NHSN Healthcare Associated Infection (HAI) Reports
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NHSN Healthcare Associated Infection (HAI) Reports, published by HL7 International - Structured Documents Work Group. This is not an authorized publication; it is the continuous build for version 2.1.0). This version is based on the current content of https://github.com/HL7/HAI/ and changes regularly. See the Directory of published versions

: Questionnaire - Outpatient Procedure Component Surgical Site Infection Event - JSON Representation

Active as of 2019-04-01

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{
  "resourceType" : "Questionnaire",
  "id" : "hai-questionnaire-opc-ssi-event",
  "meta" : {
    "versionId" : "12",
    "lastUpdated" : "2023-02-24T01:35:54.061+00:00",
    "source" : "#tP7HDDAkX8upl5OX",
    "profile" : [
      "http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaire"
    ]
  },
  "language" : "en-US",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Placeholder</div>"
  },
  "url" : "http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-opc-ssi-event",
  "identifier" : [
    {
      "value" : "hai-questionnaire-opc-ssi-event-v1"
    }
  ],
  "name" : "HAI_questionnaire_opc_ssi_event",
  "title" : "Outpatient Procedure Component Surgical Site Infection (SSI) Event",
  "status" : "active",
  "experimental" : false,
  "subjectType" : [
    "Patient"
  ],
  "date" : "2019-04-01",
  "publisher" : "HL7 International - Structured Documents Work Group",
  "contact" : [
    {
      "name" : "HL7 International - Structured Documents",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/structure"
        }
      ]
    }
  ],
  "description" : "This Questionnaire instance defines the questions and possible answers in the Outpatient Procedure Component Surgical Site Infection Event. This report is for reporting data on each patient having a SSI event related to one of the NHSN operative procedures selected for monitoring.\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",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US",
          "display" : "United States of America"
        }
      ],
      "text" : "United States of America"
    }
  ],
  "code" : [
    {
      "system" : "http://loinc.org",
      "code" : "51897-7",
      "display" : "Healthcare Associated Infection report Document"
    }
  ],
  "item" : [
    {
      "linkId" : "facility-id",
      "text" : "Facility ID",
      "type" : "url",
      "required" : true,
      "repeats" : false
    },
    {
      "linkId" : "encounter-date",
      "text" : "Date of encounter",
      "type" : "date",
      "required" : true,
      "repeats" : false
    },
    {
      "linkId" : "infection-details",
      "text" : "Infection details",
      "type" : "group",
      "required" : true,
      "repeats" : false,
      "item" : [
        {
          "linkId" : "infection-details-group-description",
          "text" : "This group records the infection type, with details. It records SSI level, all identification criteria used to identify this SSI event, and identified pathogen(s).",
          "type" : "display"
        },
        {
          "linkId" : "event-type",
          "text" : "Event Type",
          "type" : "choice",
          "required" : true,
          "repeats" : false,
          "answerValueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.20"
        },
        {
          "linkId" : "event-date",
          "text" : "Date of event",
          "type" : "date",
          "required" : true,
          "repeats" : false
        },
        {
          "linkId" : "nhsn-procedure-code-category",
          "text" : "NHSN Procedure Code Category",
          "type" : "choice",
          "required" : true,
          "repeats" : false,
          "answerValueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.34"
        },
        {
          "linkId" : "primary-cpt-procedure-code",
          "text" : "Primary CPT Procedure Code",
          "type" : "choice",
          "required" : true,
          "repeats" : false,
          "answerValueSet" : "http://hl7.org/fhir/ValueSet/cpt-all"
        },
        {
          "linkId" : "procedure-id",
          "text" : "Procedure Id",
          "type" : "url",
          "required" : true,
          "repeats" : false
        },
        {
          "linkId" : "ssi-level",
          "text" : "Surgical Site Infection (SSI) Level",
          "type" : "choice",
          "required" : true,
          "repeats" : false,
          "answerValueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3196"
        },
        {
          "linkId" : "criteria-of-diagnosis",
          "text" : "Criteria of Diagnosis",
          "type" : "group",
          "required" : true,
          "repeats" : false,
          "item" : [
            {
              "linkId" : "criteria-of-diagnosis-group-description",
              "text" : "This group records the criteria used in the diagnosis of an infection.",
              "type" : "display"
            },
            {
              "linkId" : "criteria-of-diagnosis-abscess",
              "code" : [
                {
                  "system" : "http://snomed.info/sct",
                  "code" : "128477000",
                  "display" : "Abscess"
                }
              ],
              "text" : "Criteria of Diagnosis: Abscess",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-redness",
              "code" : [
                {
                  "system" : "http://snomed.info/sct",
                  "code" : "386713009",
                  "display" : "Redness"
                }
              ],
              "text" : "Criteria of Diagnosis: Redness",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-fever",
              "code" : [
                {
                  "system" : "http://snomed.info/sct",
                  "code" : "386661006",
                  "display" : "Fever"
                }
              ],
              "text" : "Criteria of Diagnosis: Fever",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-heat",
              "code" : [
                {
                  "system" : "http://snomed.info/sct",
                  "code" : "304214002",
                  "display" : "Feels warm (finding)"
                }
              ],
