3.0.1 - STU Ballot
This page is part of the Documentation Templates and Rules (v0.2.0: STU 1 Ballot 2) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
{
"resourceType" : "Questionnaire",
"id" : "home-o2-questionnaire-stu3",
"meta" : {
"profile" : [
"http://hl7.org/fhir/us/davinci-dtr/STU3/StructureDefinition/dtr-questionnaire-stu3"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This form is used to collect information from the provider on Home Oxygen Therapy.</p></div>"
},
"contained" : [
{
"resourceType" : "ValueSet",
"id" : "gender",
"name" : "Gender",
"status" : "draft",
"description" : "Gender",
"compose" : {
"include" : [
{
"system" : "http://hl7.org/fhir/ValueSet/administrative-gender",
"concept" : [
{
"code" : "male",
"display" : "Male"
},
{
"code" : "female",
"display" : "Female"
},
{
"code" : "other",
"display" : "Other"
}
]
}
]
}
},
{
"resourceType" : "Library",
"id" : "library-oxygen-therapy-prepopulate",
"status" : "active",
"type" : {
"coding" : [
{
"code" : "logic-library"
}
]
}
}
],
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-library",
"valueReference" : {
"reference" : "#library-oxygen-therapy-prepopulate"
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-dtr/STU3/Questionnaire/home-o2-questionnaire-stu3",
"version" : "3.0.1",
"title" : "Home Oxygen Therapy",
"status" : "draft",
"date" : "2019-03-11T00:00:00-04:00",
"publisher" : "Da Vinci DTR",
"contact" : [
{
"name" : "example author"
}
],
"subjectType" : [
"Patient"
],
"item" : [
{
"linkId" : "1",
"text" : "Patient Information",
"type" : "group",
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "PatientLastName"
}
],
"linkId" : "1.1",
"text" : "Last Name",
"type" : "string",
"required" : true
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "PatientFirstName"
}
],
"linkId" : "1.2",
"text" : "First Name",
"type" : "string",
"required" : true
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "PatientMiddleInitial"
}
],
"linkId" : "1.3",
"text" : "Middle Initial",
"type" : "string",
"required" : true
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "PatientDateOfBirth"
}
],
"linkId" : "1.4",
"text" : "Date Of Birth",
"type" : "date",
"required" : true
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "PatientGender"
}
],
"linkId" : "1.5",
"text" : "Gender",
"type" : "choice",
"required" : true,
"options" : {
"reference" : "#gender"
}
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "PatientMedicareId"
}
],
"linkId" : "1.6",
"text" : "Medicare ID",
"type" : "string",
"required" : true
}
]
},
{
"linkId" : "2",
"text" : "Provider who is performing face-to-face evaluation",
"type" : "group",
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "OrderingProviderLastName"
}
],
"linkId" : "2.1",
"text" : "Last Name",
"type" : "string",
"required" : true
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "OrderingProviderFirstName"
}
],
"linkId" : "2.2",
"text" : "First Name",
"type" : "string",
"required" : true
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "OrderingProviderMiddleInitial"
}
],
"linkId" : "2.3",
"text" : "Middle Initial",
"type" : "string",
"required" : true
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "OrderingProviderNPI"
}
],
"linkId" : "2.4",
"text" : "NPI",
"type" : "string",
"required" : true
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "Today"
}
],
"linkId" : "2.5",
"text" : "Date of Face-To-Face Evaluation",
"type" : "date",
"required" : true
}
]
},
{
"linkId" : "3",
"text" : "Coverage Requirements",
"type" : "group",
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "RelevantDiagnoses"
