Questionnaire-example-bluebook.xml

Neonate record from New South Wales, Australia "My Personal Health Record" example (id = "bb")

<?xml version="1.0" encoding="UTF-8"?>

<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="bb"/> 
  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">
      <pre> 
        <b> Birth details - To be completed by health professional</b> 
  Name of child: ____________________________________
            Sex: __
            
  Neonatal Information
    Birth Weight (kg): ___________
    Birth Length (cm): ___________
    Vitamin K given  : __
             1st dose: ___________
             2nd dose: ___________
    Hep B given      : __
      Date given     : ___________
    Abnormalities noted at birth:
      _______________________________________________
      </pre> 
    </div> 
  </text> 
  <url value="http://hl7.org/fhir/Questionnaire/bb"/> 
  <title value="NSW Government My Personal Health Record"/> 
  <status value="draft"/> 
  <subjectType value="Patient"/> 
  <date value="2013-02-19"/> 
  <publisher value="New South Wales Department of Health"/> 
  <jurisdiction> 
    <coding> 
      <system value="urn:iso:std:iso:3166"/> 
      <code value="AU"/> 
    </coding> 
  </jurisdiction> 
  <item> 
    <linkId value="birthDetails"/> 
    <text value="Birth details - To be completed by health professional"/> 
    <type value="group"/> 
    <item> 
      <linkId value="group"/> 
      <type value="group"/> 
      <item> 
        <linkId value="nameOfChild"/> 
        <text value="Name of child"/> 
        <type value="string"/> 
      </item> 
      <item> 
        <linkId value="sex"/> 
        <text value="Sex"/> 
        <type value="coding"/> 
        <answerOption> 
          <valueCoding> 
            <code value="F"/> 
          </valueCoding> 
        </answerOption> 
        <answerOption> 
          <valueCoding> 
            <code value="M"/> 
          </valueCoding> 
        </answerOption> 
      </item> 
    </item> 
    <item> 
      <linkId value="neonatalInformation"/> 
      <text value="Neonatal Information"/> 
      <type value="group"/> 
      <item> 
        <linkId value="birthWeight"/> 
        <text value="Birth weight (kg)"/> 
        <type value="decimal"/> 
      </item> 
      <item> 
        <linkId value="birthLength"/> 
        <text value="Birth length (cm)"/> 
        <type value="decimal"/> 
      </item> 
      <item> 
        <linkId value="vitaminKgiven"/> 
        <text value="Vitamin K given"/> 
        <type value="coding"/> 
        <answerOption> 
          <valueCoding> 
            <code value="INJECTION"/> 
          </valueCoding> 
        </answerOption> 
        <answerOption> 
          <valueCoding> 
            <code value="INTRAVENOUS"/> 
          </valueCoding> 
        </answerOption> 
        <answerOption> 
          <valueCoding> 
            <code value="ORAL"/> 
          </valueCoding> 
        </answerOption> 
        <item> 
          <linkId value="vitaminKgivenDoses"/> 
          <type value="group"/> 
          <enableWhen> 
            <question value="vitaminKgiven"/> 
            <operator value="exists"/> 
            <answerBoolean value="true"/> 
          </enableWhen> 
          <item> 
            <linkId value="vitaminiKDose1"/> 
            <text value="1st dose"/> 
            <type value="dateTime"/> 
          </item> 
          <item> 
            <linkId value="vitaminiKDose2"/> 
            <text value="2nd dose"/> 
            <type value="dateTime"/> 
          </item> 
        </item> 
      </item> 
      <item> 
        <linkId value="hepBgiven"/> 
        <text value="Hep B given y / n"/> 
        <type value="boolean"/> 
        <item> 
          <linkId value="hepBgivenDate"/> 
          <text value="Date given"/> 
          <type value="date"/> 
        </item> 
      </item> 
      <item> 
        <linkId value="abnormalitiesAtBirth"/> 
        <text value="Abnormalities noted at birth"/> 
        <type value="string"/> 
      </item> 
    </item> 
  </item> 
</Questionnaire>