| Package | hl7.fhir.us.cql |
| Resource Type | Questionnaire |
| Id | MNACQuestionnaire |
| FHIR Version | R4 |
| Source | http://hl7.org/fhir/us/cql/https://build.fhir.org/ig/HL7/us-cql-ig/Questionnaire-MNACQuestionnaire.html |
| URL | http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire |
| Version | 1.0.0-ballot |
| Status | active |
| Date | 2024-01-17T00:00:00+00:00 |
| Name | MNACQuestionnaire |
| Title | Example Medical Necessity For Authorization Of Catheters Questionnaire |
| Realm | us |
| Authority | hl7 |
| Description | This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. |
| Copyright | This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf |
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Note: links and images are rebased to the (stated) source
Generated Narrative: Questionnaire MNACQuestionnaire
Structure| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  MNACQuestionnaire | This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. | Questionnaire | http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire#1.0.0-ballot | |
  request-info | Request Information | 0..1 | group | |
   request-info|date-of-request | DATE OF REQUEST | 0..1 | date | |
| diagnosis-info | Diagnosis Information | 0..1 | group | |
 diagnosis-info|diagnosis | Diagnosis | 0..1 | string | |
| item-requested | Item Requested | 0..1 | group | |
| item-requested|item | Item requested | 0..1 | string | |
| uti-history | UTI History | 0..1 | group | |
 uti-history|uti-last-year | The patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing | 0..1 | choice | Options: 2 options |
| uti-history|uti-dates | Dates of UTIs in the last year | 0..1 | string | Enable When: uti-history|uti-last-year = |
| uti-history|antibiotics-used | Antibiotics used for UTIs in the last year | 0..1 | string | Enable When: uti-history|uti-last-year = |
| symptoms-info | Symptoms Information | 0..1 | group | |
| symptoms-info|symptoms | Check those that apply to your patient | 0..* | choice | Options: 7 options |
 symptoms-info|fever-temperature | If fever, state temperature in degrees | 0..1 | decimal | Enable When: symptoms-info|symptoms = |
| catheterization-frequency | Catheterization Frequency | 0..1 | group | |
| catheterization-frequency|frequency | How many times per day does the patient catheterize? | 0..1 | choice | Options: 4 options |
| additional-comments | Additional Comments | 0..1 | group | |
| additional-comments|comments | Additional Comment | 0..1 | string | |
| physician-info | Physician Information | 0..1 | group | |
 physician-info|name | Physician's Name | 0..1 | string | |
| physician-info|mobile | Telephone | 0..1 | string | |
| physician-info|fax | FAX | 0..1 | string | |
 physician-info|signature | Physician's Signature | 0..1 | attachment | |
| physician-info|phone-referring | Referring Physician Telephone | 0..1 | string | |
| physician-info|date | Date | 0..1 | string | |
| Documentation for this format | ||||
Options Sets
Answer options for uti-history|uti-last-year
Answer options for symptoms-info|symptoms
Answer options for catheterization-frequency|frequency
FHIR{
"resourceType": "Questionnaire",
"id": "MNACQuestionnaire",
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
"valueCanonical": "http://hl7.org/fhir/us/cql/Library/MNACInitialExpressions"
},
{
"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": "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/MNACQuestionnaire",
"version": "1.0.0-ballot",
"name": "MNACQuestionnaire",
"title": "Example Medical Necessity For Authorization Of Catheters Questionnaire",
"status": "active",
"experimental": true,
"date": "2024-01-17T00:00:00+00:00",
"publisher": "HL7 International / Clinical Decision Support",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/dss"
}
]
}
],
"description": "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.",
"jurisdiction": [
{
"coding": [
{
"system": "urn:iso:std:iso:3166",
"code": "US",
"display": "United States of America"
}
]
}
],
"copyright": "This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf",
"item": [
{
"linkId": "request-info",
"text": "Request Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Date of Request"
}
}
],
"linkId": "request-info|date-of-request",
"text": "DATE OF REQUEST",
"type": "date"
}
]
},
{
"linkId": "diagnosis-info",
