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: Medication or Other Substance

Official URL: http://hl7.org/fhir/uv/sdc/Questionnaire/questionnaire-sdc-profile-example-loinc Version: 4.0.0
Standards status: Informative Active as of 2012-04-01 Computable Name: MedicationorOtherSubstance
Other Identifiers: OID:2.16.840.1.113883.4.642.40.17.35.13

LinkIDTextCardinalityTypeFlagsDescription & Constraintsdoco
.. MedicationorOtherSubstance Questionnaire http://hl7.org/fhir/uv/sdc/Questionnaire/questionnaire-sdc-profile-example-loinc#4.0.0
... Medication/header null 0..1 group Value Set:
.... 0 Form ID: 1..1 string iconicon Value Set:
.... 74080-3/74081-1 Event ID: 1..1 string Value Set:
.... 74080-3/30947-6 Initial Report Date (HERF Q1) 1..1 string Value Set:
... Medication/SEC00 Medication or Other Substance 0..1 group Value Set:
.... 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 Value Set:
.... Medication/SEC01/74080-3 null 1..1 group Value Set:
..... 74080-3/74076-1 1.. What type of medication/substance was involved? 1..1 choice Value Set: AHRQ_Medication_Q1
...... 74080-3/74075-3 2.. What type of medication? 1..1 choice 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 Enable When: 74080-3/74075-3 = Compounded preparations (LOINC#LA20298-8)
Value Set:
...... 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)
Value Set:
...... 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)
Value Set:
...... 74080-3/74076-1/Other/Specify null 1..1 string Enable When: 74080-3/74076-1 = Other substance: PLEASE SPECIFY (LOINC#LA20343-2)
Value Set:
..... 74080-3/74072-0 7.. Which of the following best characterizes the event? 1..1 choice Enable When:
  • 74080-3/74076-1 != Radiopharmaceuticals (LOINC#LA20340-8)
  • 74080-3/74076-1 != Patient food (not suspected in drug-food interactions) (LOINC#LA20341-6)
  • 74080-3/74076-1 != Drug-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 (LOINC#LA20342-4)

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)
Value Set:
...... 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)
Value Set:
...... 74080-3/74071-2/Other/Specify null 1..1 string Enable When: 74080-3/74071-2 = Other: PLEASE SPECIFY (LOINC#LA20318-4)
Value Set:
..... 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)
Value Set:
.... 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 Value Set:
.... 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)
Value Set:
.... 74080-3/74078-7 null 1..* group Enable When:
  • 74080-3/74072-0 != Adverse reaction in patient to the administered substance without any apparent incorrect action (LOINC#LA20315-0)
  • 74080-3/74072-0 != Unknown (LOINC#LA4489-6)
  • 74080-3/74076-1 != Expressed human breast milk (LOINC#LA20337-4)
  • 74080-3/74075-3 != Compounded preparations (LOINC#LA20298-8)

Value Set:
..... 74080-3/74078-7/74062-1 17.. Generic name or investigational drug name 0..1 string Value Set:
..... 74080-3/74078-7/74061-3 18.. Ingredient RXCUI (if known) 0..1 string Value Set:
..... 74080-3/74078-7/74060-5 19.. Brand name (if known) 0..1 string Value Set:
..... 74080-3/74078-7/74059-7 20.. Brand name RXCUI (if known) 0..1 string Value Set:
..... 74080-3/74078-7/74058-9 21.. Manufacturer (if known) 0..1 string Value Set:
..... 74080-3/74078-7/74057-1 22.. Strength or concentration of product 0..1 string Value Set:
..... 74080-3/74078-7/74056-3 23.. Clinical drug component RXCUI (if known) 0..1 string Value Set:
..... 74080-3/74078-7/74055-5 24.. Dosage form of Product 0..1 string Value Set:
..... 74080-3/74078-7/74054-8 25.. Dose form RXCUI (if known) 0..1 string Value Set:
..... 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)
Value Set:
..... 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)
Value Set:
..... 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)
Value Set:
.... Medication/SEC04 Thank you for completing these questions. 0..1 group Value Set:
..... 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 Value Set:
... Reporting Reporting information 0..1 group iconicon Value Set:
.... Reporting/who Reported by: 0..1 string Value Set:
.... Reporting/when Reported date: 0..1 date Value Set:
.... Medication/footer.0 AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance 0..1 display Value Set:

doco Documentation for this format

  • linkId: Medication/header
  • Answers:

Form ID:*

  • Flags: icon
  • linkId: 0
  • Answers:

Event ID:*

  • linkId: 74080-3/74081-1
  • Answers:

Initial Report Date (HERF Q1)*

  • linkId: 74080-3/30947-6
  • Answers:

Medication or Other Substance

  • linkId: Medication/SEC00
  • Answers:

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).

