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Packageuk.nhsengland.genomics.r4
Resource TypeQuestionnaireResponse
IdQuestionnaireResponse-RoD-PheobeSmithamFather-Example.json
FHIR VersionR4

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Source1

{
  "resourceType": "QuestionnaireResponse",
  "id": "QuestionnaireResponse-RoD-PheobeSmithamFather-Example",
  "questionnaire": "https://fhir.nhs.uk/Questionnaire/NHSDigital-Questionnaire-Genomics-Example",
  "status": "completed",
  "basedOn": [
    {
      "reference": "ServiceRequest/ServiceRequest-WGSTestOrderFormUpdated-TrioTesting-Example"
    }
  ],
  "subject": {
    "reference": "Patient/Patient-PheobeSmithamFather-Example",
    "identifier": {
      "system": "https://fhir.nhs.uk/Id/nhs-number",
      "value": "9449307636"
    }
  },
  "authored": "2023-10-01",
  "author": {
    "identifier": {
      "system": "https://fhir.nhs.uk/Id/sds-role-profile-id",
      "value": "9999999996"
    }
  },
  "source": {
    "reference": "Patient/Patient-PheobeSmithamFather-Example",
    "identifier": {
      "system": "https://fhir.nhs.uk/Id/nhs-number",
      "value": "9449307636"
    }
  },
  "item": [
    {
      "linkId": "patientDetails",
      "text": "Patient Details",
      "item": [
        {
          "linkId": "givenName",
          "text": "First Name",
          "answer": [
            {
              "valueString": "James"
            }
          ]
        },
        {
          "linkId": "familyName",
          "text": "Last Name",
          "answer": [
            {
              "valueString": "Lawrence"
            }
          ]
        },
        {
          "linkId": "nhs_Number",
          "text": "NHS number (or postcode if not not known)",
          "answer": [
            {
              "valueString": "9449307636"
            }
          ]
        },
        {
          "linkId": "birthDate",
          "text": "Date of Birth",
          "answer": [
            {
              "valueDate": "1981-08-03"
            }
          ]
        }
      ]
    },
    {
      "linkId": "declaration4",
      "text": "Confirmation of Your Genomic Test and Research Choices",
      "item": [
        {
          "linkId": "confirmation",
          "text": "I confirm that I have had the opportunity to discuss information about genomic testing, I agree to the genomic test, and my research choice is indicated below.",
          "item": [
            {
              "linkId": "researchConfirmation1",
              "text": "I have discussed taking part in the National Genomic Research Library. If your answer to A is NO then please ignore B and sign directly below",
              "answer": [
                {
                  "valueBoolean": true
                }
              ]
            },
            {
              "linkId": "researchConfirmation2",
              "text": "I agree that my data and remainder sample may contribute to the National Genomic Research Library",
              "answer": [
                {
                  "valueBoolean": true
                }
              ]
            }
          ]
        }
      ]
    },
    {
      "linkId": "isRespondentAttorney",
      "text": "Are you completing this form on behalf of someone?",
      "answer": [
        {
          "valueBoolean": false
        }
      ]
    },
    {
      "linkId": "patientValidation",
      "text": "Patient Validation",
      "item": [
        {
          "linkId": "patientNamecombined",
          "text": "Patient Name",
          "answer": [
            {
              "valueString": "James Lawrence"
            }
          ]
        },
        {
          "linkId": "patientSignature",
          "text": "Signature",
          "answer": [
            {
              "valueString": "JamesLawrence"
            }
          ]
        },
        {
          "linkId": "datePatientCompletedForm",
          "text": "Date",
          "answer": [
            {
              "valueDateTime": "2023-10-01"
            }
          ]
        }
      ]
    },
    {
      "linkId": "declaration5",
      "text": "Healthcare professional use only",
      "item": [
        {
          "linkId": "healthcareProfessional",
          "text": "To be completed by the healthcare professional recording the patient’s choices.",
          "item": [
            {
              "linkId": "patientCategory",
              "text": "Patient category",
              "answer": [
                {
                  "valueCoding": {
                    "system": "https://fhir.nhs.uk/CodeSystem/patient-choice-category-genomics",
                    "code": "adult-own-choice",
                    "display": "Adult(made their own choice)"
                  }
                }
              ]
            },
            {
              "linkId": "testType",
              "text": "Test type",
              "answer": [
                {
                  "valueCoding": {
                    "system": "https://fhir.nhs.uk/CodeSystem/test-type-genomics",
                    "code": "RID-WGS",
                    "display": "Rare and Inherited Diseases - WGS"
                  }
                }
              ]
            },
            {
              "linkId": "remoteConsent",
              "text": "Remote consent, recorded remotely by clinician, no patient signature",
              "answer": [
                {
                  "valueBoolean": true
                }
              ]
            },
            {
              "linkId": "responsibleClinician",
              "text": "Responsible clinician",
              "answer": [
                {
                  "valueString": "Dr. Eugene Smith"
                }
              ]
            },
            {
              "linkId": "patientMRN",
              "text": "Hospital number",
              "answer": [
                {
                  "valueString": "NA"
                }
              ]
            },
            {
              "linkId": "healthcareProfessionalName",
              "text": "Healthcare professional name",
              "answer": [
                {
                  "valueString": "Dr. Eugene Smith"
                }
              ]
            },
            {
              "linkId": "healthcareProfessionalSignature",
              "text": "Signature",
              "answer": [
                {
                  "valueString": "Dr. Eugene Smith"
                }
              ]
            },
            {
              "linkId": "datehealthcareProfessionalCompletedForm",
              "text": "Date",
              "answer": [
                {
                  "valueDateTime": "2023-10-01"
                }
              ]
            }
          ]
        }
      ]
    }
  ]
}