080-3/74050-6
      operator:
        v: =
      answer: Coding
        type: LA20318-4
    required:
      v: true

v: LA20318-4

v: Other: PLEASE SPECIFY

v: LA20318-4

v: Other: PLEASE SPECIFY

link id:
  v: Medication/SEC04
text:
  v: Thank you for completing these questions.
type:
  v: group
item:
  link id:
    v: Medication/SEC04.0
  text:
    v: OMB No. 0935-0143 Exp. Date 10/31/2014 Public reporting burden for the collection of information is estimated to average 10 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.
  type:
    v: display

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-hidden
    l: questionnaire-hidden
  value: Boolean
    v: true
link id:
  v: Reporting
text:
  v: Reporting information
type:
  v: group
item:
  link id:
    v: Reporting/who
  text:
    v: Reported by:
  type:
    v: string
item:
  link id:
    v: Reporting/when
  text:
    v: Reported date:
  type:
    v: date

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl
    l: questionnaire-itemControl
  value: CodeableConcept
    coding:
      system:
        v: http://hl7.org/fhir/questionnaire-item-control
        l: questionnaire-item-control
      code:
        v: footer
link id:
  v: Medication/footer
type:
  v: group
item:
  link id:
    v: Medication/footer.0
  text:
    v: AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance
  type:
    v: display