{
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  "_filename": "questionnaire-bbis-01-001-0001.R4.json",
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  "date": "2022-05-24T00:17:33.1225559+00:00",
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  },
  "publisher": "Malaysia MOH - HIE Steering Committee",
  "name": "questionnaire-bbis-01-001-0001",
  "item": [ {
    "item": [ {
      "text": "Hospital",
      "type": "string",
      "required": false
    }, {
      "text": "Ward",
      "type": "string",
      "required": false
    } ],
    "text": "Section A: Recipient Details",
    "type": "group",
    "required": false
  }, {
    "item": [ {
      "text": "Onset",
      "type": "choice",
      "required": false,
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        "valueCoding": {
          "display": "Immediate"
        }
      }, {
        "valueCoding": {
          "display": "Delay"
        }
      } ]
    } ],
    "text": "SECTION C: Onset of Adverse Event",
    "type": "group",
    "required": false
  }, {
    "item": [ {
      "item": [ {
        "text": "Whole Blood",
        "type": "choice",
        "repeats": true,
        "required": false,
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          "valueCoding": {
            "display": "Whole Blood"
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        }, {
          "valueCoding": {
            "display": "Irradiated"
          }
        }, {
          "valueCoding": {
            "display": "Filtered"
          }
        } ]
      }, {
        "text": "Packed Cells",
        "type": "choice",
        "repeats": true,
        "required": false,
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          "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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        "answerOption": [ {
          "valueCoding": {
            "display": "Packed Cells"
          }
        }, {
          "valueCoding": {
            "display": "Irradiated"
          }
        } ]
      }, {
        "text": "Apheresis Platelet",
        "type": "choice",
        "repeats": true,
        "required": false,
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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              "code": "check-box",
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          }
        } ],
        "answerOption": [ {
          "valueCoding": {
            "display": "Apheresis Platelet"
          }
        }, {
          "valueCoding": {
            "display": "Irradiated"
          }
        }, {
          "valueCoding": {
            "display": "Pathogen Inactivated"
          }
        } ]
      }, {
        "text": "Random Platelet",
        "type": "choice",
        "repeats": true,
        "required": false,
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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            "text": "Check-box",
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        } ],
        "answerOption": [ {
          "valueCoding": {
            "display": "Random Platelet"
          }
        }, {
          "valueCoding": {
            "display": "Irradiated"
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        } ]
      }, {
        "text": "Fresh Frozen Plasma",
        "type": "choice",
        "repeats": true,
        "required": false,
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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          }
        } ],
        "answerOption": [ {
          "valueCoding": {
            "display": "Fresh Frozen Plasma"
          }
        } ]
      }, {
        "text": "Cryoprecipitate",
        "type": "choice",
        "repeats": true,
        "required": false,
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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        } ],
        "answerOption": [ {
          "valueCoding": {
            "display": "Cryoprecipitate"
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        }, {
          "valueCoding": {
            "display": "Pathogen Inactivated"
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        } ]
      }, {
        "text": "Cryosupernatant/Liver Plasma",
        "type": "choice",
        "repeats": true,
        "required": false,
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        "answerOption": [ {
          "valueCoding": {
            "display": "Cryosupernatant/Liver Plasma"
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      }, {
        "item": [ {
          "text": "Please specify (Max 4000 Characters)",
          "type": "display",
          "linkId": "undefined-help",
          "extension": [ {
            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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        } ],
        "text": "Others",
        "type": "text",
        "required": false,
        "maxLength": 4000
      } ],
      "text": "Blood component implicated",
      "type": "group",
      "required": false
    } ],
    "text": "SECTION D: Blood Component Implicated In Adverse Event",
    "type": "group",
    "required": false
  }, {
    "item": [ {
      "text": "Date reaction occured",
      "type": "dateTime",
      "required": false
    } ],
    "text": "SECTION E: Date Rection Occured",
    "type": "group",
    "required": false
  }, {
    "item": [ {
      "text": "Patient Diagnosis",
      "type": "string",
      "required": false
    } ],
    "text": "SECTION F: Relevant Clinical History",
    "type": "group",
    "required": false
  }, {
    "item": [ {
      "text": "Recovered",
      "type": "boolean",
      "required": false
    }, {
      "item": [ {
        "item": [ {
          "text": "When there is conclusive evidence beyond reasonable doubt that the complication can be attributed to other causes",
          "type": "display",
          "linkId": "undefined-help",
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          } ]
        } ],
        "text": "Excluded / Unlikely",
        "type": "boolean",
        "required": false
      }, {
        "item": [ {
          "text": "Evidence is indeterminate for attributing the adverse event to the transfusion",
          "type": "display",
          "linkId": "undefined-help",
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            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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          } ]
        } ],
        "text": "Possible",
        "type": "boolean",
        "required": false
      }, {
        "item": [ {
          "text": "When the evidence is clearly in favour of the reaction",
          "type": "display",
          "linkId": "undefined-help",
          "extension": [ {
            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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                "system": "http://hl7.org/fhir/questionnaire-item-control",
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          } ]
        } ],
        "text": "Likely / Probable",
        "type": "boolean",
        "required": false
