a fhir:Questionnaire ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "referred-questionnaire"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "Example adaptive questionnaire contained in a QuestionnaireResposne
"
] ; #
fhir:url [ fhir:v "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire"^^xsd:anyURI] ; #
fhir:version [ fhir:v "2.1.0"] ; #
fhir:title [ fhir:v "Referred Questionnaire for QuestionnaireResponse"] ; #
fhir:derivedFrom ( [
fhir:v "http://hl7.org/fhir/us/davinci-dtr/dtr-base-questionnaire"^^xsd:anyURI ;
fhir:link
] ) ; #
fhir:status [ fhir:v "active"] ; #
fhir:subjectType ( [ fhir:v "Patient"] ) ; #
fhir:date [ fhir:v "2023-08-21T00:00:00+00:00"^^xsd:dateTime] ; #
fhir:publisher [ fhir:v "HL7 International / Clinical Decision Support"] ; #
fhir:contact ( [
fhir:name [ fhir:v "HL7 International / Clinical Decision Support" ] ;
fhir:telecom ( [
fhir:system [ fhir:v "url" ] ;
fhir:value [ fhir:v "http://www.hl7.org/Special/committees/dss" ]
] )
] ) ; #
fhir:jurisdiction ( [
fhir:coding ( [
fhir:system [ fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ] ;
fhir:code [ fhir:v "US" ]
] )
] ) ; #
fhir:item ( [
fhir:linkId [ fhir:v "1" ] ;
fhir:text [ fhir:v "Patient Information" ] ;
fhir:type [ fhir:v "group" ] ;
fhir:item ( [
fhir:linkId [ fhir:v "1.1" ] ;
fhir:text [ fhir:v "Last Name but Different This Time" ] ;
fhir:type [ fhir:v "text" ]
] [
fhir:linkId [ fhir:v "1.2" ] ;
fhir:text [ fhir:v "First Name" ] ;
fhir:type [ fhir:v "text" ]
] [
fhir:linkId [ fhir:v "1.3" ] ;
fhir:text [ fhir:v "Middle Initial" ] ;
fhir:type [ fhir:v "text" ]
] [
fhir:linkId [ fhir:v "1.4" ] ;
fhir:text [ fhir:v "Date Of Birth" ] ;
fhir:type [ fhir:v "date" ]
] [
fhir:linkId [ fhir:v "1.5" ] ;
fhir:text [ fhir:v "Gender" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:answerValueSet [
fhir:v "http://hl7.org/fhir/ValueSet/administrative-gender"^^xsd:anyURI ;
fhir:link
]
] [
fhir:linkId [ fhir:v "1.6" ] ;
fhir:text [ fhir:v "Medicare ID" ] ;
fhir:type [ fhir:v "text" ]
] )
] [
fhir:linkId [ fhir:v "2" ] ;
fhir:text [ fhir:v "Provider who is performing face-to-face evaluation" ] ;
fhir:type [ fhir:v "group" ] ;
fhir:item ( [
fhir:linkId [ fhir:v "2.1" ] ;
fhir:text [ fhir:v "Last Name" ] ;
fhir:type [ fhir:v "text" ]
] [
fhir:linkId [ fhir:v "2.2" ] ;
fhir:text [ fhir:v "First Name" ] ;
fhir:type [ fhir:v "text" ]
] [
fhir:linkId [ fhir:v "2.3" ] ;
fhir:text [ fhir:v "Middle Initial" ] ;
fhir:type [ fhir:v "text" ]
] [
fhir:linkId [ fhir:v "2.4" ] ;
fhir:text [ fhir:v "NPI" ] ;
fhir:type [ fhir:v "text" ]
] [
fhir:linkId [ fhir:v "2.5" ] ;
fhir:text [ fhir:v "Date of Face-To-Face Evaluation" ] ;
fhir:type [ fhir:v "date" ]
] [
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Patient" ]
] ) ;
fhir:linkId [ fhir:v "2.6" ] ;
fhir:text [ fhir:v "Record" ] ;
fhir:type [ fhir:v "reference" ] ;
fhir:required [ fhir:v "true"^^xsd:boolean ]
] )
] [
fhir:linkId [ fhir:v "3" ] ;
fhir:text [ fhir:v "Coverage Requirements" ] ;
fhir:type [ fhir:v "group" ] ;
fhir:item ( [
fhir:linkId [ fhir:v "3.1" ] ;
fhir:text [ fhir:v "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:answerOption ( [
fhir:value [
a fhir:Coding, sct:313296004 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "313296004" ] ;
fhir:display [ fhir:v "Mild chronic obstructive pulmonary disease" ]
]
] [
fhir:value [
a fhir:Coding, sct:389087006 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "389087006" ] ;
fhir:display [ fhir:v "Hypoxemia (disorder)" ]
]
] )
] [
fhir:linkId [ fhir:v "3.2" ] ;
fhir:text [ fhir:v "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)" ] ;
fhir:type [ fhir:v "quantity" ]
] [
fhir:linkId [ fhir:v "3.3" ] ;
fhir:text [ fhir:v "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)" ] ;
fhir:type [ fhir:v "quantity" ]
] [
fhir:linkId [ fhir:v "3.4" ] ;
fhir:text [ fhir:v "Arterial oxygen saturation (Patient tested during exercise)" ] ;
fhir:type [ fhir:v "quantity" ]
