Da Vinci - Documentation Templates and Rules
2.1.0 - STU 2.1

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## : Referred Questionnaire for QuestionnaireResponse - JSON Representation

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    {
      "resourceType" : "Questionnaire",
      "id" : "referred-questionnaire",
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Example adaptive questionnaire contained in a QuestionnaireResposne</div>"
      },
      "url" : "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire",
      "version" : "2.1.0",
      "title" : "Referred Questionnaire for QuestionnaireResponse",
      "derivedFrom" : [
        🔗 "http://hl7.org/fhir/us/davinci-dtr/dtr-base-questionnaire"
      ],
      "status" : "active",
      "subjectType" : [
        "Patient"
      ],
      "date" : "2023-08-21T00:00:00+00:00",
      "publisher" : "HL7 International / Clinical Decision Support",
      "contact" : [
        {
          "name" : "HL7 International / Clinical Decision Support",
          "telecom" : [
            {
              "system" : "url",
              "value" : "http://www.hl7.org/Special/committees/dss"
            }
          ]
        }
      ],
      "jurisdiction" : [
        {
          "coding" : [
            {
              "system" : "urn:iso:std:iso:3166",
              "code" : "US"
            }
          ]
        }
      ],
      "item" : [
        {
          "linkId" : "1",
          "text" : "Patient Information",
          "type" : "group",
          "item" : [
            {
              "linkId" : "1.1",
              "text" : "Last Name but Different This Time",
              "type" : "text"
            },
            {
              "linkId" : "1.2",
              "text" : "First Name",
              "type" : "text"
            },
            {
              "linkId" : "1.3",
              "text" : "Middle Initial",
              "type" : "text"
            },
            {
              "linkId" : "1.4",
              "text" : "Date Of Birth",
              "type" : "date"
            },
            {
              "linkId" : "1.5",
              "text" : "Gender",
              "type" : "choice",
              "answerValueSet" : "http://hl7.org/fhir/ValueSet/administrative-gender"
            },
            {
              "linkId" : "1.6",
              "text" : "Medicare ID",
              "type" : "text"
            }
          ]
        },
        {
          "linkId" : "2",
          "text" : "Provider who is performing face-to-face evaluation",
          "type" : "group",
          "item" : [
            {
              "linkId" : "2.1",
              "text" : "Last Name",
              "type" : "text"
            },
            {
              "linkId" : "2.2",
              "text" : "First Name",
              "type" : "text"
            },
            {
              "linkId" : "2.3",
              "text" : "Middle Initial",
              "type" : "text"
            },
            {
              "linkId" : "2.4",
              "text" : "NPI",
              "type" : "text"
            },
            {
              "linkId" : "2.5",
              "text" : "Date of Face-To-Face Evaluation",
              "type" : "date"
            },
            {
              "extension" : [
                {
                  "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
                  "valueCode" : "Patient"
                }
              ],
              "linkId" : "2.6",
              "text" : "Record",
              "type" : "reference",
              "required" : true
            }
          ]
        },
        {
          "linkId" : "3",
          "text" : "Coverage Requirements",
          "type" : "group",
          "item" : [
            {
              "linkId" : "3.1",
              "text" : "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)",
              "type" : "choice",
              "answerOption" : [
                {
                  "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)",
              "type" : "quantity"
            },
            {
              "linkId" : "3.3",
              "text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)",
              "type" : "quantity"
            },
            {
              "linkId" : "3.4",
              "text" : "Arterial oxygen saturation (Patient tested during exercise)",
              "type" : "quantity"
            },
            {
              "linkId" : "3.5",
              "text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)",
              "type" : "quantity"
            },
            {
              "linkId" : "3.6",
              "text" : "Is there a documented improvement of hypoxemia during exercise with oxygen?",
              "type" : "boolean"
            }
          ]
        },
        {
          "linkId" : "4",
          "text" : "Prescribed Use",
          "type" : "group",
          "item" : [
            {
              "linkId" : "4.1",
              "text" : "Start date",
              "type" : "date"
            },
            {
              "linkId" : "4.2",
              "text" : "Length of need: (months) (99 = lifetime)",
              "type" : "quantity"
            },
            {
              "linkId" : "4.3",
              "text" : "Peak Flow Rate",
              "type" : "group",
              "item" : [
                {
                  "linkId" : "4.3.1",
                  "text" : "LPM",
                  "type" : "quantity"
                },
                {
                  "linkId" : "4.3.2",
                  "text" : "oxygen %",
                  "type" : "quantity"
                }
              ]
            },
            {
              "linkId" : "4.4",
              "text" : "Average Flow Rate",
              "type" : "group",
              "item" : [
                {
                  "linkId" : "4.4.1",
                  "text" : "LPM",
                  "type" : "quantity"
                },
                {
                  "linkId" : "4.4.2",
                  "text" : "oxygen %",
                  "type" : "quantity"
                }
              ]
            },
            {
              "linkId" : "4.5",
              "text" : "Frequency of use (choose all that apply)",
              "type" : "text"
            }
          ]
        },
        {
          "linkId" : "5",
          "text" : "Oxygen Supply Order Details",
          "type" : "group",
          "item" : [
            {
              "linkId" : "5.1",
              "text" : "Current Order Description",
              "type" : "text"
            },
            {
              "linkId" : "5.1b",
              "text" : "Current Order Is For A Portable Device",
              "type" : "boolean"
            },
            {
              "linkId" : "5.2",
              "text" : "Type",
              "type" : "choice",
              "answerOption" : [
                {
                  "valueCoding" : {
                    "system" : "http://example.org",
                    "code" : "121",
                    "display" : "Liquid"
                  }
                },
                {
                  "valueCoding" : {
                    "system" : "http://example.org",
                    "code" : "122",
                    "display" : "Compressed Gas"
                  }
                },
                {
                  "valueCoding" : {
                    "system" : "http://example.org",
                    "code" : "123",
                    "display" : "Concentrator"
                  }
                }
              ]
            },
            {
              "linkId" : "5.3",
              "text" : "Means of oxygen delivery and accessories",
              "type" : "choice",
              "answerOption" : [
                {
                  "valueCoding" : {
                    "system" : "http://example.org",
                    "code" : "131",
                    "display" : "Nasal cannula"
                  }
                },
                {
                  "valueCoding" : {
                    "system" : "http://example.org",
                    "code" : "132",
                    "display" : "Non-rebreather"
                  }
                },
                {
                  "valueCoding" : {
                    "system" : "http://example.org",
                    "code" : "133",
                    "display" : "Ventilator"
                  }
                },
                {
                  "valueCoding" : {
                    "system" : "http://example.org",
                    "code" : "134",
                    "display" : "Mask"
                  }
                },
                {
                  "valueCoding" : {
                    "system" : "http://example.org",
                    "code" : "135",
                    "display" : "PAP bleed in"
                  }
                },
                {
                  "valueCoding" : {
                    "system" : "http://example.org",
                    "code" : "136",
                    "display" : "Oxygen conserving device"
                  }
                },
                {
                  "valueCoding" : {
                    "system" : "http://example.org",
                    "code" : "137",
                    "display" : "High flow oxygen therapy"
                  }
                }
              ]
            }
          ]
        }
      ]
    }