      }, {
        "item": [ {
          "text": "When there is conclusive evidence beyond reasonable doubt for the relation",
          "type": "display",
          "linkId": "undefined-help",
          "extension": [ {
            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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            }
          } ]
        } ],
        "text": "Confirmed / Definite",
        "type": "boolean",
        "required": false
      }, {
        "item": [ {
          "text": "(Max 4000 Characters)",
          "type": "display",
          "linkId": "undefined-help",
          "extension": [ {
            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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        } ],
        "text": "Comment",
        "type": "text",
        "required": false
      }, {
        "text": "Relation between adverse event and transfusion",
        "type": "display",
        "linkId": "undefined-help",
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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          }
        } ]
      } ],
      "text": "Imputability",
      "type": "group",
      "required": false
    } ],
    "text": "SECTION I: Patient Outcome From The Adverse Event",
    "type": "group",
    "required": false
  }, {
    "item": [ {
      "item": [ {
        "item": [ {
          "text": "ABO incompatible",
          "type": "boolean",
          "required": false
        }, {
          "item": [ {
            "text": "e.g. Rh positive given to Rh negative",
            "type": "display",
            "linkId": "undefined-help",
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            } ]
          } ],
          "text": "Other red cell incompatibility",
          "type": "boolean",
          "required": false
        } ],
        "text": "Acute Immune Haemolytic Anaemia",
        "type": "boolean",
        "required": false
      }, {
        "text": "Blood is compatible but meant for another patient",
        "type": "boolean",
        "required": false
      }, {
        "item": [ {
          "item": [ {
            "text": "e.g. irradiated, filtered, phenotyped",
            "type": "display",
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            } ]
          } ],
          "text": "Special requirement not met",
          "type": "boolean",
          "required": false
        }, {
          "item": [ {
            "text": "e.g. wrong component",
            "type": "display",
            "linkId": "undefined-help",
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          } ],
          "text": "Inappropriate transfusion",
          "type": "boolean",
          "required": false
        } ],
        "text": "Others",
        "type": "boolean",
        "required": false
      }, {
        "text": "Proceed to SECTION K for 'IBCT'",
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        } ]
      } ],
      "text": "Incorrect Blood Component/Product Transfused",
      "type": "group",
      "required": false
    }, {
      "text": "Delayed Heamolytic Transfusion Reaction",
      "type": "boolean",
      "required": false
    }, {
      "item": [ {
        "text": "Due to mechanical factor, osmotic, heat, cold, etc",
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      } ],
      "text": "Non-immune haemolytic reaction",
      "type": "boolean",
      "required": false
    }, {
      "text": "Febrile Non-Haemolytic Transfusion Reaction (FNHTR)",
      "type": "boolean",
      "required": false
    }, {
      "item": [ {
        "text": "Allergic Reaction",
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        "required": false,
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        } ],
        "answerOption": [ {
          "valueCoding": {
            "display": "Mild (Rash/Urticaria)"
          }
        }, {
          "valueCoding": {
            "display": "Moderate (Anaphylactoid)"
          }
        }, {
          "valueCoding": {
            "display": "Severe (Anaphylactic Transfusion Reaction)"
          }
        } ]
      } ],
      "text": "Allergic Reaction",
      "type": "boolean",
      "required": false
    }, {
      "text": "Transfusion-Related Acute Lung Injury (TRALI)",
      "type": "boolean",
      "required": false
    }, {
      "text": "Transfusion-Associated Circulatory Overload (TACO)",
      "type": "boolean",
      "required": false
    }, {
      "text": "Transfusion-Associated Dyspnoea (TAD)",
      "type": "boolean",
      "required": false
    }, {
      "text": "Transfusion-Associated Graft-versus-Host Disease (TA-GvHD)",
      "type": "boolean",
      "required": false
    }, {
      "text": "Post-Transfusion Purpura (PTP)",
      "type": "boolean",
      "required": false
    }, {
      "item": [ {
        "text": "Please specify",
        "type": "text",
        "required": true
      } ],
      "text": "Post-Transfusion Infection: Virus",
      "type": "boolean",
      "required": false
    }, {
      "item": [ {
        "text": "Please specify",
        "type": "text",
        "required": true
      } ],
      "text": "Post-Transfusion Infection: Bacteria",
      "type": "boolean",
      "required": false
    }, {
      "item": [ {
        "text": "Please specify",
        "type": "text",
        "required": true
      } ],
      "text": "Post-Transfusion Infection: Parasite",
      "type": "boolean",
      "required": false
    }, {
      "text": "Handling and storage error",
      "type": "boolean",
      "required": false
    }, {
      "text": "Equipment related (e.g. faulty waterbath, transfusion set, etc)",
      "type": "boolean",
      "required": false
    }, {
      "item": [ {
        "text": "Please specify",
        "type": "text",
        "required": true
      } ],
      "text": "Unclassifiable Complication of Transfusion",
      "type": "boolean",
      "required": false
    }, {
      "item": [ {
        "text": "Please specify",
        "type": "text",
        "required": true
      } ],
      "text": "Not Related To Transfusion",
      "type": "boolean",
      "required": false
    }, {
      "text": "Hypotensive Transfusion Reaction",
      "type": "boolean",
      "required": false
    }, {
      "item": [ {
        "text": "File Upload",
        "type": "attachment",
        "required": false
      }, {
        "text": "Please specify",
        "type": "text",
        "required": true
      } ],
      "text": "Others",
      "type": "boolean",
      "required": false
    } ],
    "text": "SECTION J: Type Of Adverse Event",
    "type": "group",
    "required": false
  } ],
  "type": null,
  "experimental": null,
  "resourceType": "Questionnaire",
  "title": "BBIS - Reporting Form For Transfusion-Related Adverse Event",
  "package_version": "2.0.0-alpha",
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  "status": "active",
  "id": "f907b00e-250d-4a17-8457-ef41d431220d",
  "kind": null,
  "url": "http://fhir.hie.moh.gov.my/Questionnaire/01-001-0001",
  "version": "1.0.0"
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