] [
fhir:linkId [ fhir:v "3.5" ] ;
fhir:text [ fhir:v "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)" ] ;
fhir:type [ fhir:v "quantity" ]
] [
fhir:linkId [ fhir:v "3.6" ] ;
fhir:text [ fhir:v "Is there a documented improvement of hypoxemia during exercise with oxygen?" ] ;
fhir:type [ fhir:v "boolean" ]
] )
] [
fhir:linkId [ fhir:v "4" ] ;
fhir:text [ fhir:v "Prescribed Use" ] ;
fhir:type [ fhir:v "group" ] ;
fhir:item ( [
fhir:linkId [ fhir:v "4.1" ] ;
fhir:text [ fhir:v "Start date" ] ;
fhir:type [ fhir:v "date" ]
] [
fhir:linkId [ fhir:v "4.2" ] ;
fhir:text [ fhir:v "Length of need: (months) (99 = lifetime)" ] ;
fhir:type [ fhir:v "quantity" ]
] [
fhir:linkId [ fhir:v "4.3" ] ;
fhir:text [ fhir:v "Peak Flow Rate" ] ;
fhir:type [ fhir:v "group" ] ;
fhir:item ( [
fhir:linkId [ fhir:v "4.3.1" ] ;
fhir:text [ fhir:v "LPM" ] ;
fhir:type [ fhir:v "quantity" ]
] [
fhir:linkId [ fhir:v "4.3.2" ] ;
fhir:text [ fhir:v "oxygen %" ] ;
fhir:type [ fhir:v "quantity" ]
] )
] [
fhir:linkId [ fhir:v "4.4" ] ;
fhir:text [ fhir:v "Average Flow Rate" ] ;
fhir:type [ fhir:v "group" ] ;
fhir:item ( [
fhir:linkId [ fhir:v "4.4.1" ] ;
fhir:text [ fhir:v "LPM" ] ;
fhir:type [ fhir:v "quantity" ]
] [
fhir:linkId [ fhir:v "4.4.2" ] ;
fhir:text [ fhir:v "oxygen %" ] ;
fhir:type [ fhir:v "quantity" ]
] )
] [
fhir:linkId [ fhir:v "4.5" ] ;
fhir:text [ fhir:v "Frequency of use (choose all that apply)" ] ;
fhir:type [ fhir:v "text" ]
] )
] [
fhir:linkId [ fhir:v "5" ] ;
fhir:text [ fhir:v "Oxygen Supply Order Details" ] ;
fhir:type [ fhir:v "group" ] ;
fhir:item ( [
fhir:linkId [ fhir:v "5.1" ] ;
fhir:text [ fhir:v "Current Order Description" ] ;
fhir:type [ fhir:v "text" ]
] [
fhir:linkId [ fhir:v "5.1b" ] ;
fhir:text [ fhir:v "Current Order Is For A Portable Device" ] ;
fhir:type [ fhir:v "boolean" ]
] [
fhir:linkId [ fhir:v "5.2" ] ;
fhir:text [ fhir:v "Type" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:answerOption ( [
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://example.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "121" ] ;
fhir:display [ fhir:v "Liquid" ]
]
] [
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://example.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "122" ] ;
fhir:display [ fhir:v "Compressed Gas" ]
]
] [
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://example.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "123" ] ;
fhir:display [ fhir:v "Concentrator" ]
]
] )
] [
fhir:linkId [ fhir:v "5.3" ] ;
fhir:text [ fhir:v "Means of oxygen delivery and accessories" ] ;
fhir:type [ fhir:v "choice" ] ;
fhir:answerOption ( [
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://example.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "131" ] ;
fhir:display [ fhir:v "Nasal cannula" ]
]
] [
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://example.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "132" ] ;
fhir:display [ fhir:v "Non-rebreather" ]
]
] [
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://example.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "133" ] ;
fhir:display [ fhir:v "Ventilator" ]
]
] [
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://example.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "134" ] ;
fhir:display [ fhir:v "Mask" ]
]
] [
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://example.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "135" ] ;
fhir:display [ fhir:v "PAP bleed in" ]
]
] [
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://example.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "136" ] ;
fhir:display [ fhir:v "Oxygen conserving device" ]
]
] [
fhir:value [
a fhir:Coding ;
fhir:system [ fhir:v "http://example.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "137" ] ;
fhir:display [ fhir:v "High flow oxygen therapy" ]
]
] )
] )
] ) . #
# -------------------------------------------------------------------------------------