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Packagehl7.fhir.us.hai.r4b
Resource TypeQuestionnaireResponse
IdQuestionnaireResponse-hai-questionnaireresponse-opc-ssi-event.json
FHIR VersionR4B

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Narrative

Note: links and images are rebased to the (stated) source

LinkIdTextDefinitionAnswerdoco
.. hai-questionnaireresponse-opc-ssi-eventQuestionnaire:Outpatient Procedure Component Surgical Site Infection (SSI) Event
... facility-idFacility IDurn:hl7ii:2.16.840.1.113883.3.117.1.1.5.1.1:9W
... encounter-dateDate of encounter2018-08-05
... infection-detailsInfection details
.... event-typeEvent TypeSNOMED CT (all versions) 433202001: Surgical site infection (disorder)
.... event-dateDate of event2018-08-06
.... nhsn-procedure-code-categoryNHSN Procedure Code CategoryNHSN Surveillance System Codes 2108-9: Appendix surgery
.... primary-cpt-procedure-codePrimary CPT Procedure CodeCurrent Procedural Terminology (CPT®) 44970: Laparoscopy, surgical, appendectomy
.... procedure-idProcedure Idurn:hl7ii:2.16.840.1.113883.3.117.1.1.5.2.1.1.5:21987654321
.... ssi-levelSurgical Site Infection (SSI) LevelNHSN Surveillance System Codes 1620-4: Superficial incisional primary surgical site infection (SSI)
.... criteria-of-diagnosisCriteria of Diagnosis
..... criteria-of-diagnosis-abscessCriteria of Diagnosis: Abscessfalse
..... criteria-of-diagnosis-rednessCriteria of Diagnosis: Rednessfalse
..... criteria-of-diagnosis-feverCriteria of Diagnosis: Feverfalse
..... criteria-of-diagnosis-heatCriteria of Diagnosis: Heattrue
..... criteria-of-diagnosis-incision-purulent-drainageCriteria of Diagnosis: Purulent drainagetrue
..... criteria-of-diagnosis-wound-dehiscedCriteria of Diagnosis: Wound spontaneously dehiscedfalse
..... criteria-of-diagnosis-incision-openedCriteria of Diagnosis: Incision deliberately openedfalse
..... criteria-of-diagnosis-evidence-foundCriteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic examfalse
..... criteria-of-diagnosis-localized-swellingCriteria of Diagnosis: Localized swellingfalse
..... criteria-of-diagnosis-pain-tendernessCriteria of Diagnosis: Pain or tendernessfalse
..... criteria-of-diagnosis-organism-identifiedCriteria of Diagnosis: Organism Identifiedtrue
..... criteria-of-diagnosis-testing-not-performedCriteria of Diagnosis: Culture or non-culture based testing not performedfalse
..... criteria-of-diagnosis-imaging-testCriteria of Diagnosis: Imaging test evidence of infectionfalse
..... criteria-of-diagnosis-physician-diagnosisCriteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physicianfalse
.... ssi-detection-method-typeSurveillence method type (active/passive) through which the SSI was detectedNHSN Surveillance System Codes 1309-4: Active SSI Detection Method
.... ssi-detection-methodSurveillence method through which the SSI was detectedNHSN Surveillance System Codes 1321-9: Review of patient's medical record
... findings-groupFindings Group
.... pathogen-identifiedPathogen IdentifiedSNOMED CT (all versions) 116197008: Staphylococcus, coagulase negative (organism)
.... pathogen-rankingPathogen RankingSNOMED CT (all versions) 255216001: First
... findings-groupFindings Group
.... pathogen-identifiedPathogen IdentifiedSNOMED CT (all versions) 22267009: Sarcina ventriculi (organism)
.... pathogen-rankingPathogen RankingSNOMED CT (all versions) 81170007: Second
... findings-groupFindings Group
.... pathogen-identifiedPathogen IdentifiedSNOMED CT (all versions) 243365003: Acid-fast bacillus
.... pathogen-rankingPathogen RankingSNOMED CT (all versions) 70905002: Third
... nhsn-commentCommentsNHSN text comment that is less than 2000 characters.

