| Package | hl7.fhir.us.cql |
| Resource Type | Questionnaire |
| Id | ExamplePatientAndCoverageQuestionnaire |
| FHIR Version | R4 |
| Source | http://hl7.org/fhir/us/cql/https://build.fhir.org/ig/HL7/us-cql-ig/Questionnaire-ExamplePatientAndCoverageQuestionnaire.html |
| URL | http://hl7.org/fhir/us/cql/Questionnaire/ExamplePatientAndCoverageQuestionnaire |
| Version | 1.0.0-ballot |
| Status | active |
| Date | 2024-09-16T00:00:00+00:00 |
| Name | ExamplePatientAndCoverageQuestionnaire |
| Title | Example Patient and Coverage Questionnaire |
| Realm | us |
| Authority | hl7 |
| Description | For the Prior Authorization Questionnaire Use Case, this type of in-context information is expected to be known already so it wouldn't typically be in a Questionnaire. This example illustrates how to get this information if it is needed. |
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Generated Narrative: Questionnaire ExamplePatientAndCoverageQuestionnaire
| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  ExamplePatientAndCoverageQuestionnaire | For the Prior Authorization Questionnaire Use Case, this type of in-context information is expected to be known already so it wouldn't typically be in a Questionnaire. This example illustrates how to get this information if it is needed. | Questionnaire | http://hl7.org/fhir/us/cql/Questionnaire/ExamplePatientAndCoverageQuestionnaire#1.0.0-ballot | |
  patient-info | Patient Information | 0..1 | group | |
  patient-info|patient-name | Name | 0..1 | string | |
 patient-info|date-of-birth | Date of Birth | 0..1 | date | |
 patient-info|birth-sex | Birth Sex | 0..1 | choice | Value Set: http://hl7.org/fhir/us/core/ValueSet/birthsex |
| patient-info|medical-record-number | Medical Record Number | 0..1 | string | |
| patient-info|phone-number | Phone Number | 0..1 | string | |
| patient-info|email-address | Email Address | 0..1 | string | |
| patient-info|address | Address | 0..1 | string | |
| patient-info|city | City | 0..1 | string | |
| patient-info|state | State | 0..1 | string | |
 patient-info|postal-code | Postal Code | 0..1 | string | |
| coverage-info | Coverage Information | 0..1 | group | |
| coverage-info|member-id | Member ID | 0..1 | string | |
| completing-form|patient-info|policy-number | Policy Number | 0..1 | string | |
| provider-info | Requesting Provider Information | 0..1 | group | |
| provider-info|name | Requesting provider name | 0..1 | string | |
| provider-info|phone-number | Phone | 0..1 | string | |
| provider-info|address | Ordering provider address | 0..1 | string | |
| provider-info|npi | Ordering provider Tax ID/NPI # | 0..1 | string | |
| provider-info|fax | Fax | 0..1 | string | |
| servicing-provider | Laboratory performing testing/Servicing Provider | 0..1 | group | |
 servicing-provider|name | Servicing Provider name | 0..1 | string | |
| servicing-provider|phone-number | Phone | 0..1 | string | |
| servicing-provider|address | Ordering provider address | 0..1 | string | |
| servicing-provider|npi | Ordering provider Tax ID/NPI # | 0..1 | string | |
| servicing-provider|fax | Fax | 0..1 | string | |
| Documentation for this format | ||||
FHIR{
"resourceType": "Questionnaire",
"id": "ExamplePatientAndCoverageQuestionnaire",
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
"valueCanonical": "http://hl7.org/fhir/us/cql/Library/ExamplePatientAndCoverageInitialExpressions"
},
{
"extension": [
{
"url": "name",
"valueCoding": {
"system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
"code": "patient",
"display": "Patient"
}
},
{
"url": "type",
"valueCode": "Patient"
},
{
"url": "description",
"valueString": "The patient that is to be used to pre-populate the form"
}
],
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"
},
{
"extension": [
{
"url": "name",
"valueCoding": {
"system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
"code": "Coverage",
"display": "Coverage"
}
},
{
"url": "type",
"valueCode": "Coverage"
},
{
"url": "description",
"valueString": "The coverage that is to be used to pre-populate the form"
}
],
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"
},
{
"extension": [
{
"url": "name",
"valueCoding": {
"system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
"code": "ServiceRequest",
"display": "ServiceRequest"
}
},
{
"url": "type",
"valueCode": "ServiceRequest"
},
{
"url": "description",
"valueString": "The ServiceRequest that is to be used to pre-populate the form"
}
],
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "cds"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode": "informative",
