This page is part of the Documentation Templates and Rules (v2.1.0-preview: QA Preview) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.1. For a full list of available versions, see the Directory of published versions
Page standards status: Informative |
Generated Narrative: QuestionnaireResponse home-o2-questionnaireresponse
LinkID | Text | Definition | Answer |
---|---|---|---|
![]() ![]() | Questionnaire:http://example.com/Questionnaire/referred-questionnaire | ||
![]() ![]() ![]() | Patient Information | ||
![]() ![]() ![]() ![]() | Last Name but Different This Time | Quinton | |
![]() ![]() ![]() ![]() | First Name | Vlad | |
![]() ![]() ![]() ![]() | Middle Initial | A, N | |
![]() ![]() ![]() ![]() | Date Of Birth | 1956-12-01 | |
![]() ![]() ![]() ![]() | Gender | AdministrativeGender male: Male | |
![]() ![]() ![]() ![]() | Medicare ID | 10A3D58WH22 | |
![]() ![]() ![]() | Provider who is performing face-to-face evaluation | ||
![]() ![]() ![]() ![]() | Last Name | Doe | |
![]() ![]() ![]() ![]() | First Name | Jane | |
![]() ![]() ![]() ![]() | Middle Initial | B | |
![]() ![]() ![]() ![]() | NPI | 1122334455 | |
![]() ![]() ![]() ![]() | Date of Face-To-Face Evaluation | 2019-07-18 | |
![]() ![]() ![]() | Coverage Requirements | ||
![]() ![]() ![]() ![]() | Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy) | ||
![]() ![]() ![]() ![]() | Arterial oxygen saturation (Patient on room air while at rest and awake when tested) | 95 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]') | |
![]() ![]() ![]() ![]() | Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested) | 83 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]') | |
![]() ![]() ![]() ![]() | Arterial oxygen saturation (Patient tested during exercise) | 95 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]') | |
![]() ![]() ![]() ![]() | Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise) | 78 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]') | |
![]() ![]() ![]() ![]() | Is there a documented improvement of hypoxemia during exercise with oxygen? | true | |
![]() ![]() ![]() | Prescribed Use | ||
![]() ![]() ![]() ![]() | Start date | 2019-07-18 | |
![]() ![]() ![]() ![]() | Length of need: (months) (99 = lifetime) | 99 | |
![]() ![]() ![]() ![]() | Peak Flow Rate | ||
![]() ![]() ![]() ![]() ![]() | LPM | 2 | |
![]() ![]() ![]() ![]() ![]() | oxygen % | 98 | |
![]() ![]() ![]() ![]() | Average Flow Rate | ||
![]() ![]() ![]() ![]() ![]() | LPM | 2 | |
![]() ![]() ![]() ![]() ![]() | oxygen % | 97 | |
![]() ![]() ![]() ![]() | Frequency of use (choose all that apply) | example.org 2112: At rest and awake | |
![]() ![]() ![]() | Oxygen Supply Order Details | ||
![]() ![]() ![]() ![]() | Current Order Description | HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental | |
![]() ![]() ![]() ![]() | Current Order Is For A Portable Device | ||
![]() ![]() ![]() ![]() | Type | example.org 122: Compressed Gas | |
![]() ![]() ![]() ![]() | Means of oxygen delivery and accessories | example.org 134: Mask | |