Structured Data Capture, published by HL7 International / FHIR Infrastructure. This guide is not an authorized publication; it is the continuous build for version 3.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/sdc/ and changes regularly. See the Directory of published versions
Page standards status: Informative |
LinkId | Text | Cardinality | Type | Flags | Description & Constraints |
---|---|---|---|---|---|
MedicationorOtherSubstance | Questionnaire | http://hl7.org/fhir/uv/sdc/Questionnaire/questionnaire-sdc-profile-example-loinc#3.0.0 | |||
Medication/header | null | 0..1 | group | ||
0 | Form ID: | 1..1 | string | ||
74080-3/74081-1 | Event ID: | 1..1 | string | ||
74080-3/30947-6 | Initial Report Date (HERF Q1) | 1..1 | string | ||
Medication/SEC00 | Medication or Other Substance | 0..1 | group | ||
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 | ||
Medication/SEC01/74080-3 | null | 1..1 | group | ||
74080-3/74076-1 | 1.. What type of medication/substance was involved? | 1..1 | choice | Definition: http://loinc.org/74076-1 Value Set: AHRQ_Medication_Q1 | |
74080-3/74075-3 | 2.. What type of medication? | 1..1 | choice | Definition: http://loinc.org/vs/74075-3 Enable When: 74080-3/74076-1 = Medications (LOINC#LA20271-5) Value Set: AHRQ_Medication_Q2 | |
74080-3/74077-9-q | 3.. Please list all ingredients: | 1..* | string | Definition: http://loinc.org/74077-9 Enable When: 74080-3/74075-3 = Compounded preparations (LOINC#LA20298-8) | |
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 | |
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) | |
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 | |
74080-3/74073-8/Other/Specify | null | 1..1 | string | Enable When: 74080-3/74073-8 = Other: PLEASE SPECIFY (LOINC#LA20318-4) | |
74080-3/74076-1/Other/Specify | null | 1..1 | string | Enable When: 74080-3/74076-1 = Other substance: PLEASE SPECIFY (LOINC#LA20343-2) | |
74080-3/74072-0 | 7.. Which of the following best characterizes the event? | 1..1 | choice | Enable When:
Value Set: AHRQ_Medication_Q7 | |
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 | |
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 | |
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 | |
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 | |
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 | |
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) | |
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 | |
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 | |
Medication/74064-7/Other/Specify | null | 1..1 | string | Enable When: Medication/74064-7 = Other: PLEASE SPECIFY (LOINC#LA20318-4) | |
74080-3/74071-2/Other/Specify | null | 1..1 | string | Enable When: 74080-3/74071-2 = Other: PLEASE SPECIFY (LOINC#LA20318-4) | |
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 | |
74080-3/74063-9/Other/Specify | null | 1..1 | string | Enable When: 74080-3/74063-9 = Other: PLEASE SPECIFY (LOINC#LA20318-4) | |
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 | ||
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) | |
74080-3/74078-7 | null | 0..* | group | Enable When:
| |
74080-3/74078-7/74062-1 | 17.. Generic name or investigational drug name | 0..1 | string | ||
74080-3/74078-7/74061-3 | 18.. Ingredient RXCUI (if known) | 0..1 | string | ||
74080-3/74078-7/74060-5 | 19.. Brand name (if known) | 0..1 | string | ||
74080-3/74078-7/74059-7 | 20.. Brand name RXCUI (if known) | 0..1 | string | ||
74080-3/74078-7/74058-9 | 21.. Manufacturer (if known) | 0..1 | string | ||
74080-3/74078-7/74057-1 | 22.. Strength or concentration of product | 0..1 | string | ||
74080-3/74078-7/74056-3 | 23.. Clinical drug component RXCUI (if known) | 0..1 | string | ||
74080-3/74078-7/74055-5 | 24.. Dosage form of Product | 0..1 | string | ||
74080-3/74078-7/74054-8 | 25.. Dose form RXCUI (if known) | 0..1 | string | ||
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 | |
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 | |
Medication/SEC03 | null | 0..1 | group | Enable When: 74080-3/74072-0 = Incorrect route of administration (LOINC#LA20304-4) | |
74080-3/74051-4 | 28.. What was the intended route of administration? | 1..1 | choice | Value Set: AHRQ_Medication_Q28_Q29 | |
74080-3/74051-4/Other/Specify | null | 1..1 | string | Enable When: 74080-3/74051-4 = Other: PLEASE SPECIFY (LOINC#LA20318-4) | |
74080-3/74050-6 | 29.. What was the actual route of administration (attempted or completed)? | 1..1 | choice | Value Set: AHRQ_Medication_Q28_Q29 | |
74080-3/74050-6/Other/Specify | null | 1..1 | string | Enable When: 74080-3/74050-6 = Other: PLEASE SPECIFY (LOINC#LA20318-4) | |
Medication/SEC04 | Thank you for completing these questions. | 0..1 | group | ||
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 | ||
Reporting | Reporting information | 0..1 | group | ||
Reporting/who | Reported by: | 0..1 | string | ||
Reporting/when | Reported date: | 0..1 | date | ||
Medication/footer | null | 0..1 | group | ||
Medication/footer.0 | AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance | 0..1 | display | ||
Documentation for this format |