"text": "Diagnosis Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Diagnosis"
}
}
],
"linkId": "diagnosis-info|diagnosis",
"text": "Diagnosis",
"type": "string"
}
]
},
{
"linkId": "item-requested",
"text": "Item Requested",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Item Requested"
}
}
],
"linkId": "item-requested|item",
"text": "Item requested",
"type": "string"
}
]
},
{
"linkId": "uti-history",
"text": "UTI History",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "UTI in Last Year"
}
}
],
"linkId": "uti-history|uti-last-year",
"text": "The patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "Yes",
"display": "Yes"
}
},
{
"valueCoding": {
"code": "No",
"display": "No"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Dates of UTIs"
}
}
],
"linkId": "uti-history|uti-dates",
"text": "Dates of UTIs in the last year",
"type": "string",
"enableWhen": [
{
"question": "uti-history|uti-last-year",
"operator": "=",
"answerCoding": {
"code": "true"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Antibiotics Used"
}
}
],
"linkId": "uti-history|antibiotics-used",
"text": "Antibiotics used for UTIs in the last year",
"type": "string",
"enableWhen": [
{
"question": "uti-history|uti-last-year",
"operator": "=",
"answerCoding": {
"code": "true"
}
}
]
}
]
},
{
"linkId": "symptoms-info",
"text": "Symptoms Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Check Symptoms"
}
}
],
"linkId": "symptoms-info|symptoms",
"text": "Check those that apply to your patient",
"type": "choice",
"repeats": true,
"answerOption": [
{
"valueCoding": {
"code": "Fever",
"display": "Fever; state temperature in degree"
}
},
{
"valueCoding": {
"code": "UrinaryUrgencyFrequency",
"display": "Change in urinary urgency, frequency, or incontinence"
}
},
{
"valueCoding": {
"code": "AutonomicDysreflexia",
"display": "Appearance of new or increase in autonomic dysreflexia"
}
},
{
"valueCoding": {
"code": "PhysicalSignsProstatitis",
"display": "Physical signs of prostatitis, epididymitis, orchitis"
}
},
{
"valueCoding": {
"code": "Immunosuppressed",
"display": "The patient is immunosuppressed"
}
},
{
"valueCoding": {
"code": "Pyuria",
"display": "Pyuria"
}
},
{
"valueCoding": {
"code": "SystemicLeukocytosis",
"display": "Systemic leukocytosis"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Fever Temperature"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "deg",
"display": "deg"
}
}
],
"linkId": "symptoms-info|fever-temperature",
"text": "If fever, state temperature in degrees",
"type": "decimal",
"enableWhen": [
{
"question": "symptoms-info|symptoms",
"operator": "=",
"answerCoding": {
"code": "Fever"
}
}
]
}
]
},
{
"linkId": "catheterization-frequency",
"text": "Catheterization Frequency",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Catheterization Frequency"
}
}
],
"linkId": "catheterization-frequency|frequency",
"text": "How many times per day does the patient catheterize?",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "2-4Times",
"display": "2-4 times"
}
},
{
"valueCoding": {
"code": "4-6Times",
"display": "4-6 times"
}
},
{
"valueCoding": {
"code": "6-8Times",
"display": "6-8 times"
}
},
{
"valueCoding": {
"code": "8TimesOrMore",
"display": "8 times or more"
}
}
]
}
]
},
{
"linkId": "additional-comments",
"text": "Additional Comments",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Additional Comment"
}
}
],
"linkId": "additional-comments|comments",
"text": "Additional Comment",
"type": "string"
}
]
},
{
"linkId": "physician-info",
"text": "Physician Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Physician Name"
}
}
],
"linkId": "physician-info|name",
"text": "Physician's Name",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Physician Telephone"
}
}
],
"linkId": "physician-info|mobile",
"text": "Telephone",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Physician Fax"
}
}
],
"linkId": "physician-info|fax",
"text": "FAX",
"type": "string"
},
{
"linkId": "physician-info|signature",
"text": "Physician's Signature",
"type": "attachment"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Referring Physician Telephone"
}
}
],
"linkId": "physician-info|phone-referring",
"text": "Referring Physician Telephone",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Date"
}
}
],
"linkId": "physician-info|date",
"text": "Date",
"type": "string"
}
]
}
]
}