doco Documentation for this format

Source1

{
  "resourceType": "QuestionnaireResponse",
  "id": "hai-questionnaireresponse-opc-ssi-event",
  "meta": {
    "versionId": "8",
    "lastUpdated": "2023-02-24T04:47:25.184+00:00",
    "source": "#mvn46QaKWJ7Nyg9L",
    "profile": [
      "http://hl7.org/fhir/us/hai/StructureDefinition/hai-single-person-report-questionnaireresponse"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "identifier": {
    "system": "urn:oid:2.16.840.1.113883.3.117.1.1.5.2.1.1.2",
    "value": "20202206"
  },
  "questionnaire": "http://hl7.org/fhir/us/hai/Questionnaire/hai-questionnaire-opc-ssi-event",
  "status": "completed",
  "subject": {
    "reference": "Patient/hai-patient-1",
    "display": "hai-patient-1"
  },
  "authored": "2020-03-29T22:38:59.084Z",
  "author": {
    "reference": "Device/hai-authoring-device",
    "display": "hai-authoring-device"
  },
  "item": [
    {
      "linkId": "facility-id",
      "text": "Facility ID",
      "answer": [
        {
          "valueUri": "urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.1.1:9W"
        }
      ]
    },
    {
      "linkId": "encounter-date",
      "text": "Date of encounter",
      "answer": [
        {
          "valueDate": "2018-08-05"
        }
      ]
    },
    {
      "linkId": "infection-details",
      "text": "Infection details",
      "item": [
        {
          "linkId": "event-type",
          "text": "Event Type",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "433202001",
                "display": "Surgical site infection (disorder)"
              }
            }
          ]
        },
        {
          "linkId": "event-date",
          "text": "Date of event",
          "answer": [
            {
              "valueDate": "2018-08-06"
            }
          ]
        },
        {
          "linkId": "nhsn-procedure-code-category",
          "text": "NHSN Procedure Code Category",
          "answer": [
            {
              "valueCoding": {
                "system": "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                "code": "2108-9",
                "display": "Appendix surgery"
              }
            }
          ]
        },
        {
          "linkId": "primary-cpt-procedure-code",
          "text": "Primary CPT Procedure Code",
          "answer": [
            {
              "valueCoding": {
                "system": "http://www.ama-assn.org/go/cpt",
                "code": "44970",
                "display": "Laparoscopy, surgical, appendectomy"
              }
            }
          ]
        },
        {
          "linkId": "procedure-id",
          "text": "Procedure Id",
          "answer": [
            {
              "valueUri": "urn:hl7ii:2.16.840.1.113883.3.117.1.1.5.2.1.1.5:21987654321"
            }
          ]
        },
        {
          "linkId": "ssi-level",
          "text": "Surgical Site Infection (SSI) Level",
          "answer": [
            {
              "valueCoding": {
                "system": "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                "code": "1620-4",
                "display": "Superficial incisional primary surgical site infection (SSI)"
              }
            }
          ]
        },
        {
          "linkId": "criteria-of-diagnosis",
          "text": "Criteria of Diagnosis",
          "item": [
            {
              "linkId": "criteria-of-diagnosis-abscess",
              "text": "Criteria of Diagnosis: Abscess",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-redness",
              "text": "Criteria of Diagnosis: Redness",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-fever",
              "text": "Criteria of Diagnosis: Fever",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-heat",
              "text": "Criteria of Diagnosis: Heat",
              "answer": [
                {
                  "valueBoolean": true
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-incision-purulent-drainage",
              "text": "Criteria of Diagnosis: Purulent drainage",
              "answer": [
                {
                  "valueBoolean": true
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-wound-dehisced",
              "text": "Criteria of Diagnosis: Wound spontaneously dehisced",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-incision-opened",
              "text": "Criteria of Diagnosis: Incision deliberately opened",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-evidence-found",
              "text": "Criteria of Diagnosis: Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-localized-swelling",
              "text": "Criteria of Diagnosis: Localized swelling",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-pain-tenderness",
              "text": "Criteria of Diagnosis: Pain or tenderness",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-organism-identified",
              "text": "Criteria of Diagnosis: Organism Identified",
              "answer": [
                {
                  "valueBoolean": true
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-testing-not-performed",
              "text": "Criteria of Diagnosis: Culture or non-culture based testing not performed",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-imaging-test",
              "text": "Criteria of Diagnosis: Imaging test evidence of infection",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "criteria-of-diagnosis-physician-diagnosis",
              "text": "Criteria of Diagnosis: Diagnosis of superficial SSI by surgeon or attending physician",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            }
          ]
        },
        {
          "linkId": "ssi-detection-method-type",
          "text": "Surveillence method type (active/passive) through which the SSI was detected",
          "answer": [
            {
              "valueCoding": {
                "system": "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                "code": "1309-4",
                "display": "Active SSI Detection Method"
              }
            }
          ]
        },
        {
          "linkId": "ssi-detection-method",
          "text": "Surveillence method through which the SSI was detected",
          "answer": [
            {
              "valueCoding": {
                "system": "https://www.cdc.gov/nhsn/cdaportal/terminology/codesystem/cdcnhsn.html",
                "code": "1321-9",
                "display": "Review of patient's medical record"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "findings-group",
      "text": "Findings Group",
      "item": [
        {
          "linkId": "pathogen-identified",
          "text": "Pathogen Identified",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "116197008",
                "display": "Staphylococcus, coagulase negative (organism)"
              }
            }
          ]
        },
        {
          "linkId": "pathogen-ranking",
          "text": "Pathogen Ranking",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "255216001",
                "display": "First"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "findings-group",
      "text": "Findings Group",
      "item": [
        {
          "linkId": "pathogen-identified",
          "text": "Pathogen Identified",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "22267009",
                "display": "Sarcina ventriculi (organism)"
              }
            }
          ]
        },
        {
          "linkId": "pathogen-ranking",
          "text": "Pathogen Ranking",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "81170007",
                "display": "Second"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "findings-group",
      "text": "Findings Group",
      "item": [
        {
          "linkId": "pathogen-identified",
          "text": "Pathogen Identified",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "243365003",
                "display": "Acid-fast bacillus"
              }
            }
          ]
        },
        {
          "linkId": "pathogen-ranking",
          "text": "Pathogen Ranking",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "70905002",
                "display": "Third"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "nhsn-comment",
      "text": "Comments",
      "answer": [
        {
          "valueString": "NHSN text comment that is less than 2000 characters."
        }
      ]
    }
  ]
}