# Example Medical Necessity For Authorization Of Catheters Questionnaire - Common CQL Artifacts for FHIR (US-Based) v1.0.0

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **Example Medical Necessity For Authorization Of Catheters Questionnaire**

## Questionnaire: Example Medical Necessity For Authorization Of Catheters Questionnaire (Experimental) 

| | |
| :--- | :--- |
| *Official URL*:http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire | *Version*:1.0.0 |
| *Standards status:*[Informative](http://hl7.org/fhir/R4/versions.html#std-process) | *Computable Name*:MNACQuestionnaire |
| **Copyright/Legal**: This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf | |

 
This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. 

**Structure**

* [LinkID](https://hl7.org/fhir/R4/formats.html#table): MNACQuestionnaire
  * [Text](https://hl7.org/fhir/R4/formats.html#table): This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 
  * [Type](https://hl7.org/fhir/R4/formats.html#table): Questionnaire
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire#1.0.0
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)request-info
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Request Information
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-date.png)request-info|date-of-request
  * [Text](https://hl7.org/fhir/R4/formats.html#table): DATE OF REQUEST
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [date](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)diagnosis-info
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Diagnosis Information
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)diagnosis-info|diagnosis
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Diagnosis
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)item-requested
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Item Requested
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)item-requested|item
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Item requested
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)uti-history
  * [Text](https://hl7.org/fhir/R4/formats.html#table): UTI History
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-boolean.png)uti-history|uti-last-year
  * [Text](https://hl7.org/fhir/R4/formats.html#table): 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
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [boolean](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)uti-history|uti-dates
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Dates of UTIs in the last year
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Enable When:[uti-history|uti-last-year](#item.uti-history|uti-last-year)=
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)uti-history|antibiotics-used
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Antibiotics used for UTIs in the last year
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Enable When:[uti-history|uti-last-year](#item.uti-history|uti-last-year)=
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)symptoms-info
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Symptoms Information
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-coding.png)symptoms-info|symptoms
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Check those that apply to your patient
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..*
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [choice](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Options:[7 options](#opt-item.symptoms-info|symptoms)
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-decimal.png)symptoms-info|fever-temperature
  * [Text](https://hl7.org/fhir/R4/formats.html#table): If fever, state temperature in degrees
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [decimal](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-decimal)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Enable When:[symptoms-info|symptoms](#item.symptoms-info|symptoms)=
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)catheterization-frequency
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Catheterization Frequency
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-coding.png)catheterization-frequency|frequency
  * [Text](https://hl7.org/fhir/R4/formats.html#table): How many times per day does the patient catheterize?
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [choice](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Options:[4 options](#opt-item.catheterization-frequency|frequency)
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)additional-comments
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Additional Comments
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)additional-comments|comments
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Additional Comment
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-group.png)physician-info
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Physician Information
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [group](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)physician-info|name
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Physician's Name
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)physician-info|mobile
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Telephone
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)physician-info|fax
  * [Text](https://hl7.org/fhir/R4/formats.html#table): FAX
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-attachment.png)physician-info|signature
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Physician's Signature
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [attachment](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-attachment)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)physician-info|phone-referring
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Referring Physician Telephone
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)physician-info|date
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Date
  * [Cardinality](https://hl7.org/fhir/R4/formats.html#table): 0..1
  * [Type](https://hl7.org/fhir/R4/formats.html#table): [string](https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string)
  * [Description & Constraints](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): 
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](data:image/png;base64, )Documentation for this format

-------

**Options Sets**

**Answer options for symptoms-info|symptoms**

* http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Fever ("Fever; state temperature in degree")
* http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#UrinaryUrgencyFrequency ("Change in urinary urgency, frequency, or incontinence")
* http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#AutonomicDysreflexia ("Appearance of new or increase in autonomic dysreflexia")
* http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#PhysicalSignsProstatitis ("Physical signs of prostatitis, epididymitis, orchitis")
* http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Immunosuppressed ("The patient is immunosuppressed")
* http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Pyuria ("Pyuria")
* http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#SystemicLeukocytosis ("Systemic leukocytosis")

**Answer options for catheterization-frequency|frequency**

* http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#2-4Times ("2-4 times")
* http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#4-6Times ("4-6 times")
* http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#6-8Times ("6-8 times")
* http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#8TimesOrMore ("8 times or more")



## Resource Content

```json
{
  "resourceType" : "Questionnaire",
  "id" : "MNACQuestionnaire",
  "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://example.org/fhir/CodeSystem/additionalLaunchContext",
            "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",
  "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" : "boolean"
        },
        {
          "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" : "=",
              "answerBoolean" : 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" : "=",
              "answerBoolean" : 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" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
                "code" : "Fever",
                "display" : "Fever; state temperature in degree"
              }
            },
            {
              "valueCoding" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
                "code" : "UrinaryUrgencyFrequency",
                "display" : "Change in urinary urgency, frequency, or incontinence"
              }
            },
            {
              "valueCoding" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
                "code" : "AutonomicDysreflexia",
                "display" : "Appearance of new or increase in autonomic dysreflexia"
              }
            },
            {
              "valueCoding" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
                "code" : "PhysicalSignsProstatitis",
                "display" : "Physical signs of prostatitis, epididymitis, orchitis"
              }
            },
            {
              "valueCoding" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
                "code" : "Immunosuppressed",
                "display" : "The patient is immunosuppressed"
              }
            },
            {
              "valueCoding" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
                "code" : "Pyuria",
                "display" : "Pyuria"
              }
            },
            {
              "valueCoding" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
                "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" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
                "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" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
                "code" : "2-4Times",
                "display" : "2-4 times"
              }
            },
            {
              "valueCoding" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
                "code" : "4-6Times",
                "display" : "4-6 times"
              }
            },
            {
              "valueCoding" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
                "code" : "6-8Times",
                "display" : "6-8 times"
              }
            },
            {
              "valueCoding" : {
                "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
                "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"
        }
      ]
    }
  ]
}

```
