Structured Data Capture
4.0.0 - STU 4 International flag

Structured Data Capture, published by HL7 International / FHIR Infrastructure. This guide is not an authorized publication; it is the continuous build for version 4.0.0 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

Questionnaire: SDC-LOINC AHRQ

Official URL: http://hl7.org/fhir/uv/sdc/Questionnaire/questionnaire-sdc-profile-example-loinc Version: 4.0.0
Standards status: Informative Computable Name: MedicationorOtherSubstance
Other Identifiers: OID:2.16.840.1.113883.4.642.40.17.35.13
LinkIDTextCardinalityTypeFlagsDescription & Constraintsdoco
.. MedicationorOtherSubstanceQuestionnairehttp://hl7.org/fhir/uv/sdc/Questionnaire/questionnaire-sdc-profile-example-loinc#4.0.0
... Medication/headernull0..1group
.... 0Form ID:1..1stringiconicon
.... 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
..... 74080-3/74076-11.. What type of medication/substance was involved?1..1choiceValue Set: AHRQ_Medication_Q1
...... 74080-3/74075-32.. What type of medication?1..1choiceEnable When: 74080-3/74076-1 =
Value Set: AHRQ_Medication_Q2
....... 74080-3/74077-9-q3.. Please list all ingredients:1..*stringEnable When: 74080-3/74075-3 =
...... 74080-3/74074-64.. What type of biological product?0..1choiceEnable When: 74080-3/74076-1 =
Value Set: AHRQ_Medication_Q4
....... 74080-3/30959-15.. What was the lot number of the vaccine?1..1stringEnable When: 74080-3/74074-6 =
...... 74080-3/74073-86.. What type of nutritional product?1..1choiceEnable When: 74080-3/74076-1 =
Value Set: AHRQ_Medication_Q6
....... 74080-3/74073-8/Other/Specifynull1..1stringEnable When: 74080-3/74073-8 =
...... 74080-3/74076-1/Other/Specifynull1..1stringEnable When: 74080-3/74076-1 =
..... 74080-3/74072-07.. Which of the following best characterizes the event?1..1choiceEnable When:
Value Set: AHRQ_Medication_Q7
..... 74080-3/74071-28.. What was the incorrect action?0..1choiceEnable When: 74080-3/74072-0 =
Value Set: AHRQ_Medication_Q8
...... 74080-3/74070-49.. Which best describes the incorrect dose(s)?1..1choiceEnable When: 74080-3/74071-2 =
Value Set: AHRQ_Medication_Q9
...... Medication/74069-610.. Which best describes the incorrect timing?1..1choiceEnable When: 74080-3/74071-2 =
Value Set: AHRQ_Medication_Q10
...... 74080-3/74068-811.. Which best describes the incorrect rate?1..1choiceEnable When: 74080-3/74071-2 =
Value Set: AHRQ_Medication_Q11
...... Medication/74067-012.. Which best describes the incorrect strength or concentration?1..1choiceEnable When: 74080-3/74071-2 =
Value Set: AHRQ_Medication_Q12
...... Medication/74066-213.. What was the expiration date?1..1stringEnable When: 74080-3/74071-2 =
...... Medication/74065-414.. Was there a documented history of allergies or sensitivities to the medication/substance administered?1..1choiceEnable When: 74080-3/74071-2 =
Value Set: AHRQ_Y/N/UNK
...... Medication/74064-715.. What was the contraindication (potential or actual interaction)?1..1choiceEnable When: 74080-3/74071-2 =
Value Set: AHRQ_Medication_Q15
....... Medication/74064-7/Other/Specifynull1..1stringEnable When: Medication/74064-7 =
...... 74080-3/74071-2/Other/Specifynull1..1stringEnable When: 74080-3/74071-2 =
..... 74080-3/74063-916.. At what stage in the process did the event originate, regardless of the stage at which it was discovered?1..1choiceEnable When: 74080-3/74072-0 =
Value Set: AHRQ_Medication_Q16
...... 74080-3/74063-9/Other/Specifynull1..1stringEnable When: 74080-3/74063-9 =
.... 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-xFor an near miss, omit question 270..1displayEnable When: 74080-3/74072-0 !=
.... 74080-3/74078-7null1..*groupEnable When:
..... 74080-3/74078-7/74062-117.. Generic name or investigational drug name0..1string
..... 74080-3/74078-7/74061-318.. Ingredient RXCUI (if known)0..1string
..... 74080-3/74078-7/74060-519.. Brand name (if known)0..1string
..... 74080-3/74078-7/74059-720.. Brand name RXCUI (if known)0..1string
..... 74080-3/74078-7/74058-921.. Manufacturer (if known)0..1string
..... 74080-3/74078-7/74057-122.. Strength or concentration of product0..1string
..... 74080-3/74078-7/74056-323.. Clinical drug component RXCUI (if known)0..1string
..... 74080-3/74078-7/74055-524.. Dosage form of Product0..1string
..... 74080-3/74078-7/74054-825.. Dose form RXCUI (if known)0..1string
..... 74080-3/74078-7/74053-026.. Was this medication/substance prescribed for this patient?1..1choiceEnable When: 74080-3/74072-0 !=
Value Set: AHRQ_Y/N
..... Medication/74052-227.. Was this medication/substance given to this patient?1..1choiceEnable When: 74080-3/74072-0 !=
Value Set: AHRQ_Y/N
.... Medication/SEC03null0..1groupEnable When: 74080-3/74072-0 =
..... 74080-3/74051-428.. What was the intended route of administration?1..1choiceValue Set: AHRQ_Medication_Q28_Q29
...... 74080-3/74051-4/Other/Specifynull1..1stringEnable When: 74080-3/74051-4 =
..... 74080-3/74050-629.. What was the actual route of administration (attempted or completed)?1..1choiceValue Set: AHRQ_Medication_Q28_Q29
...... 74080-3/74050-6/Other/Specifynull1..1stringEnable When: 74080-3/74050-6 =
.... 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..1groupiconicon
.... 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

