Da Vinci - Documentation Templates and Rules
2.0.1 - STU 2
Da Vinci - Documentation Templates and Rules
2.0.1 - STU 2
This page is part of the Documentation Templates and Rules (v2.0.1: STU 2.0) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
<Bundle xmlns="http://hl7.org/fhir">
<id value="home-o2-questionnaireresponse-bundle"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/DTR-QRBundle"/>
</meta>
<type value="collection"/>
<entry>
<fullUrl value="http://example.org/home-o2-questionnaireresponse"/>
<resource>
<QuestionnaireResponse>
<id value="home-o2-questionnaireresponse"/>
<meta>
<profile
value="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaireresponse"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: QuestionnaireResponse</b><a name="home-o2-questionnaireresponse"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource QuestionnaireResponse "home-o2-questionnaireresponse" </p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-dtr-questionnaireresponse.html">DTR Questionnaire Response</a></p></div><p><b>Questionnaire Response Context</b>: <a href="Coverage-CoverageExample.html">Coverage/CoverageExample</a></p><p><b>Questionnaire Response Context</b>: <a href="ServiceRequest-ServiceRequestExample.html">ServiceRequest/ServiceRequestExample</a></p><p><b>Intended Use</b>: Include with order <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://build.fhir.org/ig/HL7/davinci-crd//CodeSystem-temp.html">CRD Temporary Codes</a>#withorder)</span></p><p><b>questionnaire</b>: <a href="http://example.com/Questionnaire/referred-questionnaire">http://example.com/Questionnaire/referred-questionnaire</a></p><p><b>status</b>: completed</p><p><b>subject</b>: <a href="Patient-examplepatient.html">Patient/examplepatient: Vlad</a></p><p><b>authored</b>: 2023-08-21</p><blockquote><p><b>item</b></p><p><b>linkId</b>: 1</p><p><b>text</b>: Patient Information</p><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.1</p><p><b>text</b>: Last Name but Different This Time</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.2</p><p><b>text</b>: First Name</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.3</p><p><b>text</b>: Middle Initial</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.4</p><p><b>text</b>: Date Of Birth</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.5</p><p><b>text</b>: Gender</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.6</p><p><b>text</b>: Medicare ID</p><blockquote><p><b>answer</b></p></blockquote></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 2</p><p><b>text</b>: Provider who is performing face-to-face evaluation</p><blockquote><p><b>item</b></p><p><b>linkId</b>: 2.1</p><p><b>text</b>: Last Name</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 2.2</p><p><b>text</b>: First Name</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 2.3</p><p><b>text</b>: Middle Initial</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 2.4</p><p><b>text</b>: NPI</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 2.5</p><p><b>text</b>: Date of Face-To-Face Evaluation</p><blockquote><p><b>answer</b></p></blockquote></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 3</p><p><b>text</b>: Coverage Requirements</p><blockquote><p><b>item</b></p><p><b>linkId</b>: 3.1</p><p><b>text</b>: Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)</p><blockquote><p><b>answer</b></p></blockquote><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 3.2</p><p><b>text</b>: Arterial oxygen saturation (Patient on room air while at rest and awake when tested)</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 3.3</p><p><b>text</b>: Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 3.4</p><p><b>text</b>: Arterial oxygen saturation (Patient tested during exercise)</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 3.5</p><p><b>text</b>: Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 3.6</p><p><b>text</b>: Is there a documented improvement of hypoxemia during exercise with oxygen?