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Packagelt.hl7.fhir.colorectal
Resource TypeQuestionnaireResponse
IdQuestionnaireResponse-questionnaireresponse-colonoscopy-espbi-example.json
FHIR VersionR5

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Narrative

Note: links and images are rebased to the (stated) source


English


Generated Narrative: QuestionnaireResponse questionnaireresponse-colonoscopy-espbi-example

Language: en

LinkIDTextDefinitionAnswerdoco
.. questionnaireresponse-colonoscopy-espbi-exampleQuestionnaire:ESPBI Colonoscopy Form
... basicInfoBasic descriptive part
.... basicInfo.postponedColonoscopyWas colonoscopy postponed for screening?false
.... basicInfo.anesthesiaAnesthesiaSNOMED CT: 398166005 (Performed)
.... basicInfo.videoColonoscopeVideo colonoscope used?SNOMED CT: 373066001 (Yes)
.... basicInfo.withdrawalTimeWithdrawal time (minutes)8
.... basicInfo.procedureDateProcedure date2026-03-12T10:00:00+02:00
... bowelPrepBowel preparation assessment
.... bowelPrep.prepQualityBowel preparation quality adequate?SNOMED CT: 373066001 (Yes)
.... bowelPrep.bbpsRightBBPS Right colon / ascending (0-3)2
.... bowelPrep.bbpsTransverseBBPS Transverse colon (0-3)2
.... bowelPrep.bbpsLeftBBPS Left colon / descending + sigmoid (0-3)3
.... bowelPrep.totalBbpsTotal BBPS score (0-9)7
.... bowelPrep.dietaryRecommendationsWere dietary recommendations given?SNOMED CT: 373066001 (Yes)
.... bowelPrep.splitDoseWas split-dose protocol used?SNOMED CT: 373066001 (Yes)
.... bowelPrep.writtenInfoWas written information about preparation given?SNOMED CT: 373066001 (Yes)
.... bowelPrep.usedPreparationsUsed preparations for bowel preparationSNOMED CT: 712567003 (Macrogol 4000 (substance))
... scopeReachColonoscope reach
.... scopeReach.reachLocationDeepest point reached by colonoscopeSNOMED CT: 32713005 (Cecum structure)
... polypFindingsPolyp findings
.... polypFindings.polypFoundPolyp found?true
.... polypFindings.locationPolyp locationSNOMED CT: 60184004 (Sigmoid colon structure)
.... polypFindings.sizeMmPolyp size (mm)8
.... polypFindings.parisClassificationParis endoscopic classification[not stated]: (IIa Slightly elevated)
.... polypFindings.niceClassificationNICE classification[not stated]: (Type II (Adenoma))
.... polypFindings.predictedHistologyPredicted histology[not stated]: (Adenoma)
.... polypFindings.locationSideLocation side[not stated]: (Left side)
.... polypFindings.accessDifficultyAccess difficulty[not stated]: (Easy)
.... polypFindings.smsaScoreSMSA total score5
.... polypFindings.smsaLevelSMSA level[not stated]: (Level 1 (4-5 points))
.... polypFindings.polypRemovedWas polyp removed?SNOMED CT: 373066001 (Yes)
.... polypFindings.removalMethodRemoval method[not stated]: (Cold snare)
.... polypFindings.complicationAfterRemovalComplication after polyp removal?SNOMED CT: 373067005 (No)
.... polypFindings.allPolypsRemovedSimultaneouslyAll polyps removed simultaneously?SNOMED CT: 373066001 (Yes)
.... polypFindings.sentForHistologySent for histological examination?SNOMED CT: 373066001 (Yes)
... tumorFindingsTumor findings
.... tumorFindings.tumorFoundTumor found?false
... complicationsComplications after colonoscopy
.... complications.complicationPresenceWere there complications?SNOMED CT: 373067005 (No)
... conclusionsFinal conclusions
.... conclusions.conclusionConclusion[not stated]: (Polyps found)
.... conclusions.conclusionNotesConclusion notesSingle 8mm adenomatous polyp in the sigmoid colon, removed with cold snare. No other pathology detected.
... recommendationsFollow-up recommendations
.... recommendations.nextColonoscopyRecommended interval for next colonoscopy[not stated]: (3 years)
.... recommendations.additionalNotesAdditional notesPolyp sent for histological examination. Patient informed about the follow-up plan.
... signaturesSignatures
.... signatures.examinerNameExaminer first nameJonas
.... signatures.examinerSurnameExaminer surnameKazlauskas
.... signatures.examDateExamination date2026-03-12T14:30:00+02:00

doco Documentation for this format

Lithuanian


Generated Narrative: QuestionnaireResponse questionnaireresponse-colonoscopy-espbi-example

