Structured Data Capture
2.8.0 - CI Build

Structured Data Capture, published by HL7 International - FHIR Infrastructure Work Group. This is not an authorized publication; it is the continuous build for version 2.8.0). This version is based on the current content of https://github.com/HL7/sdc/ and changes regularly. See the Directory of published versions

Example Questionnaire: SDC-LOINC AHRQ

LinkIdTextCardinalityTypeFlagsDescription & Constraintsdoco
.. Questionnaire
... Medication/headernull0..1group
.... 0Form ID:1..1string
.... 74080-3/74081-1Event ID:1..1string
.... 74080-3/30947-6Initial Report Date (HERF Q1)1..1string
... Medication/SEC00Medication or Other Substance0..1group
.... Medication/SEC00.0Use 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..1display
.... Medication/SEC01/74080-3null1..1group
..... 74080-3/74076-1What type of medication/substance was involved?1..1open-choiceDefinition: http://loinc.org/74076-1
Value Set: AHRQ_Medication_Q1
...... 74080-3/74075-3What type of medication?1..1choiceDefinition: http://loinc.org/vs/74075-3
Value Set: AHRQ_Medication_Q2
....... 74080-3/74077-9-qPlease list all ingredients:0..*stringDefinition: http://loinc.org/74077-9
...... 74080-3/74074-6What type of biological product?0..1open-choiceValue Set: AHRQ_Medication_Q4
....... 74080-3/30959-1What was the lot number of the vaccine?1..1string
...... 74080-3/74073-8What type of nutritional product?1..1open-choiceValue Set: AHRQ_Medication_Q6
....... 74080-3/74073-8/Other/SpecifyPLEASE SPECIFY1..1string
...... 74080-3/74076-1/Other/SpecifyPLEASE SPECIFY1..1string
..... 74080-3/74072-0Which of the following best characterizes the event?1..1open-choiceValue Set: AHRQ_Medication_Q7
..... 74080-3/74071-2What was the incorrect action?0..1choiceValue Set: AHRQ_Medication_Q8
...... 74080-3/74070-4Which best describes the incorrect dose(s)?1..1open-choiceValue Set: AHRQ_Medication_Q9
...... Medication/74069-6Which best describes the incorrect timing?1..1open-choiceValue Set: AHRQ_Medication_Q10
...... 74080-3/74068-8Which best describes the incorrect rate?1..1open-choiceValue Set: AHRQ_Medication_Q11
...... Medication/74067-0Which best describes the incorrect strength or concentration?1..1open-choiceValue Set: AHRQ_Medication_Q12
...... Medication/74066-2What was the expiration date?1..1string
...... Medication/74065-4Was there a documented history of allergies or sensitivities to the medication/substance administered?1..1open-choiceValue Set: AHRQ_Y/N/UNK
...... Medication/74064-7What was the contraindication (potential or actual interaction)?1..1open-choiceValue Set: AHRQ_Medication_Q15
....... Medication/74064-7/Other/SpecifyPLEASE SPECIFY1..1string
...... 74080-3/74071-2/Other/SpecifyPLEASE SPECIFY1..1string
..... 74080-3/74063-9At what stage in the process did the event originate, regardless of the stage at which it was discovered?1..1open-choiceValue Set: AHRQ_Medication_Q16
...... 74080-3/74063-9/Other/SpecifyPLEASE SPECIFY1..1string
.... 74080-3/74078-7null0..*group
..... 74080-3/74078-7.0Please provide the following medication details for any medications or other substances directly involved in the event.0..1display
..... 74080-3/74078-7/74062-1Generic name or investigational drug name0..1string
..... 74080-3/74078-7/74061-3Ingredient RXCUI (if known)0..1string
..... 74080-3/74078-7/74060-5Brand name (if known)0..1string
..... 74080-3/74078-7/74059-7Brand name RXCUI (if known)0..1string
..... 74080-3/74078-7/74058-9Manufacturer (if known)0..1string
..... 74080-3/74078-7/74057-1Strength or concentration of product0..1string
..... 74080-3/74078-7/74056-3Clinical drug component RXCUI (if known)0..1string
..... 74080-3/74078-7/74055-5Dosage form of Product0..1string
..... 74080-3/74078-7/74054-8Dose form RXCUI (if known)0..1string
..... 74080-3/74078-7/74053-0Was this medication/substance prescribed for this patient?1..1choiceValue Set: AHRQ_Y/N
..... Medication/74052-2Was this medication/substance given to this patient?1..1choiceValue Set: AHRQ_Y/N
.... Medication/SEC03null0..1group
..... 74080-3/74051-4What was the intended route of administration?1..1open-choiceValue Set: AHRQ_Medication_Q28_Q29
...... 74080-3/74051-4/Other/SpecifyPLEASE SPECIFY1..1string
..... 74080-3/74050-6What was the actual route of administration (attempted or completed)?1..1open-choiceValue Set: AHRQ_Medication_Q28_Q29
...... 74080-3/74050-6/Other/SpecifyPLEASE SPECIFY1..1string
.... Medication/SEC04Thank you for completing these questions.0..1group
..... Medication/SEC04.0OMB 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..1display
... ReportingReporting information0..1group
.... Reporting/whoReported by:0..1string
.... Reporting/whenReported date:0..1date
... Medication/footernull0..1group
.... Medication/footer.0AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance0..1display

doco Documentation for this format