}
],
"linkId" : "3.1",
"text" : "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)",
"type" : "open-choice",
"required" : true,
"repeats" : true,
"option" : [
{
"valueCoding" : {
"code" : "COPD"
}
},
{
"valueCoding" : {
"code" : "Bronchiectasis"
}
},
{
"valueCoding" : {
"code" : "Hypoxemia"
}
},
{
"valueCoding" : {
"code" : "Diffuse interstitial lung disease"
}
},
{
"valueCoding" : {
"code" : "Cystic fibrosis"
}
},
{
"valueCoding" : {
"code" : "Pulmonary neoplasm"
}
},
{
"valueCoding" : {
"code" : "Erythrocytosis"
}
},
{
"valueCoding" : {
"code" : "Pulmonary hypertension"
}
},
{
"valueCoding" : {
"code" : "Recurring CHF d/t Cor Pulmonale"
}
}
]
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "ArterialOxygenSaturation"
}
],
"linkId" : "3.2",
"text" : "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)",
"type" : "quantity",
"required" : false
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "ArterialPartialPressureOfOxygen"
}
],
"linkId" : "3.3",
"text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)",
"type" : "quantity",
"required" : false
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "ArterialOxygenSaturationExercise"
}
],
"linkId" : "3.4",
"text" : "Arterial oxygen saturation (Patient tested during exercise)",
"type" : "quantity",
"required" : false
},
{
"linkId" : "3.5",
"text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)",
"type" : "quantity",
"required" : false
},
{
"linkId" : "3.6",
"text" : "Is there a documented improvement of hypoxemia during exercise with oxygen?",
"type" : "boolean",
"required" : false
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "PatientMobile"
}
],
"linkId" : "3.7",
"text" : "Is the patient mobile within the home?",
"type" : "boolean",
"enableWhen" : [
{
"question" : "5.1b",
"answerBoolean" : true
}
],
"required" : false
},
{
"linkId" : "3.8",
"text" : "Does the patient have dependent edema due to congestive heart failure?",
"type" : "boolean",
"enableWhen" : [
{
"question" : "3.2",
"answerQuantity" : {
"value" : 89,
"unit" : "%"
}
}
],
"required" : false
},
{
"linkId" : "3.9",
"text" : "Does the patient have cor pulmonale or pulmonary hypertension documented by P pulmonale on an EKG or by an echocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement?",
"type" : "boolean",
"enableWhen" : [
{
"question" : "3.2",
"answerQuantity" : {
"value" : 89,
"unit" : "%"
}
}
],
"required" : false
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "PatientHasHematocritThatIsGreaterThanThreshold"
}
],
"linkId" : "3.10",
"text" : "Does the patient have a hematocrit greater than 56%?",
"type" : "boolean",
"enableWhen" : [
{
"question" : "3.2",
"answerQuantity" : {
"value" : 89,
"unit" : "%"
}
}
],
"required" : false
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "HematocritThatIsGreaterThanThreshold"
}
],
"linkId" : "3.11",
"text" : "Recent hematocrit result",
"type" : "quantity",
"enableWhen" : [
{
"question" : "3.10",
"answerBoolean" : true
}
],
"required" : false
}
]
},
{
"linkId" : "4",
"text" : "Prescribed Use",
"type" : "group",
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "Today"
}
],
"linkId" : "4.1",
"text" : "Start date",
"type" : "date",
"required" : true
},
{
"linkId" : "4.2",
"text" : "Length of need: (months) (99 = lifetime)",
"type" : "integer",
"required" : false
},
{
"linkId" : "4.4",
"text" : "Peak Flow Rate",
"type" : "group",
"item" : [
{
"linkId" : "4.4.1",
"text" : "LPM",
"type" : "integer",
"required" : true
},
{
"linkId" : "4.4.2",
"text" : "oxygen %",
"type" : "integer",
"required" : true
}
]
},
{
"linkId" : "4.4b",
