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

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Raw json

{
  "resourceType" : "QuestionnaireResponse",
  "id" : "home-o2-questionnaireresponse-stu3",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-dtr/STU3/StructureDefinition/dtr-questionnaireresponse-stu3"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This completed form contains all of the information collected from the provider on Home Oxygen Therapy.</p></div>"
  },
  "contained" : [
    {
      "resourceType" : "Patient",
      "id" : "example1",
      "gender" : "male",
      "birthDate" : "1996-12-23",
      "address" : [
        {
          "use" : "home",
          "type" : "both",
          "state" : "MA"
        }
      ]
    }
  ],
  "questionnaire" : {
    "display" : "Questionnaire/q045"
  },
  "status" : "completed",
  "subject" : {
    "reference" : "#example1",
    "display" : "Vlad"
  },
  "authored" : "2019-07-18",
  "item" : [
    {
      "linkId" : "1",
      "text" : "Patient Information",
      "item" : [
        {
          "linkId" : "1.1",
          "text" : "Last Name but Different This Time",
          "answer" : [
            {
              "valueString" : "Quinton"
            }
          ]
        },
        {
          "linkId" : "1.2",
          "text" : "First Name",
          "answer" : [
            {
              "valueString" : "Vlad"
            }
          ]
        },
        {
          "linkId" : "1.3",
          "text" : "Middle Initial",
          "answer" : [
            {
              "valueString" : "A, N"
            }
          ]
        },
        {
          "linkId" : "1.4",
          "text" : "Date Of Birth",
          "answer" : [
            {
              "valueDate" : "1956-12-01"
            }
          ]
        },
        {
          "linkId" : "1.5",
          "text" : "Gender",
          "answer" : [
            {
              "valueCoding" : {
                "code" : "male",
                "display" : "Male"
              }
            }
          ]
        },
        {
          "linkId" : "1.6",
          "text" : "Medicare ID",
          "answer" : [
            {
              "valueString" : "10A3D58WH22"
            }
          ]
        }
      ]
    },
    {
      "linkId" : "2",
      "text" : "Provider who is performing face-to-face evaluation",
      "item" : [
        {
          "linkId" : "2.1",
          "text" : "Last Name",
          "answer" : [
            {
              "valueString" : "Doe"
            }
          ]
        },
        {
          "linkId" : "2.2",
          "text" : "First Name",
          "answer" : [
            {
              "valueString" : "Jane"
            }
          ]
        },
        {
          "linkId" : "2.3",
          "text" : "Middle Initial",
          "answer" : [
            {
              "valueString" : "B"
            }
          ]
        },
        {
          "linkId" : "2.4",
          "text" : "NPI",
          "answer" : [
            {
              "valueString" : "1122334455"
            }
          ]
        },
        {
          "linkId" : "2.5",
          "text" : "Date of Face-To-Face Evaluation",
          "answer" : [
            {
              "valueDate" : "2019-07-18"
            }
          ]
        }
      ]
    },
    {
      "linkId" : "3",
      "text" : "Coverage Requirements",
      "item" : [
        {
          "linkId" : "3.1",
          "text" : "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)",
          "answer" : [
            {
              "valueCoding" : {
                "code" : "COPD",
                "display" : "COPD"
              }
            },
            {
              "valueCoding" : {
                "code" : "Hypoxemia",
                "display" : "Hypoxemia"
              }
            }
          ]
        },
        {
          "linkId" : "3.2",
          "text" : "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)"
        },
        {
          "linkId" : "3.3",
          "text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)"
        },
        {
          "linkId" : "3.4",
          "text" : "Arterial oxygen saturation (Patient tested during exercise)"
        },
        {
          "linkId" : "3.5",
          "text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)"
        },
        {
          "linkId" : "3.6",
          "text" : "Is there a documented improvement of hypoxemia during exercise with oxygen?"
        }
      ]
    },
    {
      "linkId" : "4",
      "text" : "Prescribed Use",
      "item" : [
        {
          "linkId" : "4.1",
          "text" : "Start date",
          "answer" : [
            {
              "valueDate" : "2019-07-18"
            }
          ]
        },
        {
          "linkId" : "4.2",
          "text" : "Length of need: (months) (99 = lifetime)",
          "answer" : [
            {
              "valueInteger" : 99
            }
          ]
        },
        {
          "linkId" : "4.4",
          "text" : "Peak Flow Rate",
          "item" : [
            {
              "linkId" : "4.4.1",
              "text" : "LPM",
              "answer" : [
                {
                  "valueInteger" : 2
                }
              ]
            },
            {
              "linkId" : "4.4.2",
              "text" : "oxygen %",
              "answer" : [
                {
                  "valueInteger" : 98
                }
              ]
            }
          ]
        },
        {
          "linkId" : "4.5",
          "text" : "Average Flow Rate",
          "item" : [
            {
              "linkId" : "4.5.1",
              "text" : "LPM",
              "answer" : [
                {
                  "valueInteger" : 2
                }
              ]
            },
            {
              "linkId" : "4.5.2",
              "text" : "oxygen %",
              "answer" : [
                {
                  "valueInteger" : 97
                }
              ]
            }
          ]
        },
        {
          "linkId" : "4.6",
          "text" : "Frequency of use (choose all that apply)",
          "answer" : [
            {
              "valueCoding" : {
                "code" : "At rest and awake",
                "display" : "At rest and awake"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId" : "5",
      "text" : "Oxygen Supply Order Details",
      "item" : [
        {
          "linkId" : "5.1",
          "text" : "Current Order Description",
          "answer" : [
            {
              "valueString" : "HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental"
            }
          ]
        },
        {
          "linkId" : "5.1b",
          "text" : "Current Order Is For A Portable Device"
        },
        {
          "linkId" : "5.2",
          "text" : "Type",
          "answer" : [
            {
              "valueCoding" : {
                "code" : "Compressed Gas",
                "display" : "Compressed Gas"
              }
            }
          ]
        },
        {
          "linkId" : "5.3",
          "text" : "Means of oxygen delivery and accessories",
          "answer" : [
            {
              "valueCoding" : {
                "code" : "Mask",
                "display" : "Mask"
              }
            },
            {
              "valueCoding" : {
                "code" : "Ventilator",
                "display" : "Ventilator"
              }
            }
          ]
        },
        {
          "linkId" : "5.4",
          "text" : "Type of order",
          "answer" : [
            {
              "valueCoding" : {
                "code" : "Initial or original order for certification",
                "display" : "Initial or original order for certification"
              }
            }
          ]
        }
      ]
    }
  ]
}