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4.26 Resource Questionnaire - Content

Patient Care Work Group

Maturity Level: 0

Compartments: Not linked to any defined compartments

A structured set of questions intended to guide the collection of answers. The questions are ordered and grouped into coherent subsets, corresponding to the structure of the grouping of the underlying questions.

This resource is referenced by questionnaireresponse

4.26.4 Resource Content

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

4.26.4.1 Terminology Bindings

Path	Definition	Type	Reference
Questionnaire.status	Lifecycle status of the questionnaire	Required	QuestionnaireStatus
Questionnaire.subjectType	One of the resource types defined as part of FHIR	Required	http://hl7.org/fhir/valueset/resource-typesResourceType
Questionnaire.group.concept	Codes for groupings of questionnaire questions	Example	Questionnaire Question Codes
Questionnaire.group.question.concept	Codes corresponding to individual questions	Example	Questionnaire Question Codes
Questionnaire.group.question.type	The expected format of an answer	Required	AnswerFormat
Questionnaire.group.question.option	Allowed values to answer questions	Example	Questionnaire Answer Codes

4.26.4.2 Constraints

• que-1: On Questionnaire.group: Groups may either contain questions or groups but not both (xpath on f:Questionnaire/f:group: not(exists(f:group) and exists(f:question)))
• que-2: The link ids for groups and questions must be unique within the questionnaire (xpath: count(descendant::f:linkId/@value)=count(distinct-values(descendant::f:linkId/@value)))
• que-3: If root group must be "required" (xpath: f:group/f:required/@value='true')
• que-4: On Questionnaire.group.question: A question must use either option or options, not both (xpath on f:Questionnaire/f:group/f:question: not(f:options and f:option))

4.26.5 Notes:

• Questionnaires may be used to represent predefined forms or pannels, referenced using Questionnaire.group.concept.
• A Questionnaire's contents are placed inside its single nested Group, which may contain Questions or subgroups with Questions.
• Groups and Questions may have linkIds allowing groups and question answers captured in a QuestionnaireResponse to be associated with their corresponding group or question.
• Questionnaire allows for flexible naming and structuring of its contents to reflect the flexible and varying nature of forms and questionnaires. It explicitly does not try to standardize or streamline exchange of its contents outside its context of use, although exchanging partners may further constrain its structure and flexibility using profiles to define standardized, reusable forms.
• Because of the lack of explicit support for Questionnaires in HL7v3, HL7 CDA Documents frequently used named sections with Observations to model Questionnaires. Such use cases should now utilize the Questionnaire Resource instead.
• The order of questions within groups, groups within groups and groups within questions is relevant and must be retained for display and capture.

4.26.5.1 Using Questionnaires versus using Resources

There is considerable overlap between the information covered by Questionnaires and other Resources (especially FamilyMemberHistory, MedicationStatement, Observation, Procedure, etc.): Questionnaire's flexible structure can easily be misused to capture any data, even data that should be captured as separate Resources. The choice between using Questionnaires or separate Resources may be dictated by the procedure of collection and recording. E.g. if the data is captured as a physician-agreed (electronic) form, it might be impossible or undesirable to distill separate resources from it and capturing the data in a Questionnaire would be most appropriate.

However, data captured only in Questionnaires can be difficult to query after-the-fact. Queries against other Resources will not return data captured only in Questionnaires, and querying against Questionnaires directly may not find all desired data, depending on how the questions may have been phrased or encoded over time or by different clinicians. Moreover, interoperability of such Questionnaires is limited as interpretation of its contents is only known to the circle of parties that were involved in its definition: encoding data from such Questionnaires using other, more specific, Resources increases the ability and consistency with which it can be understood and queried.

It is entirely possible for data to exist in both QuestionnaireResponse and in other resources. For example, data may be captured in QuestionnaireResponse as part of an intake questionnaire. That data may then be propagated into the Patient resource (demographics), FamilyMemberHistory, AllergyIntolerance, MedicationStatement and Observation resources to allow the data to be queried and analyzed. The original QuestionnaireResponse instance can be retained for traceability purposes. For example, if a questionnaire question asks "what is your weight", that can then result in the creation of an Observation with the appropriate Observation.code and the specified answer as the Observation.valueQuantity.

4.26.5.2 Structure of the Questionnaire

A Questionnaire is built out of three components:

• The main component is Questionnaire, which holds information about the Questionnaire, like the identifier, publisher, date authored, etc. The Questionnaire contains one "root" Group, which contains all the content of the questionnaire. This "root" group contains elements that apply to the entire questionnaire - the title for the questionnaire, the concept that represents the meaning of the overall questionnaire (e.g. a code for "family history"), the text to display at the top of the questionnaire, etc. (In most cases, required would be 'true' and repeats would be false for the root group
• This Group can contain either nested Groups (to represent sections and subsections on a questionnaire form) or Questions. This way, any form containing sections or subsections can be represented, down to the actual questions.
• The Questions themselves may be simple questions with a prompt text and one expected answer, but they may also contain nested groups, each containing sets of nested questions. This way, one can model "panels" of questions which would only be relevant (and thus would only be displayed) depending on the answers of a parent question. E.g. a question "Did the patient receive treatment in the past six months?" would contain a nested group of questions asking for further details about the treatment. See an example from the Australian New South Wales blue book
• Specific controls on dynamic display of groups, questions, etc. based on the answers to other questions is outside the scope of the base resource and are expected to be introduced as extensions.