Language: en

LinkIDTextDefinitionAnswerdoco
.. questionnaireresponse-colonoscopy-espbi-exampleQuestionnaire:ESPBI Colonoscopy Form
... basicInfoBasic descriptive part
.... basicInfo.postponedColonoscopyWas colonoscopy postponed for screening?false
.... basicInfo.anesthesiaAnesthesiaSNOMED CT: 398166005 (Performed)
.... basicInfo.videoColonoscopeVideo colonoscope used?SNOMED CT: 373066001 (Yes)
.... basicInfo.withdrawalTimeWithdrawal time (minutes)8
.... basicInfo.procedureDateProcedure date2026-03-12T10:00:00+02:00
... bowelPrepBowel preparation assessment
.... bowelPrep.prepQualityBowel preparation quality adequate?SNOMED CT: 373066001 (Yes)
.... bowelPrep.bbpsRightBBPS Right colon / ascending (0-3)2
.... bowelPrep.bbpsTransverseBBPS Transverse colon (0-3)2
.... bowelPrep.bbpsLeftBBPS Left colon / descending + sigmoid (0-3)3
.... bowelPrep.totalBbpsTotal BBPS score (0-9)7
.... bowelPrep.dietaryRecommendationsWere dietary recommendations given?SNOMED CT: 373066001 (Yes)
.... bowelPrep.splitDoseWas split-dose protocol used?SNOMED CT: 373066001 (Yes)
.... bowelPrep.writtenInfoWas written information about preparation given?SNOMED CT: 373066001 (Yes)
.... bowelPrep.usedPreparationsUsed preparations for bowel preparationSNOMED CT: 712567003 (Macrogol 4000 (substance))
... scopeReachColonoscope reach
.... scopeReach.reachLocationDeepest point reached by colonoscopeSNOMED CT: 32713005 (Cecum structure)
... polypFindingsPolyp findings
.... polypFindings.polypFoundPolyp found?true
.... polypFindings.locationPolyp locationSNOMED CT: 60184004 (Sigmoid colon structure)
.... polypFindings.sizeMmPolyp size (mm)8
.... polypFindings.parisClassificationParis endoscopic classification[not stated]: (IIa Slightly elevated)
.... polypFindings.niceClassificationNICE classification[not stated]: (Type II (Adenoma))
.... polypFindings.predictedHistologyPredicted histology[not stated]: (Adenoma)
.... polypFindings.locationSideLocation side[not stated]: (Left side)
.... polypFindings.accessDifficultyAccess difficulty[not stated]: (Easy)
.... polypFindings.smsaScoreSMSA total score5
.... polypFindings.smsaLevelSMSA level[not stated]: (Level 1 (4-5 points))
.... polypFindings.polypRemovedWas polyp removed?SNOMED CT: 373066001 (Yes)
.... polypFindings.removalMethodRemoval method[not stated]: (Cold snare)
.... polypFindings.complicationAfterRemovalComplication after polyp removal?SNOMED CT: 373067005 (No)
.... polypFindings.allPolypsRemovedSimultaneouslyAll polyps removed simultaneously?SNOMED CT: 373066001 (Yes)
.... polypFindings.sentForHistologySent for histological examination?SNOMED CT: 373066001 (Yes)
... tumorFindingsTumor findings
.... tumorFindings.tumorFoundTumor found?false
... complicationsComplications after colonoscopy
.... complications.complicationPresenceWere there complications?SNOMED CT: 373067005 (No)
... conclusionsFinal conclusions
.... conclusions.conclusionConclusion[not stated]: (Polyps found)
.... conclusions.conclusionNotesConclusion notesSingle 8mm adenomatous polyp in the sigmoid colon, removed with cold snare. No other pathology detected.
... recommendationsFollow-up recommendations
.... recommendations.nextColonoscopyRecommended interval for next colonoscopy[not stated]: (3 years)
.... recommendations.additionalNotesAdditional notesPolyp sent for histological examination. Patient informed about the follow-up plan.
... signaturesSignatures
.... signatures.examinerNameExaminer first nameJonas
.... signatures.examinerSurnameExaminer surnameKazlauskas
.... signatures.examDateExamination date2026-03-12T14:30:00+02:00

