Generated Narrative: Questionnaire questionnaire-sdc-profile-example-loinc Profile: SDC Base Questionnaire LinkID Text Cardinality Type Flags Description & Constraints 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 = Vaccines (LOINC#LA20283-0) #xD; 74080-3/74073-8 6.. What type of nutritional product? 1..1 choice Enable When: 74080-3/74076-1 = Nutritional products (LOINC#LA20336-6) Value Set: AHRQ_Medication_Q6 #xD; 74080-3/74073-8/Other/Specify null 1..1 string Enable When: 74080-3/74073-8 = Other: PLEASE SPECIFY (LOINC#LA20318-4) #xD; 74080-3/74076-1/Other/Specify null 1..1 string Enable When: 74080-3/74076-1 = Other substance: PLEASE SPECIFY (LOINC#LA20343-2) #xD; 74080-3/74072-0 7.. Which of the following best characterizes the event? 1..1 choice Enable When: 74080-3/74076-1 != Radiopharmaceuticals (LOINC#LA20340-8) 74080-3/74076-1 != Patient food (not suspected in drug-food interactions) (LOINC#LA20341-6) 74080-3/74076-1 != 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 (LOINC#LA20342-4) Value Set: AHRQ_Medication_Q7 #xD; 74080-3/74071-2 8.. What was the incorrect action? 0..1 choice Enable When: 74080-3/74072-0 = Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication) (LOINC#LA20275-6) Value Set: AHRQ_Medication_Q8 #xD; 74080-3/74070-4 9.. Which best describes the incorrect dose(s)? 1..1 choice Enable When: 74080-3/74071-2 = Incorrect dose(s) (LOINC#LA20303-6) Value Set: AHRQ_Medication_Q9 #xD; Medication/74069-6 10.. Which best describes the incorrect timing? 1..1 choice Enable When: 74080-3/74071-2 = Incorrect timing (LOINC#LA20305-1) Value Set: AHRQ_Medication_Q10 #xD; 74080-3/74068-8 11.. Which best describes the incorrect rate? 1..1 choice Enable When: 74080-3/74071-2 = Incorrect rate (LOINC#LA20306-9) Value Set: AHRQ_Medication_Q11 #xD; Medication/74067-0 12.. Which best describes the incorrect strength or concentration? 1..1 choice Enable When: 74080-3/74071-2 = Incorrect strength or concentration (LOINC#LA20309-3) Value Set: AHRQ_Medication_Q12 #xD; Medication/74066-2 13.. What was the expiration date? 1..1 string Enable When: 74080-3/74071-2 = Expired or deteriorated medication/substance (LOINC#LA20311-9) #xD; Medication/74065-4 14.. Was there a documented history of allergies or sensitivities to the medication/substance administered? 1..1 choice Enable When: 74080-3/74071-2 = Medication/substance that is known to be an allergen to the patient (LOINC#LA20312-7) Value Set: AHRQ_Y/N/UNK #xD; Medication/74064-7 15.. What was the contraindication (potential or actual interaction)? 1..1 choice Enable When: 74080-3/74071-2 = Medication/substance that is known to be contraindicated for the patient (LOINC#LA20345-7) Value Set: AHRQ_Medication_Q15 #xD; Medication/74064-7/Other/Specify null 1..1 string Enable When: Medication/74064-7 = Other: PLEASE SPECIFY (LOINC#LA20318-4) #xD; 74080-3/74071-2/Other/Specify null 1..1 string Enable When: 74080-3/74071-2 = Other: PLEASE SPECIFY (LOINC#LA20318-4) #xD; 74080-3/74063-9 16.. At what stage in the process did the event originate, regardless of the stage at which it was discovered? 1..1 choice Enable When: 74080-3/74072-0 = Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication) (LOINC#LA20275-6) Value Set: AHRQ_Medication_Q16 #xD; 74080-3/74063-9/Other/Specify null 1..1 string Enable When: 74080-3/74063-9 = Other: PLEASE SPECIFY (LOINC#LA20318-4) #xD; 74080-3/74078-7.0 Please provide the following medication details for any medications or other substances directly involved in the event. 0..1 display #xD; 74080-3/74078-x For an near miss, omit question 27 0..1 display Enable When: 74080-3/74072-0 != Unsafe condition (LOINC#LA20314-3) #xD; 74080-3/74078-7 null 1..* group Enable When: 74080-3/74072-0 != Adverse reaction in patient to the administered substance without any apparent incorrect action (LOINC#LA20315-0) 74080-3/74072-0 != Unknown (LOINC#LA4489-6) 74080-3/74076-1 != Expressed human breast milk (LOINC#LA20337-4) 74080-3/74075-3 != Compounded preparations (LOINC#LA20298-8) #xD; 74080-3/74078-7/74062-1 17.. Generic name or investigational drug name 0..1 string #xD; 74080-3/74078-7/74061-3 18.. Ingredient RXCUI (if known) 0..1 string #xD; 74080-3/74078-7/74060-5 19.. Brand name (if known) 0..1 string #xD; 74080-3/74078-7/74059-7 20.. Brand name RXCUI (if known) 0..1 string #xD; 74080-3/74078-7/74058-9 21.. Manufacturer (if known) 0..1 string #xD; 74080-3/74078-7/74057-1 22.. Strength or concentration of product 0..1 string #xD; 74080-3/74078-7/74056-3 23.. Clinical drug component RXCUI (if known) 0..1 string #xD; 74080-3/74078-7/74055-5 24.. Dosage form of Product 0..1 string #xD; 74080-3/74078-7/74054-8 25.. Dose form RXCUI (if known) 0..1 string #xD; 74080-3/74078-7/74053-0 26.. Was this medication/substance prescribed for this patient? 