Da Vinci - Documentation Templates and Rules
1.0.0 - STU 1

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

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