4.26.5.3 Identifiers within Questionnaire

There are three different "identifying" elements within Questionnaire: identifier, id and linkId. Each serves very distinct purposes:

• identifier is used to reference the overall questionnaire in business terms. It is the number printed across the top of the form or listed beside the form when making a choice between alternate forms.
• The id attribute supported on each element is used for references within a resource, for example linking narrative to discrete elements
• The linkId element on questions and groups establishes a link between elements in a QuestionnaireAnsers and their definition inside a Questionnaire. This is the only way to link between the groups and questions in a Questionnaire and QuestionnaireResponse

4.26.5.4 Question Definitions

Questionnaires can be crafted using any questions the author can conceive phrased in whatever manner is appropriate or convenient. However, standardization of questions and the constraints enforced on the accompanying answers increases the ability to compare data gathered across questionnaires. There are two mechanisms defined in the specification for linking a Question (or Group) to a standardized definition:

• The concept element on both Group and Question allows an individual question, a group of questions or even the questionnaire as a whole to be associated with a pre-defined terminology of questions and question groups such as LOINC
• The deReference extension allows a question or group to be associated with the DataElement (DE) resource that formally defines the data element.

Linking to formal definitions of a question allows data captured by distinct questionnaires to be compared. If systems have the necessary mappings to the formal definition, linkages to formal definitions may also be used to automatically pre-populate or extract data from a corresponding QuestionnaireResponse resource.

NOTE: Even if standard question definitions are referenced using concept or the deReference extension, information such as the question text, data type and value set SHOULD still be declared for the question. Systems processing the questionnaire may not have access to or support the ability to look up the question definitions from external sources. If the information is not included in-line within the questionnaire, other systems may not be able to to render or use the Questionnaire.

If an external reference (concept or deReference extension) is included along with question information such as question text, data type or value set, it is expected that the content for the question and the referenced definition would be in alignment. However, FHIR does not dictate what degree of alignment is required. E.g. Does the question text need to match exactly? Is it legitimate for a question to constrain the allowed value set of possible answers? These rules will need to be established within implementation environments.

4.26.5.5 Question types

The codes for the data type for each question is slightly different than the data types allowed in the QuestionnaireResponse resource. Where the names are the same (ignoring case), the "answer" must use the specified type. Where the names are different, the mappings are as follows:

Questionnaire AnswerFormat code	QuestionnaireResponse data type
text	string
url	uri
choice	Coding
open-choice	Coding

4.26.5.6 Permitted values for questions

Many questionnaires place constraints on the allowed list of values for a given question. FHIR supports this notion through the ...question.choices element. However, rather than listing the choices directly, the choices element points to a ValueSet resource. This approach adds complexity for questionnaires having a simple list of strings as choices for a question, but provides several benefits:

• Questionnaires that reference codes from externally defined code systems have a means of doing so
• Answer sets can be shared across questions (and there are many questionnaires where this capability is useful)
• The full capability of value sets can be brought into play, including the ability to use ConceptMap to link to translate from questionnaire-specific codes to other codes, the use of multiple display names (e.g. different languages), the ability to use coded ordinals, the ability to allow choices from larger value sets (e.g. "all SNOMED CT procedure codes")
• etc.

In many cases, the set of code choices will be specific to a given questionnaire and should be maintained as part of the questionnaire. In this case, the referenced ValueSet can be included as a contained resource. All contained ValueSets are listed together and then are referenced by the individual questions as necessary.

4.26.5.7 Useful Value Sets

Many questions have a set of possible codes for their answer. These value sets may be useful to help, and when referenced by full URL, do not need to be provided as part of the questionnaire:

• Yes | No | Don't Know: http://hl7.org/fhir/ValueSet/yesnodontknow

4.26.5.8 Questions with multiple answer types

In some questionnaires, it may be possible to respond to a question with multiple types of answers. For example, capturing a coded answer plus free text, capturing a coded value plus a numeric priority, etc. In FHIR, this is handled through nested questions. Each question has a single data type. However, each question can have nested child questions. These nested child questions can have text (e.g. "Please specify") or can have no text at all if the appropriate guidance is provided by the parent question or group.

4.26.5.9 Questionnaires with Math

While not defined (yet) at the international level, extensions may be defined to perform mathematical functions on questionnaire responses. For example, tabulating scores. One extension that is defined that may be useful in this process is the Ordinal extension. This allows a numeric value to be associated with a coded data element. There are two extensions defined - one for defining the numeric weighting of a code defined in a value set - valueset-ordinalValue and the other is a code that can appear within a Coding itself - iso21090-CO-value.

4.26.5.10 Extensions for Additional capabilities

The core elements defined in the questionnaire resource are sufficient for simple questionnaires. For more sophisticated capabilities, a number of "common" extensions are defined in the Questionnaire Core extensions and the Element extensions profiles. For example, strict control over allowed number of conditions, conditional display of questionnaire content, etc. The conditional display extension [enable-when] can be used to enable groups nested beneath a question based on the selection of a specific answer, giving the behavior of "questions under answers" where this sort of more sophisticated behavior is needed.

4.26.6 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name	Type	Description	Paths
code	token	A code that corresponds to the questionnaire or one of its groups	Questionnaire.group.concept
date	date	When the questionnaire was last changed	Questionnaire.date
identifier	token	An identifier for the questionnaire	Questionnaire.identifier
publisher	string	The author of the questionnaire	Questionnaire.publisher
status	token	The status of the questionnaire	Questionnaire.status
title	string	All or part of the name of the questionnaire (title for the root group of the questionnaire)	Questionnaire.group.title
version	string	The business version of the questionnaire	Questionnaire.version