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 |
<Questionnaire xmlns="http://hl7.org/fhir">
<id value="referred-questionnaire"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">Example adaptive questionnaire contained in a QuestionnaireResposne</div>
</text>
<url
value="http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire"/>
<version value="2.1.0"/>
<title value="Referred Questionnaire for QuestionnaireResponse"/>
<derivedFrom
value="http://hl7.org/fhir/us/davinci-dtr/dtr-base-questionnaire"/>
<status value="active"/>
<subjectType value="Patient"/>
<date value="2023-08-21T00:00:00+00:00"/>
<publisher value="HL7 International / Clinical Decision Support"/>
<contact>
<name value="HL7 International / Clinical Decision Support"/>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/dss"/>
</telecom>
</contact>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="US"/>
</coding>
</jurisdiction>
<item>
<linkId value="1"/>
<text value="Patient Information"/>
<type value="group"/>
<item>
<linkId value="1.1"/>
<text value="Last Name but Different This Time"/>
<type value="text"/>
</item>
<item>
<linkId value="1.2"/>
<text value="First Name"/>
<type value="text"/>
</item>
<item>
<linkId value="1.3"/>
<text value="Middle Initial"/>
<type value="text"/>
</item>
<item>
<linkId value="1.4"/>
<text value="Date Of Birth"/>
<type value="date"/>
</item>
<item>
<linkId value="1.5"/>
<text value="Gender"/>
<type value="choice"/>
<answerValueSet
value="http://hl7.org/fhir/ValueSet/administrative-gender"/>
</item>
<item>
<linkId value="1.6"/>
<text value="Medicare ID"/>
<type value="text"/>
</item>
</item>
<item>
<linkId value="2"/>
<text value="Provider who is performing face-to-face evaluation"/>
<type value="group"/>
<item>
<linkId value="2.1"/>
<text value="Last Name"/>
<type value="text"/>
</item>
<item>
<linkId value="2.2"/>
<text value="First Name"/>
<type value="text"/>
</item>
<item>
<linkId value="2.3"/>
<text value="Middle Initial"/>
<type value="text"/>
</item>
<item>
<linkId value="2.4"/>
<text value="NPI"/>
<type value="text"/>
</item>
<item>
<linkId value="2.5"/>
<text value="Date of Face-To-Face Evaluation"/>
<type value="date"/>
</item>
<item>
<extension
url="http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource">
<valueCode value="Patient"/>
</extension>
<linkId value="2.6"/>
<text value="Record"/>
<type value="reference"/>
<required value="true"/>
</item>
</item>
<item>
<linkId value="3"/>
<text value="Coverage Requirements"/>
<type value="group"/>
<item>
<linkId value="3.1"/>
<text
value="Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)"/>
<type value="choice"/>
<answerOption>
<valueCoding>
<system value="http://snomed.info/sct"/>
<code value="313296004"/>
<display value="Mild chronic obstructive pulmonary disease"/>
</valueCoding>
</answerOption>
<answerOption>
<valueCoding>
<system value="http://snomed.info/sct"/>
<code value="389087006"/>
<display value="Hypoxemia (disorder)"/>
</valueCoding>
</answerOption>
</item>
<item>
<linkId value="3.2"/>
<text
value="Arterial oxygen saturation (Patient on room air while at rest and awake when tested)"/>
<type value="quantity"/>
</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)"/>
<type value="quantity"/>
</item>
<item>
<linkId value="3.4"/>
<text
value="Arterial oxygen saturation (Patient tested during exercise)"/>
<type value="quantity"/>
</item>
<item>
<linkId value="3.5"/>
<text
value="Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)"/>
<type value="quantity"/>
</item>
<item>
<linkId value="3.6"/>
<text
value="Is there a documented improvement of hypoxemia during exercise with oxygen?"/>
<type value="boolean"/>
</item>
</item>
<item>
<linkId value="4"/>
<text value="Prescribed Use"/>
<type value="group"/>
<item>
<linkId value="4.1"/>
<text value="Start date"/>
<type value="date"/>
</item>
<item>
<linkId value="4.2"/>
<text value="Length of need: (months) (99 = lifetime)"/>
<type value="quantity"/>
</item>
<item>
<linkId value="4.3"/>
<text value="Peak Flow Rate"/>
<type value="group"/>
<item>
<linkId value="4.3.1"/>
<text value="LPM"/>
<type value="quantity"/>
</item>
<item>
<linkId value="4.3.2"/>
<text value="oxygen %"/>
<type value="quantity"/>
</item>
</item>
<item>
<linkId value="4.4"/>
<text value="Average Flow Rate"/>
<type value="group"/>
<item>
<linkId value="4.4.1"/>
<text value="LPM"/>
<type value="quantity"/>
</item>
<item>
<linkId value="4.4.2"/>
<text value="oxygen %"/>
<type value="quantity"/>
</item>
</item>
<item>
<linkId value="4.5"/>
<text value="Frequency of use (choose all that apply)"/>
<type value="text"/>
</item>
</item>
<item>
<linkId value="5"/>
<text value="Oxygen Supply Order Details"/>
<type value="group"/>
<item>
<linkId value="5.1"/>
<text value="Current Order Description"/>
<type value="text"/>
</item>
<item>
<linkId value="5.1b"/>
<text value="Current Order Is For A Portable Device"/>
<type value="boolean"/>
</item>
<item>
<linkId value="5.2"/>
<text value="Type"/>
<type value="choice"/>
<answerOption>
<valueCoding>
<system value="http://example.org"/>
<code value="121"/>
<display value="Liquid"/>
</valueCoding>
</answerOption>
<answerOption>
<valueCoding>
<system value="http://example.org"/>
<code value="122"/>
<display value="Compressed Gas"/>
</valueCoding>
</answerOption>
<answerOption>
<valueCoding>
<system value="http://example.org"/>
<code value="123"/>
<display value="Concentrator"/>
</valueCoding>
</answerOption>
</item>
<item>
<linkId value="5.3"/>
<text value="Means of oxygen delivery and accessories"/>
<type value="choice"/>
<answerOption>
<valueCoding>
<system value="http://example.org"/>
<code value="131"/>
<display value="Nasal cannula"/>
</valueCoding>
</answerOption>
<answerOption>
<valueCoding>
<system value="http://example.org"/>
<code value="132"/>
<display value="Non-rebreather"/>
</valueCoding>
</answerOption>
<answerOption>
<valueCoding>
<system value="http://example.org"/>
<code value="133"/>
<display value="Ventilator"/>
</valueCoding>
</answerOption>
<answerOption>
<valueCoding>
<system value="http://example.org"/>
<code value="134"/>
<display value="Mask"/>
</valueCoding>
</answerOption>
<answerOption>
<valueCoding>
<system value="http://example.org"/>
<code value="135"/>
<display value="PAP bleed in"/>
</valueCoding>
</answerOption>
<answerOption>
<valueCoding>
<system value="http://example.org"/>
<code value="136"/>
<display value="Oxygen conserving device"/>
</valueCoding>
</answerOption>
<answerOption>
<valueCoding>
<system value="http://example.org"/>
<code value="137"/>
<display value="High flow oxygen therapy"/>
</valueCoding>
</answerOption>
</item>
</item>
</Questionnaire>
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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