doco Documentation for this format

Source1

{
  "resourceType": "QuestionnaireResponse",
  "id": "questionnaireresponse-colonoscopy-espbi-example",
  "language": "en",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "questionnaire": "https://hl7.lt/fhir/colorectal/Questionnaire/questionnaire-colonoscopy-espbi",
  "status": "completed",
  "subject": {
    "reference": "Patient/patient-male-example"
  },
  "authored": "2026-03-12T14:30:00+02:00",
  "author": {
    "reference": "Practitioner/practitioner-example"
  },
  "item": [
    {
      "linkId": "basicInfo",
      "text": "Basic descriptive part",
      "item": [
        {
          "linkId": "basicInfo.postponedColonoscopy",
          "text": "Was colonoscopy postponed for screening?",
          "answer": [
            {
              "valueBoolean": false
            }
          ]
        },
        {
          "linkId": "basicInfo.anesthesia",
          "text": "Anesthesia",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "398166005",
                "display": "Performed"
              }
            }
          ]
        },
        {
          "linkId": "basicInfo.videoColonoscope",
          "text": "Video colonoscope used?",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373066001",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "linkId": "basicInfo.withdrawalTime",
          "text": "Withdrawal time (minutes)",
          "answer": [
            {
              "valueInteger": 8
            }
          ]
        },
        {
          "linkId": "basicInfo.procedureDate",
          "text": "Procedure date",
          "answer": [
            {
              "valueDateTime": "2026-03-12T10:00:00+02:00"
            }
          ]
        }
      ]
    },
    {
      "linkId": "bowelPrep",
      "text": "Bowel preparation assessment",
      "item": [
        {
          "linkId": "bowelPrep.prepQuality",
          "text": "Bowel preparation quality adequate?",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373066001",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "linkId": "bowelPrep.bbpsRight",
          "text": "BBPS Right colon / ascending (0-3)",
          "answer": [
            {
              "valueInteger": 2
            }
          ]
        },
        {
          "linkId": "bowelPrep.bbpsTransverse",
          "text": "BBPS Transverse colon (0-3)",
          "answer": [
            {
              "valueInteger": 2
            }
          ]
        },
        {
          "linkId": "bowelPrep.bbpsLeft",
          "text": "BBPS Left colon / descending + sigmoid (0-3)",
          "answer": [
            {
              "valueInteger": 3
            }
          ]
        },
        {
          "linkId": "bowelPrep.totalBbps",
          "text": "Total BBPS score (0-9)",
          "answer": [
            {
              "valueInteger": 7
            }
          ]
        },
        {
          "linkId": "bowelPrep.dietaryRecommendations",
          "text": "Were dietary recommendations given?",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373066001",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "linkId": "bowelPrep.splitDose",
          "text": "Was split-dose protocol used?",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373066001",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "linkId": "bowelPrep.writtenInfo",
          "text": "Was written information about preparation given?",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373066001",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "linkId": "bowelPrep.usedPreparations",
          "text": "Used preparations for bowel preparation",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "712567003",
                "display": "Macrogol 4000 (substance)"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "scopeReach",
      "text": "Colonoscope reach",
      "item": [
        {
          "linkId": "scopeReach.reachLocation",
          "text": "Deepest point reached by colonoscope",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "32713005",
                "display": "Cecum structure"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "polypFindings",
      "text": "Polyp findings",
      "item": [
        {
          "linkId": "polypFindings.polypFound",
          "text": "Polyp found?",
          "answer": [
            {
              "valueBoolean": true
            }
          ]
        },
        {
          "linkId": "polypFindings.location",
          "text": "Polyp location",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "60184004",
                "display": "Sigmoid colon structure"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.sizeMm",
          "text": "Polyp size (mm)",
          "answer": [
            {
              "valueInteger": 8
            }
          ]
        },
        {
          "linkId": "polypFindings.parisClassification",
          "text": "Paris endoscopic classification",
          "answer": [
            {
              "valueCoding": {
