Da Vinci - Documentation Templates and Rules
2.1.0 - STU 2.1

Publication Build: This will be filled in by the publication tooling

## Example QuestionnaireResponse: home-o2-questionnaireresponse

Page standards status: Informative

Generated Narrative: QuestionnaireResponse home-o2-questionnaireresponse

LinkID | Text | Definition | Answer
--- | --- | --- | ---
home-o2-questionnaireresponse |  |  | Questionnaire:Referred Questionnaire for QuestionnaireResponse
1 | Patient Information |  |
1.1 | Last Name but Different This Time |  | Quinton
1.2 | First Name |  | Vlad
1.3 | Middle Initial |  | A, N
1.4 | Date Of Birth |  | 1956-12-01
1.5 | Gender |  | AdministrativeGender male: Male
1.6 | Medicare ID |  | 10A3D58WH22
2 | Provider who is performing face-to-face evaluation |  |
2.1 | Last Name |  | Doe
2.2 | First Name |  | Jane
2.3 | Middle Initial |  | B
2.4 | NPI |  | 1122334455
2.5 | Date of Face-To-Face Evaluation |  | 2019-07-18
2.6 | Record |  | Mr. Saul Moki
3 | Coverage Requirements |  |
3.1 | Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy) |  | SNOMED CT 313296004: Mild chronic obstructive pulmonary disease
3.2 | Arterial oxygen saturation (Patient on room air while at rest and awake when tested) |  | 95 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')
3.3 | Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested) |  | 83 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')
3.4 | Arterial oxygen saturation (Patient tested during exercise) |  | 95 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')
3.5 | Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise) |  | 78 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')
3.6 | Is there a documented improvement of hypoxemia during exercise with oxygen? |  | true
4 | Prescribed Use |  |
4.1 | Start date |  | 2019-07-18
4.2 | Length of need: (months) (99 = lifetime) |  | 99
4.3 | Peak Flow Rate |  |
4.3.1 | LPM |  | 2
4.3.2 | oxygen % |  | 98
4.4 | Average Flow Rate |  |
4.4.1 | LPM |  | 2
4.4.2 | oxygen % |  | 97
4.5 | Frequency of use (choose all that apply) |  | At rest and awake
5 | Oxygen Supply Order Details |  |
5.1 | Current Order Description |  | HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental
5.1b | Current Order Is For A Portable Device |  |
5.2 | Type |  | example.org 122: Compressed Gas
5.3 | Means of oxygen delivery and accessories |  | example.org 134: Mask
Documentation for this format