{
  "description": "This Questionnaire instance defines the questions and possible answers in the Late Onset Sepsis/Meningitis Event (LOS) Report. It records a late onset sepsis/meningitis infection event. For Late Onset Sepsis/Meningitis Event Reports, a Medicaid beneficiary number may be present.",
  "_filename": "Questionnaire-hai-questionnaire-los-event.json",
  "package_name": "hl7.fhir.us.hai",
  "subjectType": [ "Patient" ],
  "date": "2018-09-30",
  "meta": {
    "profile": [ "http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire" ],
    "versionId": "3",
    "lastUpdated": "2019-03-13T19:43:37.000-04:00"
  },
  "publisher": "HL7",
  "jurisdiction": [ {
    "coding": [ {
      "code": "US",
      "system": "urn:iso:std:iso:3166"
    } ]
  } ],
  "name": null,
  "item": [ {
    "text": "Facility ID",
    "type": "url",
    "linkId": "facility",
    "repeats": false,
    "required": true
  }, {
    "text": "Event #",
    "type": "url",
    "linkId": "event-number",
    "repeats": false,
    "required": false
  }, {
    "text": "Event Type",
    "type": "choice",
    "linkId": "event-type",
    "options": {
      "reference": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.20"
    },
    "repeats": false,
    "required": true
  }, {
    "text": "Date of Event",
    "type": "date",
    "linkId": "date-of-event",
    "repeats": false,
    "required": true
  }, {
    "text": "Facility Location",
    "type": "choice",
    "linkId": "facility-location",
    "options": {
      "reference": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.19"
    },
    "repeats": false,
    "required": true
  }, {
    "text": "Date Admitted to Facility:",
    "type": "date",
    "linkId": "date-admitted-to-facility",
    "repeats": false,
    "required": true
  }, {
    "code": [ {
      "code": "445087001",
      "system": "http://snomed.info/sct",
      "display": "Born before arrival to hospital (situation)"
    } ],
    "text": "Inborn/Outborn: If the infant was outborn (born at a location other than the reporting hospital), select true. If the infant was inborn (born at the reporting hospital) select false.",
    "type": "boolean",
    "linkId": "inborn-outborn-observation",
    "repeats": false,
    "required": true
  }, {
    "code": [ {
      "code": "51898-5",
      "system": "http://loinc.org",
      "display": "Risk factors Document"
    } ],
    "item": [ {
      "code": [ {
        "code": "1006-6",
        "system": "http://hl7.org/fhir/us/hai/CodeSystem/2.16.840.1.113883.6.277",
        "display": "central line including umbilical catheter"
      } ],
      "text": "Risk Factor: Central line present prior to event, including umbilical catheter",
      "type": "boolean",
      "linkId": "risk-factor-central-line",
      "repeats": false,
      "required": false
    }, {
      "code": [ {
        "code": "364589006",
        "system": "http://snomed.info/sct",
        "display": "Birth Weight"
      } ],
      "text": "Risk Factor: Birth weight (grams)",
      "type": "quantity",
      "linkId": "risk-factor-birth-weight",
      "repeats": false,
      "required": true
    }, {
      "code": [ {
        "code": "76516-4",
        "system": "http://loinc.org",
        "display": "Gestational age--at birth"
      } ],
      "text": "Risk Factor: Gestational age (days)",
      "type": "quantity",
      "linkId": "risk-factor-gestational-age",
      "repeats": false,
      "required": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
        "valueCoding": {
          "code": "d",
          "system": "http://unitsofmeasure.org",
          "display": "d"
        }
      } ]
    } ],
    "text": "Risk Factors: Contains central line present, birth weight, gestational age",
    "type": "group",
    "linkId": "risk-factors",
    "repeats": false
  }, {
    "code": [ {
      "code": "51899-3",
      "system": "http://loinc.org",
      "display": "Details Document"
    } ],
    "item": [ {
      "text": "Specific Event",
      "type": "choice",
      "linkId": "infection-condition",
      "options": {
        "reference": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3196"
      },
      "repeats": false,
      "required": true
    }, {
      "text": "Laboratory Criteria Used",
      "type": "choice",
      "linkId": "criteria-used",
      "options": {
        "reference": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3195"
      },
      "repeats": false,
      "required": true
    }, {
      "code": [ {
        "code": "419099009",
        "system": "http://snomed.info/sct",
        "display": "dead"
      } ],
      "text": "Died",
      "type": "boolean",
      "linkId": "died",
      "repeats": false,
      "required": true
    }, {
      "text": "Infection contributed to death",
      "type": "boolean",
      "linkId": "los-contributed-to-death",
      "repeats": false,
      "required": true,
      "enableWhen": [ {
        "question": "died",
        "answerBoolean": true
      } ]
    }, {
      "text": "Discharge Date",
      "type": "date",
      "linkId": "discharge-date",
      "repeats": false,
      "required": false
    } ],
    "text": "Event Details",
    "type": "group",
    "linkId": "event-details",
    "repeats": false
  }, {
    "code": [ {
      "code": "18769-0",
      "system": "http://loinc.org",
      "display": "Microbial susceptibility tests Set"
    } ],
    "item": [ {
      "text": "Pathogen Identified",
      "type": "choice",
      "linkId": "pathogen-identified",
      "options": {
        "reference": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.16"
      },
      "repeats": false,
      "required": true
    }, {
      "text": "Pathogen Ranking",
      "type": "choice",
      "linkId": "pathogen-ranking",
      "options": {
        "reference": "http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking"
      },
      "repeats": false,
      "required": true
    }, {
      "item": [ {
        "text": "Drug Susceptibility Test",
        "type": "choice",
        "linkId": "drug-susceptibility-test",
        "options": {
          "reference": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.15"
        },
        "repeats": false,
        "required": true
      }, {
        "text": "Drug Susceptibility Test Interpretation",
        "type": "choice",
        "linkId": "drug-susceptibility-test-interpretation",
        "options": {
          "reference": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.13"
        },
        "repeats": false,
        "required": false
      } ],
      "text": "Drug Susceptibility Test Group",
      "type": "group",
      "linkId": "drug-susceptibility-test-group",
      "repeats": true
    } ],
    "text": "Findings Group: Records whether infection organisms were identified and, if so, records details about them.",
    "type": "group",
    "linkId": "findings-group",
    "repeats": true
  }, {
    "code": [ {
      "code": "86468-6",
      "system": "http://www.loinc.org",
      "display": "Report Comment Section"
    } ],
    "text": "Comments",
    "type": "text",
    "linkId": "nhsn-comment",
    "repeats": false,
    "required": false,
    "maxLength": 2000
  } ],
  "type": null,
  "experimental": null,
  "resourceType": "Questionnaire",
  "title": "Late Onset Sepsis/Meningitis Event (LOS)",
  "package_version": "1.1.0",
  "status": "draft",
  "language": "en-US",
  "id": "b9744f71-fa02-4a96-b635-b0a110109dcf",
  "kind": null,
  "url": "http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-los-event",
  "code": [ {
    "code": "51897-7",
    "system": "http://loinc.org",
    "display": "Healthcare Associated Infection report Document"
  } ],
  "identifier": [ {
    "value": "hai-questionnaire-los-event-v1"
  } ],
  "version": "R1"
}