Da Vinci - Documentation Templates and Rules
2.1.0 - STU 2.1
Da Vinci - Documentation Templates and Rules
2.1.0 - STU 2.1
This page is part of the Documentation Templates and Rules (v2.1.0: STU 2.1) 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
| Page standards status: Informative |
{
"resourceType" : "Questionnaire",
"id" : "referred-questionnaire",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Example adaptive questionnaire contained in a QuestionnaireResposne</div>"
},
"url" : "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire",
"version" : "2.1.0",
"title" : "Referred Questionnaire for QuestionnaireResponse",
"derivedFrom" : [
🔗 "http://hl7.org/fhir/us/davinci-dtr/dtr-base-questionnaire"
],
"status" : "active",
"subjectType" : [
"Patient"
],
"date" : "2023-08-21T00:00:00+00:00",
"publisher" : "HL7 International / Clinical Decision Support",
"contact" : [
{
"name" : "HL7 International / Clinical Decision Support",
"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" : [
{
"linkId" : "1.1",
"text" : "Last Name but Different This Time",
"type" : "text"
},
{
"linkId" : "1.2",
"text" : "First Name",
"type" : "text"
},
{
"linkId" : "1.3",
"text" : "Middle Initial",
"type" : "text"
},
{
"linkId" : "1.4",
"text" : "Date Of Birth",
"type" : "date"
},
{
"linkId" : "1.5",
"text" : "Gender",
"type" : "choice",
"answerValueSet" : "http://hl7.org/fhir/ValueSet/administrative-gender"
},
{
"linkId" : "1.6",
"text" : "Medicare ID",
"type" : "text"
}
]
},
{
"linkId" : "2",
"text" : "Provider who is performing face-to-face evaluation",
"type" : "group",
"item" : [
{
"linkId" : "2.1",
"text" : "Last Name",
"type" : "text"
},
{
"linkId" : "2.2",
"text" : "First Name",
"type" : "text"
},
{
"linkId" : "2.3",
"text" : "Middle Initial",
"type" : "text"
},
{
"linkId" : "2.4",
"text" : "NPI",
"type" : "text"
},
{
"linkId" : "2.5",
"text" : "Date of Face-To-Face Evaluation",
"type" : "date"
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
"valueCode" : "Patient"
}
],
"linkId" : "2.6",
"text" : "Record",
"type" : "reference",
"required" : true
}
]
},
{
"linkId" : "3",
"text" : "Coverage Requirements",
"type" : "group",
"item" : [
{
"linkId" : "3.1",
"text" : "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)",
"type" : "choice",
"answerOption" : [
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "313296004",
"display" : "Mild chronic obstructive pulmonary disease"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "389087006",
"display" : "Hypoxemia (disorder)"
}
}
]
},
{
"linkId" : "3.2",
"text" : "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)",
"type" : "quantity"
},
{
"linkId" : "3.3",
"text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)",
"type" : "quantity"
},
{
"linkId" : "3.4",
"text" : "Arterial oxygen saturation (Patient tested during exercise)",
"type" : "quantity"
},
{
"linkId" : "3.5",
"text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)",
"type" : "quantity"
},
{
"linkId" : "3.6",
"text" : "Is there a documented improvement of hypoxemia during exercise with oxygen?",
"type" : "boolean"
}
]
},
{
"linkId" : "4",
"text" : "Prescribed Use",
"type" : "group",
"item" : [
{
"linkId" : "4.1",
"text" : "Start date",
"type" : "date"
},
{
"linkId" : "4.2",
"text" : "Length of need: (months) (99 = lifetime)",
"type" : "quantity"
},
{
"linkId" : "4.3",
"text" : "Peak Flow Rate",
"type" : "group",
"item" : [
{
"linkId" : "4.3.1",
"text" : "LPM",
"type" : "quantity"
},
{
"linkId" : "4.3.2",
"text" : "oxygen %",
"type" : "quantity"
}
]
},
{
"linkId" : "4.4",
"text" : "Average Flow Rate",
"type" : "group",
"item" : [
{
"linkId" : "4.4.1",
"text" : "LPM",
"type" : "quantity"
},
{
"linkId" : "4.4.2",
"text" : "oxygen %",
"type" : "quantity"
}
]
},
{
"linkId" : "4.5",
"text" : "Frequency of use (choose all that apply)",
"type" : "text"
}
]
},
{
"linkId" : "5",
"text" : "Oxygen Supply Order Details",
"type" : "group",
"item" : [
{
"linkId" : "5.1",
"text" : "Current Order Description",
"type" : "text"
},
{
"linkId" : "5.1b",
"text" : "Current Order Is For A Portable Device",
"type" : "boolean"
},
{
"linkId" : "5.2",
"text" : "Type",
"type" : "choice",
"answerOption" : [
{
"valueCoding" : {
"system" : "http://example.org",
"code" : "121",
"display" : "Liquid"
}
},
{
"valueCoding" : {
"system" : "http://example.org",
"code" : "122",
"display" : "Compressed Gas"
}
},
{
"valueCoding" : {
"system" : "http://example.org",
"code" : "123",
"display" : "Concentrator"
}
}
]
},
{
"linkId" : "5.3",
"text" : "Means of oxygen delivery and accessories",
"type" : "choice",
"answerOption" : [
{
"valueCoding" : {
"system" : "http://example.org",
"code" : "131",
"display" : "Nasal cannula"
}
},
{
"valueCoding" : {
"system" : "http://example.org",
"code" : "132",
"display" : "Non-rebreather"
}
},
{
"valueCoding" : {
"system" : "http://example.org",
"code" : "133",
"display" : "Ventilator"
}
},
{
"valueCoding" : {
"system" : "http://example.org",
"code" : "134",
"display" : "Mask"
}
},
{
"valueCoding" : {
"system" : "http://example.org",
"code" : "135",
"display" : "PAP bleed in"
}
},
{
"valueCoding" : {
"system" : "http://example.org",
"code" : "136",
"display" : "Oxygen conserving device"
}
},
{
"valueCoding" : {
"system" : "http://example.org",
"code" : "137",
"display" : "High flow oxygen therapy"
}
}
]
}
]
}
]
}
IG © 2022+ HL7 International / Clinical Decision Support. Package hl7.fhir.us.davinci-dtr#2.1.0 based on FHIR 4.0.1. Generated 2024-12-21
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