</p><blockquote><p><b>answer</b></p></blockquote></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 4</p><p><b>text</b>: Prescribed Use</p><blockquote><p><b>item</b></p><p><b>linkId</b>: 4.1</p><p><b>text</b>: Start date</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 4.2</p><p><b>text</b>: Length of need: (months) (99 = lifetime)</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 4.3</p><p><b>text</b>: Peak Flow Rate</p><blockquote><p><b>item</b></p></blockquote><blockquote><p><b>item</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 4.4</p><p><b>text</b>: Average Flow Rate</p><blockquote><p><b>item</b></p></blockquote><blockquote><p><b>item</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 4.5</p><p><b>text</b>: Frequency of use (choose all that apply)</p><blockquote><p><b>answer</b></p></blockquote></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 5</p><p><b>text</b>: Oxygen Supply Order Details</p><blockquote><p><b>item</b></p><p><b>linkId</b>: 5.1</p><p><b>text</b>: Current Order Description</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 5.1b</p><p><b>text</b>: Current Order Is For A Portable Device</p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 5.2</p><p><b>text</b>: Type</p><blockquote><p><b>answer</b></p></blockquote></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 5.3</p><p><b>text</b>: Means of oxygen delivery and accessories</p><blockquote><p><b>answer</b></p></blockquote></blockquote></blockquote></div>
</text>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context">
<valueReference>🔗
<reference value="Coverage/CoverageExample"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context">
<valueReference>🔗
<reference value="ServiceRequest/ServiceRequestExample"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse">
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/davinci-crd/CodeSystem/temp"/>
<code value="withorder"/>
<display value="Include with order"/>
</coding>
</valueCodeableConcept>
</extension>
<questionnaire
value="http://example.com/Questionnaire/referred-questionnaire"/>
<status value="completed"/>
<subject>🔗
<reference value="Patient/examplepatient"/>
<display value="Vlad"/>
</subject>
<authored value="2023-08-21"/>
<item>
<linkId value="1"/>
<text value="Patient Information"/>
<item>
<linkId value="1.1"/>
<text value="Last Name but Different This Time"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="override"/>
</extension>
<extension url="author">
<extension url="role">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/practitioner-role"/>
<code value="doctor"/>
<display value="Doctor"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="practitioner">
<valueReference>🔗
<reference value="Practitioner/PractitionerExample"/>
<display value="Dr. Jane Doe"/>
</valueReference>
</extension>
</extension>
</extension>
<valueString value="Quinton"/>
</answer>
</item>
<item>
<linkId value="1.2"/>
<text value="First Name"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueString value="Vlad"/>
</answer>
</item>
<item>
<linkId value="1.3"/>
<text value="Middle Initial"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueString value="A, N"/>
</answer>
</item>
<item>
<linkId value="1.4"/>
<text value="Date Of Birth"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueDate value="1956-12-01"/>
</answer>
</item>
<item>
<linkId value="1.5"/>
<text value="Gender"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueCoding>
<system value="http://hl7.org/fhir/administrative-gender"/>
<code value="male"/>
<display value="Male"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="1.6"/>
<text value="Medicare ID"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueString value="10A3D58WH22"/>
</answer>
</item>
</item>
<item>
<linkId value="2"/>
<text value="Provider who is performing face-to-face evaluation"/>
<item>
<linkId value="2.1"/>
<text value="Last Name"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueString value="Doe"/>
</answer>
</item>
<item>
<linkId value="2.2"/>
<text value="First Name"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueString value="Jane"/>
</answer>
</item>
<item>
<linkId value="2.3"/>
<text value="Middle Initial"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueString value="B"/>
</answer>
</item>
<item>
<linkId value="2.4"/>
<text value="NPI"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueString value="1122334455"/>
</answer>
</item>
<item>
<linkId value="2.5"/>
<text value="Date of Face-To-Face Evaluation"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="override"/>
</extension>
<extension url="author">
<extension url="role">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/practitioner-role"/>
<code value="doctor"/>
<display value="Doctor"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="practitioner">
<valueReference>🔗
<reference value="Practitioner/PractitionerExample"/>
<display value="Dr. Jane Doe"/>
</valueReference>
</extension>
</extension>
