This page is part of the Documentation Templates and Rules (v1.0.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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: DTR Home Oxygen Therapy Questionnaire - R4 - JSON Representation

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{
  "resourceType" : "Questionnaire",
  "id" : "home-o2-questionnaire",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaire-r4"
    ]
  },
  "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>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-library",
      "valueCanonical" : "#HomeOxygenTherapy-prepopulation"
    }
  ],
  "url" : "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/home-o2-questionnaire",
  "version" : "1.0.0",
  "name" : "HomeOxygenTherapyQuestionnaire",
  "title" : "Home Oxygen Therapy Order Template",
  "status" : "draft",
  "subjectType" : [
    "Patient"
  ],
  "date" : "2019-03-11T00:00:00+00:00",
  "publisher" : "HL7 Clinical Decision Support Work Group",
  "contact" : [
    {
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/dss"
        }
      ]
    }
  ],
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US"
        }
      ]
    }
  ],
  "item" : [
    {
      "linkId" : "1",
      "text" : "Patient Information",
      "type" : "group",
      "item" : [
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/StructureDefinition/cqf-expression",
              "valueExpression" : {
                "language" : "text/cql",
                "expression" : "PatientLastName"
              }
            }
          ],
          "linkId" : "1.1",
          "text" : "Last Name",
          "type" : "string",
          "required" : true
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/StructureDefinition/cqf-expression",
              "valueExpression" : {
                "language" : "text/cql",
                "expression" : "PatientMiddleInitial"
              }
            }
          ],
          "linkId" : "1.3",
          "text" : "Middle Initial",
          "type" : "text",
          "required" : false
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/StructureDefinition/cqf-expression",
              "valueExpression" : {
                "language" : "text/cql",
                "expression" : "PatientFirstName"
              }
            }
          ],
          "linkId" : "1.2",
          "text" : "First Name",
          "type" : "string",
          "enableWhen" : [
            {
              "question" : "1.3",
              "operator" : "=",
              "answerString" : "S"
            }
          ],
          "required" : true
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/StructureDefinition/cqf-expression",
              "valueExpression" : {
                "language" : "text/cql",
                "expression" : "PatientDateOfBirth"
              }
            }
          ],
          "linkId" : "1.4",
          "text" : "Date Of Birth",
          "type" : "date",
          "required" : true
        },
        {
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/StructureDefinition/cqf-expression",
              "valueExpression" : {
                "language" : "text/cql",
                "expression" : "PatientGender"
              }
            }
          ],
          "linkId" : "1.5",
          "text" : "Gender",
          "type" : "choice",
          "required" : true,
          "answerValueSet" : "http://hl7.org/fhir/ValueSet/administrative-gender"
        }
      ]
    }
  ]
}