Da Vinci - Documentation Templates and Rules
2.1.0 - STU 2.1

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## : Referred Questionnaire for QuestionnaireResponse - XML Representation

Page standards status: Informative

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    <Questionnaire xmlns="http://hl7.org/fhir">
      <id value="referred-questionnaire"/>
      <text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml">Example adaptive questionnaire contained in a QuestionnaireResposne</div>
      </text>
      <url
           value="http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire"/>
      <version value="2.1.0"/>
      <title value="Referred Questionnaire for QuestionnaireResponse"/>
      <derivedFrom
                   value="http://hl7.org/fhir/us/davinci-dtr/dtr-base-questionnaire"/>
      <status value="active"/>
      <subjectType value="Patient"/>
      <date value="2023-08-21T00:00:00+00:00"/>
      <publisher value="HL7 International / Clinical Decision Support"/>
      <contact>
        <name value="HL7 International / Clinical Decision Support"/>
        <telecom>
          <system value="url"/>
          <value value="http://www.hl7.org/Special/committees/dss"/>
        </telecom>
      </contact>
      <jurisdiction>
        <coding>
          <system value="urn:iso:std:iso:3166"/>
          <code value="US"/>
        </coding>
      </jurisdiction>
      <item>
        <linkId value="1"/>
        <text value="Patient Information"/>
        <type value="group"/>
        <item>
          <linkId value="1.1"/>
          <text value="Last Name but Different This Time"/>
          <type value="text"/>
        </item>
        <item>
          <linkId value="1.2"/>
          <text value="First Name"/>
          <type value="text"/>
        </item>
        <item>
          <linkId value="1.3"/>
          <text value="Middle Initial"/>
          <type value="text"/>
        </item>
        <item>
          <linkId value="1.4"/>
          <text value="Date Of Birth"/>
          <type value="date"/>
        </item>
        <item>
          <linkId value="1.5"/>
          <text value="Gender"/>
          <type value="choice"/>
          <answerValueSet
                          value="http://hl7.org/fhir/ValueSet/administrative-gender"/>
        </item>
        <item>
          <linkId value="1.6"/>
          <text value="Medicare ID"/>
          <type value="text"/>
        </item>
      </item>
      <item>
        <linkId value="2"/>
        <text value="Provider who is performing face-to-face evaluation"/>
        <type value="group"/>
        <item>
          <linkId value="2.1"/>
          <text value="Last Name"/>
          <type value="text"/>
        </item>
        <item>
          <linkId value="2.2"/>
          <text value="First Name"/>
          <type value="text"/>
        </item>
        <item>
          <linkId value="2.3"/>
          <text value="Middle Initial"/>
          <type value="text"/>
        </item>
        <item>
          <linkId value="2.4"/>
          <text value="NPI"/>
          <type value="text"/>
        </item>
        <item>
          <linkId value="2.5"/>
          <text value="Date of Face-To-Face Evaluation"/>
          <type value="date"/>
        </item>
        <item>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource">
            <valueCode value="Patient"/>
          </extension>
          <linkId value="2.6"/>
          <text value="Record"/>
          <type value="reference"/>
          <required value="true"/>
        </item>
      </item>
      <item>
        <linkId value="3"/>
        <text value="Coverage Requirements"/>
        <type value="group"/>
        <item>
          <linkId value="3.1"/>
          <text
                value="Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)"/>
          <type value="choice"/>
          <answerOption>
            <valueCoding>
              <system value="http://snomed.info/sct"/>
              <code value="313296004"/>
              <display value="Mild chronic obstructive pulmonary disease"/>
            </valueCoding>
          </answerOption>
          <answerOption>
            <valueCoding>
              <system value="http://snomed.info/sct"/>
              <code value="389087006"/>
              <display value="Hypoxemia (disorder)"/>
            </valueCoding>
          </answerOption>
        </item>
        <item>
          <linkId value="3.2"/>
          <text
                value="Arterial oxygen saturation (Patient on room air while at rest and awake when tested)"/>
          <type value="quantity"/>
        </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)"/>
          <type value="quantity"/>
        </item>
        <item>
          <linkId value="3.4"/>
          <text
                value="Arterial oxygen saturation (Patient tested during exercise)"/>
          <type value="quantity"/>
        </item>