1..1 choice Enable When: 74080-3/74072-0 != Unsafe condition (LOINC#LA20314-3) Value Set: AHRQ_Y/N #xD; Medication/74052-2 27.. Was this medication/substance given to this patient? 1..1 choice Enable When: 74080-3/74072-0 != Unsafe condition (LOINC#LA20314-3) Value Set: AHRQ_Y/N #xD; Medication/SEC03 null 0..1 group Enable When: 74080-3/74072-0 = Incorrect route of administration (LOINC#LA20304-4) #xD; 74080-3/74051-4 28.. What was the intended route of administration? 1..1 choice Value Set: AHRQ_Medication_Q28_Q29 #xD; 74080-3/74051-4/Other/Specify null 1..1 string Enable When: 74080-3/74051-4 = Other: PLEASE SPECIFY (LOINC#LA20318-4) #xD; 74080-3/74050-6 29.. What was the actual route of administration (attempted or completed)? 1..1 choice Value Set: AHRQ_Medication_Q28_Q29 #xD; 74080-3/74050-6/Other/Specify null 1..1 string Enable When: 74080-3/74050-6 = Other: PLEASE SPECIFY (LOINC#LA20318-4) #xD; Medication/SEC04 Thank you for completing these questions. 0..1 group #xD; Medication/SEC04.0 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. 0..1 display #xD; Reporting Reporting information 0..1 group #xD; Reporting/who Reported by: 0..1 string #xD; Reporting/when Reported date: 0..1 date #xD; Medication/footer null 0..1 group #xD; Medication/footer.0 AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance 0..1 display #xD; Documentation for this format Contained Resources ValueSet #ll2654-3 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20271-5 Medications LA20335-8 Biological products LA20336-6 Nutritional products LA20337-4 Expressed human breast milk LA20338-2 Medical gases (e.g., oxygen, nitrogen, nitrous oxide) LA20339-0 Contrast media LA20340-8 Radiopharmaceuticals LA20341-6 Patient food (not suspected in drug-food interactions) LA20342-4 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 LA20343-2 Other substance: PLEASE SPECIFY ValueSet #ll2655-0 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20278-0 Prescription or over-the-counter (including herbal supplements) LA20298-8 Compounded preparations LA20299-6 Investigational drugs LA4489-6 Unknown ValueSet #ll2657-6 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20283-0 Vaccines LA20287-1 Other biological products (e.g., thrombolytic) ValueSet #ll2659-2 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20273-1 Dietary supplements (other than vitamins or minerals) LA16117-6 Vitamins or minerals LA20320-0 Enteral nutritional products, including infant formula LA20321-8 Parenteral nutritional products LA20318-4 Other: PLEASE SPECIFY ValueSet #ll2660-0 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20275-6 Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication) LA20314-3 Unsafe condition LA20315-0 Adverse reaction in patient to the administered substance without any apparent incorrect action LA4489-6 Unknown ValueSet #ll2661-8 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20276-4 Incorrect patient LA20302-8 Incorrect medication/substance LA20303-6 Incorrect dose(s) LA20304-4 Incorrect route of administration LA20305-1 Incorrect timing LA20306-9 Incorrect rate LA20307-7 Incorrect duration of administration or course of therapy LA20308-5 Incorrect dosage form (e.g., sustained release instead of immediate release) LA20309-3 Incorrect strength or concentration LA20310-1 Incorrect preparation, including inappropriate cutting of tablets, error in compounding, mixing, etc. LA20311-9 Expired or deteriorated medication/substance LA20312-7 Medication/substance that is known to be an allergen to the patient LA20345-7 Medication/substance that is known to be contraindicated for the patient LA20313-5 Incorrect patient/family action (e.g., self-administration error) LA20318-4 Other: PLEASE SPECIFY ValueSet #ll2662-6 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20277-2 Overdose LA20300-2 Underdose LA20301-0 Missed or omitted dose LA7271-5 Extra dose LA4489-6 Unknown ValueSet #ll2663-4 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20280-6 Too early LA20290-5 Too late LA4489-6 Unknown ValueSet #ll2664-2 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20282-2 Too quickly LA20288-9 Too slowly LA4489-6 Unknown ValueSet #ll2665-9 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20281-4 Too high LA20289-7 Too low LA4489-6 Unknown ValueSet #ll2817-6 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA33-6 Yes LA32-8 No LA4489-6 Unknown ValueSet #ll2668-3 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20274-9 Drug-drug LA20316-8 Drug-food LA20317-6 Drug-disease LA20318-4 Other: PLEASE SPECIFY ValueSet #ll2669-1 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20279-8 Purchasing LA20291-3 Storing LA20292-1 Prescribing/ordering LA20293-9 Transcribing LA20294-7 Preparing LA20295-4 Dispensing LA20296-2 Administering LA20297-0 Monitoring LA4489-6 Unknown LA20318-4 Other: PLEASE SPECIFY ValueSet #ll2828-3 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA33-6 Yes LA32-8 No ValueSet #ll2682-4 Include these codes as defined in http://loinc.org version Not Stated (use latest from terminology server) Code Display LA20272-3 Cutaneous, topical application, including ointment, spray, patch LA9451-1 Subcutaneous LA9444-6 Ophthalmic LA20324-2 Oral, including sublingual or buccal LA9445-3 Otic LA9263-0 Nasal LA9427-1 Inhalation LA9437-0 Intravenous LA9429-7 Intramuscular LA9435-4 Intrathecal LA9418-0 Epidural LA20332-5 Gastric LA9369-5 Rectal LA9459-4 Vaginal LA4489-6 Unknown LA20318-4 Other: PLEASE SPECIFY
The answer list for question 1 on the AHRQ "Medication or Other Substance" form
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
Medical gases (e.g., oxygen, nitrogen, nitrous oxide)
Patient food (not suspected in drug-food interactions)
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
The answer list for question 2 on the AHRQ "Medication or Other Substance" form
Prescription or over-the-counter (including herbal supplements)
The answer list for question 4 on the AHRQ "Medication or Other Substance" form
Other biological products (e.g., thrombolytic)
The answer list for question 6 on the AHRQ "Medication or Other Substance" form
Dietary supplements (other than vitamins or minerals)
Enteral nutritional products, including infant formula
The answer list for question 7 on the AHRQ 'Medication or Other Substance' form
Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication)
Adverse reaction in patient to the administered substance without any apparent incorrect action
The answer list for question 8 on the AHRQ 'Medication or Other Substance' form
Incorrect duration of administration or course of therapy
Incorrect dosage form (e.g., sustained release instead of immediate release)
Incorrect preparation, including inappropriate cutting of tablets, error in compounding, mixing, etc.
Expired or deteriorated medication/substance
Medication/substance that is known to be an allergen to the patient
Medication/substance that is known to be contraindicated for the patient
Incorrect patient/family action (e.g., self-administration error)
The answer list for question 9 on the AHRQ 'Medication or Other Substance' form
The answer list for question 10 on the AHRQ 'Medication or Other Substance' form
The answer list for question 11 on the AHRQ 'Medication or Other Substance' form
The answer list for question 12 on the AHRQ 'Medication or Other Substance' form
AHRQ Common Format Answer list for Yes (A15), No (A18), Unknown (UNK)
The answer list for question 15 on the AHRQ 'Medication or Other Substance' form
The answer list for question 16 on the AHRQ 'Medication or Other Substance' form
AHRQ Common Format Answer list for Yes (A15) and No (A18)
The answer list for questions 28 and 29 on the AHRQ 'Medication or Other Substance' form
Cutaneous, topical application, including ointment, spray, patch
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).
What type of medication/substance was involved?
Which of the following best characterizes the event?
Which best describes the incorrect dose(s)?
Which best describes the incorrect timing?
Which best describes the incorrect rate?
Which best describes the incorrect strength or concentration?
Was there a documented history of allergies or sensitivities to the medication/substance administered?
What was the contraindication (potential or actual interaction)?
At what stage in the process did the event originate, regardless of the stage at which it was discovered?
Please provide the following medication details for any medications or other substances directly involved in the event.
Generic name or investigational drug name
Clinical drug component RXCUI (if known)
Was this medication/substance prescribed for this patient?
Was this medication/substance given to this patient?
What was the intended route of administration?
What was the actual route of administration (attempted or completed)?
Thank you for completing these questions.
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.
AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance