| Package | hl7.fhir.us.davinci-dtr |
| Resource Type | Questionnaire |
| Id | referred-questionnaire |
| FHIR Version | R4 |
| Source | http://hl7.org/fhir/us/davinci-dtr/https://build.fhir.org/ig/HL7/davinci-dtr/Questionnaire-referred-questionnaire.html |
| URL | http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire |
| Version | 2.2.0-ballot |
| Status | active |
| Date | 2023-08-21T00:00:00+00:00 |
| Title | Referred Questionnaire for QuestionnaireResponse |
| Realm | us |
| Authority | hl7 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
FHIR{
"resourceType": "Questionnaire",
"id": "referred-questionnaire",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"url": "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire",
"version": "2.2.0-ballot",
"title": "Referred Questionnaire for QuestionnaireResponse",
"derivedFrom": [
"http://hl7.org/fhir/us/davinci-dtr/dtr-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"
}
}
]
}
]
}
]
}