{
  "resourceType": "QuestionnaireResponse",
  "id": "home-o2-questionnaireresponse",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaireresponse-r4"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This completed form contains all of the information collected from the provider on Home Oxygen Therapy.</p></div>"
  },
  "contained": [
    {
      "resourceType": "Patient",
      "id": "example1",
      "gender": "male",
      "birthDate": "1996-12-23",
      "address": [
        {
          "use": "home",
          "type": "both",
          "state": "MA"
        }
      ]
    }
  ],
  "questionnaire": "#Questionnaire/q045",
  "status": "completed",
  "subject": {
    "reference": "#example1",
    "display": "Vlad"
  },
  "authored": "2019-07-18",
  "item": [
    {
      "linkId": "1",
      "text": "Patient Information",
      "item": [
        {
          "linkId": "1.1",
          "text": "Last Name but Different This Time",
          "answer": [
            {
              "valueString": "Quinton"
            }
          ]
        },
        {
          "linkId": "1.2",
          "text": "First Name",
          "answer": [
            {
              "valueString": "Vlad"
            }
          ]
        },
        {
          "linkId": "1.3",
          "text": "Middle Initial",
          "answer": [
            {
              "valueString": "A, N"
            }
          ]
        },
        {
          "linkId": "1.4",
          "text": "Date Of Birth",
          "answer": [
            {
              "valueDate": "1956-12-01"
            }
          ]
        },
        {
          "linkId": "1.5",
          "text": "Gender",
          "answer": [
            {
              "valueCoding": {
                "system": "http://hl7.org/fhir/administrative-gender",
                "code": "male",
                "display": "Male"
              }
            }
          ]
        },
        {
          "linkId": "1.6",
          "text": "Medicare ID",
          "answer": [
            {
              "valueString": "10A3D58WH22"
            }
          ]
        }
      ]
    },
    {
      "linkId": "2",
      "text": "Provider who is performing face-to-face evaluation",
      "item": [
        {
          "linkId": "2.1",
          "text": "Last Name",
          "answer": [
            {
              "valueString": "Doe"
            }
          ]
        },
        {
          "linkId": "2.2",
          "text": "First Name",
          "answer": [
            {
              "valueString": "Jane"
            }
          ]
        },
        {
          "linkId": "2.3",
          "text": "Middle Initial",
          "answer": [
            {
              "valueString": "B"
            }
          ]
        },
        {
          "linkId": "2.4",
          "text": "NPI",
          "answer": [
            {
              "valueString": "1122334455"
            }
          ]
        },
        {
          "linkId": "2.5",
          "text": "Date of Face-To-Face Evaluation",
          "answer": [
            {
              "valueDate": "2019-07-18"
            }
          ]
        }
      ]
    },
    {
      "linkId": "3",
      "text": "Coverage Requirements",
      "item": [
        {
          "linkId": "3.1",
          "text": "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "313296004",
                "display": "Mild chronic obstructive pulmonary disease"
              }
            },
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "389087006",
                "display": "Hypoxemia (disorder)"
              }
            }
          ]
        },
        {
          "linkId": "3.2",
          "text": "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)"
        },
        {
          "linkId": "3.3",
          "text": "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)"
        },
        {
          "linkId": "3.4",
          "text": "Arterial oxygen saturation (Patient tested during exercise)"
        },
        {
          "linkId": "3.5",
          "text": "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)"
        },
        {
          "linkId": "3.6",
          "text": "Is there a documented improvement of hypoxemia during exercise with oxygen?"
        }
      ]
    },
    {
      "linkId": "4",
      "text": "Prescribed Use",
      "item": [
        {
          "linkId": "4.1",
          "text": "Start date",
          "answer": [
            {
              "valueDate": "2019-07-18"
            }
          ]
        },
        {
          "linkId": "4.2",
          "text": "Length of need: (months) (99 = lifetime)",
          "answer": [
            {
              "valueInteger": 99
            }
          ]
        },
        {
          "linkId": "4.4",
          "text": "Peak Flow Rate",
          "item": [
            {
              "linkId": "4.4.1",
              "text": "LPM",
              "answer": [
                {
                  "valueInteger": 2
                }
              ]
            },
            {
              "linkId": "4.4.2",
              "text": "oxygen %",
              "answer": [
                {
                  "valueInteger": 98
                }
              ]
            }
          ]
        },
        {
          "linkId": "4.5",
          "text": "Average Flow Rate",
          "item": [
            {
              "linkId": "4.5.1",
              "text": "LPM",
              "answer": [
                {
                  "valueInteger": 2
                }
              ]
            },
            {
              "linkId": "4.5.2",
              "text": "oxygen %",
              "answer": [
                {
                  "valueInteger": 97
                }
              ]
            }
          ]
        },
        {
          "linkId": "4.6",
          "text": "Frequency of use (choose all that apply)",
          "answer": [
            {
              "valueCoding": {
                "code": "At rest and awake",
                "display": "At rest and awake"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "5",
      "text": "Oxygen Supply Order Details",
      "item": [
        {
          "linkId": "5.1",
          "text": "Current Order Description",
          "answer": [
            {
              "valueString": "HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental"
            }
          ]
        },
        {
          "linkId": "5.1b",
          "text": "Current Order Is For A Portable Device"
        },
        {
          "linkId": "5.2",
          "text": "Type",
          "answer": [
            {
              "valueCoding": {
                "code": "E0424",
                "display": "Compressed Gas"
              }
            }
          ]
        },
        {
          "linkId": "5.3",
          "text": "Means of oxygen delivery and accessories",
          "answer": [
            {
              "valueCoding": {
                "code": "Mask",
                "display": "Mask"
              }
            },
            {
              "valueCoding": {
                "code": "Ventilator",
                "display": "Ventilator"
              }
            }
          ]
        },
        {
          "linkId": "5.4",
          "text": "Type of order",
          "answer": [
            {
              "valueCoding": {
                "code": "Initial or original order for certification",
                "display": "Initial or original order for certification"
              }
            }
          ]
        }
      ]
    }
  ]
}