</extension>
<valueDate value="2019-07-18"/>
</answer>
</item>
</item>
<item>
<linkId value="3"/>
<text value="Coverage Requirements"/>
<item>
<linkId value="3.1"/>
<text
value="Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueCoding>
<system value="http://snomed.info/sct"/>
<code value="313296004"/>
<display value="Mild chronic obstructive pulmonary disease"/>
</valueCoding>
</answer>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueCoding>
<system value="http://snomed.info/sct"/>
<code value="389087006"/>
<display value="Hypoxemia (disorder)"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="3.2"/>
<text
value="Arterial oxygen saturation (Patient on room air while at rest and awake when tested)"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueQuantity>
<value value="95"/>
<system value="http://unitsofmeasure.org"/>
<code value="mm[Hg]"/>
</valueQuantity>
</answer>
</item>
<item>
<linkId value="3.3"/>
<text
value="Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueQuantity>
<value value="83"/>
<system value="http://unitsofmeasure.org"/>
<code value="mm[Hg]"/>
</valueQuantity>
</answer>
</item>
<item>
<linkId value="3.4"/>
<text
value="Arterial oxygen saturation (Patient tested during exercise)"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueQuantity>
<value value="95"/>
<system value="http://unitsofmeasure.org"/>
<code value="mm[Hg]"/>
</valueQuantity>
</answer>
</item>
<item>
<linkId value="3.5"/>
<text
value="Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueQuantity>
<value value="78"/>
<system value="http://unitsofmeasure.org"/>
<code value="mm[Hg]"/>
</valueQuantity>
</answer>
</item>
<item>
<linkId value="3.6"/>
<text
value="Is there a documented improvement of hypoxemia during exercise with oxygen?"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueBoolean value="true"/>
</answer>
</item>
</item>
<item>
<linkId value="4"/>
<text value="Prescribed Use"/>
<item>
<linkId value="4.1"/>
<text value="Start date"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueDate value="2019-07-18"/>
</answer>
</item>
<item>
<linkId value="4.2"/>
<text value="Length of need: (months) (99 = lifetime)"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueQuantity>
<value value="99"/>
</valueQuantity>
</answer>
</item>
<item>
<linkId value="4.3"/>
<text value="Peak Flow Rate"/>
<item>
<linkId value="4.3.1"/>
<text value="LPM"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueInteger value="2"/>
</answer>
</item>
<item>
<linkId value="4.3.2"/>
<text value="oxygen %"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueInteger value="98"/>
</answer>
</item>
</item>
<item>
<linkId value="4.4"/>
<text value="Average Flow Rate"/>
<item>
<linkId value="4.4.1"/>
<text value="LPM"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueInteger value="2"/>
</answer>
</item>
<item>
<linkId value="4.4.2"/>
<text value="oxygen %"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueInteger value="97"/>
</answer>
</item>
</item>
<item>
<linkId value="4.5"/>
<text value="Frequency of use (choose all that apply)"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueCoding>
<system value="http://example.org"/>
<code value="2112"/>
<display value="At rest and awake"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="5"/>
<text value="Oxygen Supply Order Details"/>
<item>
<linkId value="5.1"/>
<text value="Current Order Description"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueString
value="HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental"/>
</answer>
</item>
<item>
<linkId value="5.1b"/>
<text value="Current Order Is For A Portable Device"/>
</item>
<item>
<linkId value="5.2"/>
<text value="Type"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueCoding>
<system value="http://example.org"/>
<code value="122"/>
<display value="Compressed Gas"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="5.3"/>
<text value="Means of oxygen delivery and accessories"/>
<answer>
<extension
url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin">
<extension url="source">
<valueCode value="auto"/>
</extension>
</extension>
<valueCoding>
<system value="http://example.org"/>
<code value="134"/>
<display value="Mask"/>
</valueCoding>
</answer>
</item>
</item>
</QuestionnaireResponse>
</resource>
</entry>
</Bundle>
IG © 2022+ HL7 International / Clinical Decision Support. Package hl7.fhir.us.davinci-dtr#2.0.1 based on FHIR 4.0.1. Generated 2024-01-11
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