  • linkId: Medication/SEC00.0
  • Answers:

*

  • linkId: Medication/SEC01/74080-3
  • Answers:

1.: What type of medication/substance was involved?*

2.: What type of medication?*

3.: Please list all ingredients:*

  • linkId: 74080-3/74077-9-q
  • Enable When: todo
  • Answers:

4.: What type of biological product?

5.: What was the lot number of the vaccine?*

  • linkId: 74080-3/30959-1
  • Enable When: todo
  • Answers:

6.: What type of nutritional product?*

*

  • linkId: 74080-3/74073-8/Other/Specify
  • Enable When: todo
  • Answers:

*

  • linkId: 74080-3/74076-1/Other/Specify
  • Enable When: todo
  • Answers:

7.: Which of the following best characterizes the event?*

8.: What was the incorrect action?

9.: Which best describes the incorrect dose(s)?*

10.: Which best describes the incorrect timing?*

11.: Which best describes the incorrect rate?*

12.: Which best describes the incorrect strength or concentration?*

13.: What was the expiration date?*

  • linkId: Medication/74066-2
  • Enable When: todo
  • Answers:

14.: Was there a documented history of allergies or sensitivities to the medication/substance administered?*

  • linkId: Medication/74065-4
  • Enable When: todo
  • Answers: AHRQ_Y/N/UNK

15.: What was the contraindication (potential or actual interaction)?*

*

  • linkId: Medication/74064-7/Other/Specify
  • Enable When: todo
  • Answers:

*

  • linkId: 74080-3/74071-2/Other/Specify
  • Enable When: todo
  • Answers:

16.: At what stage in the process did the event originate, regardless of the stage at which it was discovered?*

*

  • linkId: 74080-3/74063-9/Other/Specify
  • Enable When: todo
  • Answers:

Please provide the following medication details for any medications or other substances directly involved in the event.

  • linkId: 74080-3/74078-7.0
  • Answers:

For an near miss, omit question 27

  • linkId: 74080-3/74078-x
  • Enable When: todo
  • Answers:

*

  • linkId: 74080-3/74078-7
  • Enable When: todo
  • Answers:

17.: Generic name or investigational drug name

  • linkId: 74080-3/74078-7/74062-1
  • Answers:

18.: Ingredient RXCUI (if known)

  • linkId: 74080-3/74078-7/74061-3
  • Answers:

19.: Brand name (if known)

  • linkId: 74080-3/74078-7/74060-5
  • Answers:

20.: Brand name RXCUI (if known)

  • linkId: 74080-3/74078-7/74059-7
  • Answers:

21.: Manufacturer (if known)

  • linkId: 74080-3/74078-7/74058-9
  • Answers:

22.: Strength or concentration of product

  • linkId: 74080-3/74078-7/74057-1
  • Answers:

23.: Clinical drug component RXCUI (if known)

  • linkId: 74080-3/74078-7/74056-3
  • Answers:

24.: Dosage form of Product

  • linkId: 74080-3/74078-7/74055-5
  • Answers:

25.: Dose form RXCUI (if known)

  • linkId: 74080-3/74078-7/74054-8
  • Answers:

26.: Was this medication/substance prescribed for this patient?*

  • linkId: 74080-3/74078-7/74053-0
  • Enable When: todo
  • Answers: AHRQ_Y/N

27.: Was this medication/substance given to this patient?*

  • linkId: Medication/74052-2
  • Enable When: todo
  • Answers: AHRQ_Y/N

  • linkId: Medication/SEC03
  • Enable When: todo
  • Answers:

28.: What was the intended route of administration?*

*

  • linkId: 74080-3/74051-4/Other/Specify
  • Enable When: todo
  • Answers:

29.: What was the actual route of administration (attempted or completed)?*

*

  • linkId: 74080-3/74050-6/Other/Specify
  • Enable When: todo
  • Answers:

Thank you for completing these questions.

  • linkId: Medication/SEC04
  • Answers:

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.