Contained Resources

  • Include these codes as defined in http://loinc.org
    CodeDisplay
    LA20271-5Medications
    LA20335-8Biological products
    LA20336-6Nutritional products
    LA20337-4Expressed human breast milk
    LA20338-2Medical gases (e.g., oxygen, nitrogen, nitrous oxide)
    LA20339-0Contrast media
    LA20340-8Radiopharmaceuticals
    LA20341-6Patient food (not suspected in drug-food interactions)
    LA20342-4Drug-drug, drug-food, or adverse drug reaction as a result of a prescription and/or administration of a drug and/or food prior to admission
    LA20343-2Other substance: PLEASE SPECIFY
  • Include these codes as defined in http://loinc.org
    CodeDisplay
    LA20275-6Incorrect action (process failure or error) (e.g., such as administering overdose or incorrect medication)
    LA20314-3Unsafe condition
    LA20315-0Adverse reaction in patient to the administered substance without any apparent incorrect action
    LA4489-6Unknown
  • Include these codes as defined in http://loinc.org
    CodeDisplay
    LA20276-4Incorrect patient
    LA20302-8Incorrect medication/substance
    LA20303-6Incorrect dose(s)
    LA20304-4Incorrect route of administration
    LA20305-1Incorrect timing
    LA20306-9Incorrect rate
    LA20307-7Incorrect duration of administration or course of therapy
    LA20308-5Incorrect dosage form (e.g., sustained release instead of immediate release)
    LA20309-3Incorrect strength or concentration
    LA20310-1Incorrect preparation, including inappropriate cutting of tablets, error in compounding, mixing, etc.
    LA20311-9Expired or deteriorated medication/substance
    LA20312-7Medication/substance that is known to be an allergen to the patient
    LA20345-7Medication/substance that is known to be contraindicated for the patient
    LA20313-5Incorrect patient/family action (e.g., self-administration error)
    LA20318-4Other: PLEASE SPECIFY