"_valueCode": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
"valueCanonical": "http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql"
}
]
}
}
],
"url": "http://hl7.org/fhir/us/cql/Questionnaire/ExamplePatientAndCoverageQuestionnaire",
"version": "1.0.0-ballot",
"name": "ExamplePatientAndCoverageQuestionnaire",
"title": "Example Patient and Coverage Questionnaire",
"status": "active",
"experimental": true,
"date": "2024-09-16T00:00:00+00:00",
"publisher": "HL7 International / Clinical Decision Support",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/dss"
}
]
}
],
"description": "For the Prior Authorization Questionnaire Use Case, this type of in-context information is expected to be known already so it wouldn't typically be in a Questionnaire. This example illustrates how to get this information if it is needed.",
"jurisdiction": [
{
"coding": [
{
"system": "urn:iso:std:iso:3166",
"code": "US",
"display": "United States of America"
}
]
}
],
"item": [
{
"linkId": "patient-info",
"text": "Patient Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Patient Name"
}
}
],
"linkId": "patient-info|patient-name",
"text": "Name",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Date of Birth"
}
}
],
"linkId": "patient-info|date-of-birth",
"text": "Date of Birth",
"type": "date"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Birth Sex"
}
}
],
"linkId": "patient-info|birth-sex",
"text": "Birth Sex",
"type": "choice",
"answerValueSet": "http://hl7.org/fhir/us/core/ValueSet/birthsex"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Medical Record Number"
}
}
],
"linkId": "patient-info|medical-record-number",
"text": "Medical Record Number",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Phone Number"
}
}
],
"linkId": "patient-info|phone-number",
"text": "Phone Number",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Email Address"
}
}
],
"linkId": "patient-info|email-address",
"text": "Email Address",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Address"
}
}
],
"linkId": "patient-info|address",
"text": "Address",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "City"
}
}
],
"linkId": "patient-info|city",
"text": "City",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "State"
}
}
],
"linkId": "patient-info|state",
"text": "State",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Postal Code"
}
}
],
"linkId": "patient-info|postal-code",
"text": "Postal Code",
"type": "string"
}
]
},
{
"linkId": "coverage-info",
"text": "Coverage Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Member ID"
}
}
],
"linkId": "coverage-info|member-id",
"text": "Member ID",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Policy Number"
}
}
],
"linkId": "completing-form|patient-info|policy-number",
"text": "Policy Number",
"type": "string"
}
]
},
{
"linkId": "provider-info",
"text": "Requesting Provider Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Requesting Provider Name"
}
}
],
"linkId": "provider-info|name",
"text": "Requesting provider name",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Requesting Provider Phone"
}
}
],
"linkId": "provider-info|phone-number",
"text": "Phone",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Requesting Provider Address"
}
}
],
"linkId": "provider-info|address",
"text": "Ordering provider address",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Requesting Provider NPI"
}
}
],
"linkId": "provider-info|npi",
"text": "Ordering provider Tax ID/NPI #",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Requesting Provider Fax"
}
}
],
"linkId": "provider-info|fax",
"text": "Fax",
"type": "string"
}
]
},
{
"linkId": "servicing-provider",
"text": "Laboratory performing testing/Servicing Provider",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Servicing Provider Name"
}
}
],
"linkId": "servicing-provider|name",
"text": "Servicing Provider name",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Servicing Provider Phone"
}
}
],
"linkId": "servicing-provider|phone-number",
"text": "Phone",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Servicing Provider Address"
}
}
],
"linkId": "servicing-provider|address",
"text": "Ordering provider address",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Servicing Provider NPI"
}
}
],
"linkId": "servicing-provider|npi",
"text": "Ordering provider Tax ID/NPI #",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Servicing Provider Fax"
}
}
],
"linkId": "servicing-provider|fax",
"text": "Fax",
"type": "string"
}
]
}
]
}