  • linkId: Medication/SEC04.0
  • Answers:

Reporting information

  • Flags: icon
  • linkId: Reporting
  • Answers:

Reported by:

  • linkId: Reporting/who
  • Answers:

Reported date:

  • linkId: Reporting/when
  • Answers:

  • linkId: Medication/footer
  • Answers:

AHRQ Common Formats - Hospital Version 1.2 - 2012 Medication or Other Substance

  • linkId: Medication/footer.0
  • Answers:

LinkIDDescription & Constraintsdoco
.. Medication/header Value Set:
... 0 Value Set:
... 74080-3/74081-1 Value Set:
... 74080-3/30947-6 Value Set:
.. Medication/SEC00 Value Set:
... Medication/SEC00.0 Value Set:
... Medication/SEC01/74080-3 Value Set:
.... 74080-3/74076-1 Value Set: AHRQ_Medication_Q1
..... 74080-3/74075-3 Enable When: Not done yet
Value Set: AHRQ_Medication_Q2
...... 74080-3/74077-9-q Enable When: Not done yet
Value Set:
..... 74080-3/74074-6 Enable When: Not done yet
Value Set: AHRQ_Medication_Q4
...... 74080-3/30959-1 Enable When: Not done yet
Value Set:
..... 74080-3/74073-8 Enable When: Not done yet
Value Set: AHRQ_Medication_Q6
...... 74080-3/74073-8/Other/Specify Enable When: Not done yet
Value Set:
..... 74080-3/74076-1/Other/Specify Enable When: Not done yet
Value Set:
.... 74080-3/74072-0 Enable When: Not done yet
Value Set: AHRQ_Medication_Q7
.... 74080-3/74071-2 Enable When: Not done yet
Value Set: AHRQ_Medication_Q8
..... 74080-3/74070-4 Enable When: Not done yet
Value Set: AHRQ_Medication_Q9
..... Medication/74069-6 Enable When: Not done yet
Value Set: AHRQ_Medication_Q10
..... 74080-3/74068-8 Enable When: Not done yet
Value Set: AHRQ_Medication_Q11
..... Medication/74067-0 Enable When: Not done yet
Value Set: AHRQ_Medication_Q12
..... Medication/74066-2 Enable When: Not done yet
Value Set:
..... Medication/74065-4 Enable When: Not done yet
Value Set: AHRQ_Y/N/UNK
..... Medication/74064-7 Enable When: Not done yet
Value Set: AHRQ_Medication_Q15
...... Medication/74064-7/Other/Specify Enable When: Not done yet
Value Set:
..... 74080-3/74071-2/Other/Specify Enable When: Not done yet
Value Set:
.... 74080-3/74063-9 Enable When: Not done yet
Value Set: AHRQ_Medication_Q16
..... 74080-3/74063-9/Other/Specify Enable When: Not done yet
Value Set:
... 74080-3/74078-7.0 Value Set:
... 74080-3/74078-x Enable When: Not done yet
Value Set:
... 74080-3/74078-7 Enable When: Not done yet
Value Set:
.... 74080-3/74078-7/74062-1 Value Set:
.... 74080-3/74078-7/74061-3 Value Set:
.... 74080-3/74078-7/74060-5 Value Set:
.... 74080-3/74078-7/74059-7 Value Set:
.... 74080-3/74078-7/74058-9 Value Set:
.... 74080-3/74078-7/74057-1 Value Set:
.... 74080-3/74078-7/74056-3 Value Set:
.... 74080-3/74078-7/74055-5 Value Set:
.... 74080-3/74078-7/74054-8 Value Set:
.... 74080-3/74078-7/74053-0 Enable When: Not done yet
Value Set: AHRQ_Y/N
.... Medication/74052-2 Enable When: Not done yet
Value Set: AHRQ_Y/N
... Medication/SEC03 Enable When: Not done yet
Value Set:
.... 74080-3/74051-4 Value Set: AHRQ_Medication_Q28_Q29
..... 74080-3/74051-4/Other/Specify Enable When: Not done yet
Value Set:
.... 74080-3/74050-6 Value Set: AHRQ_Medication_Q28_Q29
..... 74080-3/74050-6/Other/Specify Enable When: Not done yet
Value Set:
... Medication/SEC04 Value Set:
.... Medication/SEC04.0 Value Set:
.. Reporting Value Set:
... Reporting/who Value Set:
... Reporting/when Value Set:
.. Medication/footer Value Set:
... Medication/footer.0 Value Set:

doco Documentation for this format

Contained resources

Test this Questionnaire

Try this questionnaire out:

Responses for this Questionnaire

There are currently no QuestionnaireResponse instances for this Questionnaire defined in this IG.