                "display": "IIa Slightly elevated"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.niceClassification",
          "text": "NICE classification",
          "answer": [
            {
              "valueCoding": {
                "display": "Type II (Adenoma)"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.predictedHistology",
          "text": "Predicted histology",
          "answer": [
            {
              "valueCoding": {
                "display": "Adenoma"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.locationSide",
          "text": "Location side",
          "answer": [
            {
              "valueCoding": {
                "display": "Left side"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.accessDifficulty",
          "text": "Access difficulty",
          "answer": [
            {
              "valueCoding": {
                "display": "Easy"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.smsaScore",
          "text": "SMSA total score",
          "answer": [
            {
              "valueInteger": 5
            }
          ]
        },
        {
          "linkId": "polypFindings.smsaLevel",
          "text": "SMSA level",
          "answer": [
            {
              "valueCoding": {
                "display": "Level 1 (4-5 points)"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.polypRemoved",
          "text": "Was polyp removed?",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373066001",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.removalMethod",
          "text": "Removal method",
          "answer": [
            {
              "valueCoding": {
                "display": "Cold snare"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.complicationAfterRemoval",
          "text": "Complication after polyp removal?",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373067005",
                "display": "No"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.allPolypsRemovedSimultaneously",
          "text": "All polyps removed simultaneously?",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373066001",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "linkId": "polypFindings.sentForHistology",
          "text": "Sent for histological examination?",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373066001",
                "display": "Yes"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "tumorFindings",
      "text": "Tumor findings",
      "item": [
        {
          "linkId": "tumorFindings.tumorFound",
          "text": "Tumor found?",
          "answer": [
            {
              "valueBoolean": false
            }
          ]
        }
      ]
    },
    {
      "linkId": "complications",
      "text": "Complications after colonoscopy",
      "item": [
        {
          "linkId": "complications.complicationPresence",
          "text": "Were there complications?",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "373067005",
                "display": "No"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "conclusions",
      "text": "Final conclusions",
      "item": [
        {
          "linkId": "conclusions.conclusion",
          "text": "Conclusion",
          "answer": [
            {
              "valueCoding": {
                "display": "Polyps found"
              }
            }
          ]
        },
        {
          "linkId": "conclusions.conclusionNotes",
          "text": "Conclusion notes",
          "answer": [
            {
              "valueString": "Single 8mm adenomatous polyp in the sigmoid colon, removed with cold snare. No other pathology detected."
            }
          ]
        }
      ]
    },
    {
      "linkId": "recommendations",
      "text": "Follow-up recommendations",
      "item": [
        {
          "linkId": "recommendations.nextColonoscopy",
          "text": "Recommended interval for next colonoscopy",
          "answer": [
            {
              "valueCoding": {
                "display": "3 years"
              }
            }
          ]
        },
        {
          "linkId": "recommendations.additionalNotes",
          "text": "Additional notes",
          "answer": [
            {
              "valueString": "Polyp sent for histological examination. Patient informed about the follow-up plan."
            }
          ]
        }
      ]
    },
    {
      "linkId": "signatures",
      "text": "Signatures",
      "item": [
        {
          "linkId": "signatures.examinerName",
          "text": "Examiner first name",
          "answer": [
            {
              "valueString": "Jonas"
            }
          ]
        },
        {
          "linkId": "signatures.examinerSurname",
          "text": "Examiner surname",
          "answer": [
            {
              "valueString": "Kazlauskas"
            }
          ]
        },
        {
          "linkId": "signatures.examDate",
          "text": "Examination date",
          "answer": [
            {
              "valueDateTime": "2026-03-12T14:30:00+02:00"
            }
          ]
        }
      ]
    }
  ]
}