"text" : "Since > 4 LPM prescribed, enter arterial oxygen saturation or PO2 while patient was on 4 LPM in stable state.",
"type" : "quantity",
"enableWhen" : [
{
"question" : "4.4.1",
"answerInteger" : 4
}
],
"required" : true
},
{
"linkId" : "4.5",
"text" : "Average Flow Rate",
"type" : "group",
"item" : [
{
"linkId" : "4.5.1",
"text" : "LPM",
"type" : "integer",
"required" : true
},
{
"linkId" : "4.5.2",
"text" : "oxygen %",
"type" : "integer",
"required" : true
}
]
},
{
"linkId" : "4.6",
"text" : "Frequency of use (choose all that apply)",
"type" : "open-choice",
"required" : true,
"repeats" : true,
"option" : [
{
"valueCoding" : {
"code" : "At rest and awake"
}
},
{
"valueCoding" : {
"code" : "During exertion"
}
},
{
"valueCoding" : {
"code" : "During sleep"
}
}
]
}
]
},
{
"linkId" : "5",
"text" : "Oxygen Supply Order Details",
"type" : "group",
"item" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "DeviceRequestDescription"
}
],
"linkId" : "5.1",
"text" : "Current Order Description",
"type" : "string",
"readOnly" : true
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString" : "DeviceRequestedIsPortable"
}
],
"linkId" : "5.1b",
"text" : "Current Order Is For A Portable Device",
"type" : "boolean",
"readOnly" : true
},
{
"linkId" : "5.2",
"text" : "Type",
"type" : "choice",
"required" : true,
"option" : [
{
"valueCoding" : {
"code" : "Liquid"
}
},
{
"valueCoding" : {
"code" : "Compressed Gas"
}
},
{
"valueCoding" : {
"code" : "Concentrator"
}
}
]
},
{
"linkId" : "5.3",
"text" : "Means of oxygen delivery and accessories",
"type" : "open-choice",
"required" : true,
"repeats" : true,
"option" : [
{
"valueCoding" : {
"code" : "Nasal cannula"
}
},
{
"valueCoding" : {
"code" : "Non-rebreather"
}
},
{
"valueCoding" : {
"code" : "Ventilator"
}
},
{
"valueCoding" : {
"code" : "Mask"
}
},
{
"valueCoding" : {
"code" : "PAP bleed in"
}
},
{
"valueCoding" : {
"code" : "Oxygen conserving device"
}
},
{
"valueCoding" : {
"code" : "High flow oxygen therapy"
}
}
]
},
{
"linkId" : "5.4",
"text" : "Type of order",
"type" : "choice",
"required" : true,
"option" : [
{
"valueCoding" : {
"code" : "Initial or original order for certification"
}
},
{
"valueCoding" : {
"code" : "Change in status"
}
},
{
"valueCoding" : {
"code" : "Revision or change in equipment"
}
},
{
"valueCoding" : {
"code" : "Replacement"
}
}
]
},
{
"linkId" : "5.5",
"text" : "Reason for Change in Status",
"type" : "open-choice",
"enableWhen" : [
{
"question" : "5.4",
"answerCoding" : {
"code" : "Change in status"
}
}
],
"required" : true,
"option" : [
{
"valueCoding" : {
"code" : "Patient relocated"
}
},
{
"valueCoding" : {
"code" : "Different supplier"
}
}
]
},
{
"linkId" : "5.6",
"text" : "Reason for Revision or change in equipment",
"type" : "open-choice",
"enableWhen" : [
{
"question" : "5.4",
"answerCoding" : {
"code" : "Revision or change in equipment"
}
}
],
"required" : true,
"option" : [
{
"valueCoding" : {
"code" : "New Physician order"
}
},
{
"valueCoding" : {
"code" : "Beneficiary requested upgrade with signed ABN"
}
}
]
},
{
"linkId" : "5.7",
"text" : "Reason for Replacement",
"type" : "open-choice",
"enableWhen" : [
{
"question" : "5.4",
"answerCoding" : {
"code" : "Replacement"
}
}
],
"required" : true,
"option" : [
{
"valueCoding" : {
"code" : "Lost or stolen"
}
},
{
"valueCoding" : {
"code" : "End of lifetime"
}
},
{
"valueCoding" : {
"code" : "Repair exceeds 60% of cost"
}
}
]
}
]
}
]
}
IG © 2019 HL7 Clinical Decision Support Work Group. Package hl7.fhir.us.davinci-dtr#3.0.1 based on FHIR 3.0.1. Generated 2019-08-06
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