This page is part of the Documentation Templates and Rules (v1.1.0-ballot: STU 1.1 Ballot 1) 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

• Narrative Content
• JSON

Example QuestionnaireResponse: home-o2-questionnaireresponse

LinkId	Text	Definition	Answer
home-o2-questionnaireresponse		QuestionnaireResponse
1	Patient Information
1.1	Last Name but Different This Time		Quinton
1.2	First Name		Vlad
1.3	Middle Initial		A, N
1.4	Date Of Birth		1956-12-01
1.5	Gender		http://hl7.org/fhir/administrative-gender male: Male
1.6	Medicare ID		10A3D58WH22
2	Provider who is performing face-to-face evaluation
2.1	Last Name		Doe
2.2	First Name		Jane
2.3	Middle Initial		B
2.4	NPI		1122334455
2.5	Date of Face-To-Face Evaluation		2019-07-18
3	Coverage Requirements
3.1	Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)
3.2	Arterial oxygen saturation (Patient on room air while at rest and awake when tested)		95 mm[Hg]
3.3	Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)		83 mm[Hg]
3.4	Arterial oxygen saturation (Patient tested during exercise)		95 mm[Hg]
3.5	Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)		78 mm[Hg]
3.6	Is there a documented improvement of hypoxemia during exercise with oxygen?		true
4	Prescribed Use
4.1	Start date		2019-07-18
4.2	Length of need: (months) (99 = lifetime)		99
4.3	Peak Flow Rate
4.3.1	LPM		2
4.3.2	oxygen %		98
4.4	Average Flow Rate
4.4.1	LPM		2
4.4.2	oxygen %		97
4.5	Frequency of use (choose all that apply)		[not stated] At rest and awake: At rest and awake
5	Oxygen Supply Order Details
5.1	Current Order Description		HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental
5.1b	Current Order Is For A Portable Device
5.2	Type		http://example.org 122: Compressed Gas
5.3	Means of oxygen delivery and accessories		http://example.org 134: Mask
Documentation for this format