        <item>
          <linkId value="3.5"/>
          <text
                value="Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)"/>
          <type value="quantity"/>
        </item>
        <item>
          <linkId value="3.6"/>
          <text
                value="Is there a documented improvement of hypoxemia during exercise with oxygen?"/>
          <type value="boolean"/>
        </item>
      </item>
      <item>
        <linkId value="4"/>
        <text value="Prescribed Use"/>
        <type value="group"/>
        <item>
          <linkId value="4.1"/>
          <text value="Start date"/>
          <type value="date"/>
        </item>
        <item>
          <linkId value="4.2"/>
          <text value="Length of need: (months) (99 = lifetime)"/>
          <type value="quantity"/>
        </item>
        <item>
          <linkId value="4.3"/>
          <text value="Peak Flow Rate"/>
          <type value="group"/>
          <item>
            <linkId value="4.3.1"/>
            <text value="LPM"/>
            <type value="quantity"/>
          </item>
          <item>
            <linkId value="4.3.2"/>
            <text value="oxygen %"/>
            <type value="quantity"/>
          </item>
        </item>
        <item>
          <linkId value="4.4"/>
          <text value="Average Flow Rate"/>
          <type value="group"/>
          <item>
            <linkId value="4.4.1"/>
            <text value="LPM"/>
            <type value="quantity"/>
          </item>
          <item>
            <linkId value="4.4.2"/>
            <text value="oxygen %"/>
            <type value="quantity"/>
          </item>
        </item>
        <item>
          <linkId value="4.5"/>
          <text value="Frequency of use (choose all that apply)"/>
          <type value="text"/>
        </item>
      </item>
      <item>
        <linkId value="5"/>
        <text value="Oxygen Supply Order Details"/>
        <type value="group"/>
        <item>
          <linkId value="5.1"/>
          <text value="Current Order Description"/>
          <type value="text"/>
        </item>
        <item>
          <linkId value="5.1b"/>
          <text value="Current Order Is For A Portable Device"/>
          <type value="boolean"/>
        </item>
        <item>
          <linkId value="5.2"/>
          <text value="Type"/>
          <type value="choice"/>
          <answerOption>
            <valueCoding>
              <system value="http://example.org"/>
              <code value="121"/>
              <display value="Liquid"/>
            </valueCoding>
          </answerOption>
          <answerOption>
            <valueCoding>
              <system value="http://example.org"/>
              <code value="122"/>
              <display value="Compressed Gas"/>
            </valueCoding>
          </answerOption>
          <answerOption>
            <valueCoding>
              <system value="http://example.org"/>
              <code value="123"/>
              <display value="Concentrator"/>
            </valueCoding>
          </answerOption>
        </item>
        <item>
          <linkId value="5.3"/>
          <text value="Means of oxygen delivery and accessories"/>
          <type value="choice"/>
          <answerOption>
            <valueCoding>
              <system value="http://example.org"/>
              <code value="131"/>
              <display value="Nasal cannula"/>
            </valueCoding>
          </answerOption>
          <answerOption>
            <valueCoding>
              <system value="http://example.org"/>
              <code value="132"/>
              <display value="Non-rebreather"/>
            </valueCoding>
          </answerOption>
          <answerOption>
            <valueCoding>
              <system value="http://example.org"/>
              <code value="133"/>
              <display value="Ventilator"/>
            </valueCoding>
          </answerOption>
          <answerOption>
            <valueCoding>
              <system value="http://example.org"/>
              <code value="134"/>
              <display value="Mask"/>
            </valueCoding>
          </answerOption>
          <answerOption>
            <valueCoding>
              <system value="http://example.org"/>
              <code value="135"/>
              <display value="PAP bleed in"/>
            </valueCoding>
          </answerOption>
          <answerOption>
            <valueCoding>
              <system value="http://example.org"/>
              <code value="136"/>
              <display value="Oxygen conserving device"/>
            </valueCoding>
          </answerOption>
          <answerOption>
            <valueCoding>
              <system value="http://example.org"/>
              <code value="137"/>
              <display value="High flow oxygen therapy"/>
            </valueCoding>
          </answerOption>
        </item>
      </item>
    </Questionnaire>