{
"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.\\n\\nFor further details on reporting healthcare-associated infections see the specific protocols and data collection forms on the NHSN website [https://www.cdc.gov/nhsn/](https://www.cdc.gov/nhsn/).\\n",
"_filename": "Questionnaire-hai-questionnaire-los-event.json",
"package_name": "hl7.fhir.us.hai",
"subjectType": [ "Patient" ],
"date": "2019-04-01",
"meta": {
"profile": [ "http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire" ]
},
"publisher": "HL7 Structured Documents Work Group",
"jurisdiction": [ {
"coding": [ {
"code": "US",
"system": "urn:iso:std:iso:3166"
} ]
} ],
"name": "HAI_questionnaire_los_event",
"item": [ {
"text": "Facility ID",
"type": "url",
"linkId": "facility",
"repeats": false,
"required": true
}, {
"text": "Event Number",
"type": "url",
"linkId": "event-number",
"repeats": false,
"required": false
}, {
"text": "Event Type",
"type": "choice",
"linkId": "event-type",
"repeats": false,
"required": true,
"answerValueSet": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.20"
}, {
"text": "Date of Event",
"type": "date",
"linkId": "date-of-event",
"repeats": false,
"required": true
}, {
"text": "Facility Location",
"type": "choice",
"linkId": "facility-location",
"repeats": false,
"required": true,
"answerValueSet": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.19"
}, {
"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": [ {
"text": "This group contains risk factors such as central line present, birth weight, and gestational age.",
"type": "display",
"linkId": "risk-factors-group"
}, {
"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
}, {
"text": "Gestational age known: set true if known and false if unknown",
"type": "boolean",
"linkId": "gestational-age-known",
"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": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"code": "d",
"system": "http://unitsofmeasure.org",
"display": "d"
}
} ],
"enableWhen": [ {
"operator": "=",
"question": "gestational-age-known",
"answerBoolean": true
} ]
} ],
"text": "Risk Factors",
"type": "group",
"linkId": "risk-factors",
"repeats": false,
"required": true
}, {
"code": [ {
"code": "51899-3",
"system": "http://loinc.org",
"display": "Details Document"
} ],
"item": [ {
"text": "This group contains details aboout the late onset septis infection event.",
"type": "display",
"linkId": "event-details-group"
}, {
"text": "Specific Event",
"type": "choice",
"linkId": "infection-condition",
"repeats": false,
"required": true,
"answerValueSet": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3196"
}, {
"text": "Laboratory Criteria Used",
"type": "choice",
"linkId": "criteria-used",
"repeats": false,
"required": true,
"answerValueSet": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.114222.4.11.3195"
}, {
"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": false,
"enableWhen": [ {
"operator": "=",
"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,
"required": true
}, {
"code": [ {
"code": "18769-0",
"system": "http://loinc.org",
"display": "Microbial susceptibility tests Set"
} ],
"item": [ {
"text": "This group records whether infection organisms were identified and, if so, records details about them.",
"type": "display",
"linkId": "findings-group-description"
}, {
"text": "Pathogen Identified",
"type": "choice",
"linkId": "pathogen-identified",
"repeats": false,
"required": true,
"answerValueSet": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.16"
}, {
"text": "Pathogen Ranking",
"type": "choice",
"linkId": "pathogen-ranking",
"repeats": false,
"required": true,
"answerValueSet": "http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking"
}, {
"item": [ {
"text": "This group contains drug-susceptibility information such as the drug and the pathogen's susceptibility to it.",
"type": "display",
"linkId": "drug-susceptibility-test-group-description"
}, {
"text": "Drug Susceptibility Test",
"type": "choice",
"linkId": "drug-susceptibility-test",
"repeats": false,
"required": true,
"answerValueSet": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.15"
}, {
"text": "Drug Susceptibility Test Interpretation",
"type": "choice",
"linkId": "drug-susceptibility-test-interpretation",
"repeats": false,
"required": false,
"answerValueSet": "http://hl7.org/fhir/us/hai/ValueSet/2.16.840.1.113883.13.13"
} ],
"text": "Drug Susceptibility Test Group",
"type": "group",
"linkId": "drug-susceptibility-test-group",
"repeats": true
} ],
"text": "Findings Group",
"type": "group",
"linkId": "findings-group",
"repeats": true,
"required": 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": "2.0.0",
"status": "draft",
"language": "en-US",
"id": "fbd3757a-4324-4471-99c8-e3008b3c1bbd",
"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-v2"
} ],
"version": "2.0.0"
}