Da Vinci - Documentation Templates and Rules
1.0.0 - STU 1

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## : DTR Home Oxygen Therapy QuestionnaireResponse - R4 - JSON Representation

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    {
      "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"
                  }
                }
              ]
            }
          ]
        }
      ]
    }