              "text" : "Criteria of Diagnosis: Heat",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-incision-purulent-drainage",
              "code" : [
                {
                  "system" : "http://snomed.info/sct",
                  "code" : "255320000",
                  "display" : "Infection - suppurative (disorder)"
                }
              ],
              "text" : "Criteria of Diagnosis: Purulent drainage",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-wound-dehisced",
              "code" : [
                {
                  "system" : "http://snomed.info/sct",
                  "code" : "225553008",
                  "display" : "Wound dehiscence"
                }
              ],
              "text" : "Criteria of Diagnosis: Wound spontaneously dehisced",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-incision-opened",
              "code" : [
                {
                  "system" : "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                  "code" : "1967-9",
                  "display" : "Incision deliberately opened or otherwise drained by physician"
                }
              ],
              "text" : "Criteria of Diagnosis: Incision deliberately opened",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-evidence-found",
              "code" : [
                {
                  "system" : "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                  "code" : "1905-9",
                  "display" : "Other evidence of infection found on direct exam, during surgery, or by diagnostic tests"
                }
              ],
              "text" : "Criteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-localized-swelling",
              "code" : [
                {
                  "system" : "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                  "code" : "1920-8",
                  "display" : "Localized swelling"
                }
              ],
              "text" : "Criteria of Diagnosis: Localized swelling",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-pain-tenderness",
              "code" : [
                {
                  "system" : "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                  "code" : "1960-4",
                  "display" : "Pain or tenderness"
                }
              ],
              "text" : "Criteria of Diagnosis: Pain or tenderness",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-organism-identified",
              "code" : [
                {
                  "system" : "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                  "code" : "1952-1",
                  "display" : "Positive culture"
                }
              ],
              "text" : "Criteria of Diagnosis: Organism Identified",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-testing-not-performed",
              "code" : [
                {
                  "system" : "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                  "code" : "1901-8",
                  "display" : "Not cultured"
                }
              ],
              "text" : "Criteria of Diagnosis: Culture or non-culture based testing not performed",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-imaging-test",
              "code" : [
                {
                  "system" : "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                  "code" : "1924-0",
                  "display" : "Radiographic evidence of infection"
                }
              ],
              "text" : "Criteria of Diagnosis: Imaging test evidence of infection",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            },
            {
              "linkId" : "criteria-of-diagnosis-physician-diagnosis",
              "code" : [
                {
                  "system" : "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                  "code" : "1963-8",
                  "display" : "Physician Diagnosis of this event type"
                }
              ],
              "text" : "Criteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physician",
              "type" : "boolean",
              "required" : true,
              "repeats" : false
            }
          ]
        },
        {
          "linkId" : "ssi-detection-method-type",
          "text" : "Surveillence method type (active/passive) through which the SSI was detected",
          "type" : "choice",
          "required" : true,
          "repeats" : false,
          "answerValueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.31"
        },
        {
          "linkId" : "ssi-detection-method",
          "text" : "Surveillence method through which the SSI was detected",
          "type" : "choice",
          "required" : true,
          "repeats" : false,
          "answerValueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.10.20.5.9.29"
        }
      ]
    },
    {
      "linkId" : "findings-group",
      "code" : [
        {
          "system" : "http://loinc.org",
          "code" : "18769-0",
          "display" : "Microbial susceptibility tests Set"
        }
      ],
      "text" : "Findings Group",
      "type" : "group",
      "required" : true,
      "repeats" : true,
      "item" : [
        {
          "linkId" : "findings-group-description",
          "text" : "This group records whether infection organisms were identified and, if so, records details about them.",
          "type" : "display"
        },
        {
          "linkId" : "pathogen-identified",
          "text" : "Pathogen Identified",
          "type" : "choice",
          "required" : true,
          "repeats" : false,
          "answerValueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.13.16"
        },
        {
          "linkId" : "pathogen-ranking",
          "text" : "Pathogen Ranking",
          "type" : "choice",
          "required" : true,
          "repeats" : false,
          "answerValueSet" : "http://hl7.org/fhir/us/hai/ValueSet/nhsn-pathogen-ranking"
        }
      ]
    },
    {
      "linkId" : "nhsn-comment",
      "code" : [
        {
          "system" : "http://loinc.org",
          "code" : "86468-6",
          "display" : "Report Comment Section"
        }
      ],
      "text" : "Comments",
      "type" : "text",
      "required" : false,
      "repeats" : false,
      "maxLength" : 2000
    }
  ]
}