{ "resourceType" : "Parameters", "id" : "QuestionnairePackageOutputParamsExample", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-qpackage-output-parameters"] }, "language" : "en", "parameter" : [{ "name" : "packagebundle", "resource" : { "resourceType" : "Bundle", "id" : "home-o2-questionnairepackage-bundle", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/DTR-QPackageBundle"] }, "language" : "en", "type" : "collection", "entry" : [{ "fullUrl" : "http://example.org/fhir/home-o2-questionnairepackage", "resource" : { "resourceType" : "Questionnaire", "id" : "home-o2-std-questionnaire", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-std-questionnaire"] }, "language" : "en", "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/artifact-versionAlgorithm", "valueCoding" : { "system" : "http://hl7.org/fhir/version-algorithm", "code" : "semver" } }, { "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/questionnaireAudience", "valueCode" : "clinical" }, { "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/request-specific", "valueBoolean" : false }, { "url" : "http://hl7.org/fhir/StructureDefinition/rendering-styleSensitive", "valueBoolean" : false }, { "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-entryMode", "valueCode" : "sequential" }, { "extension" : [{ "url" : "totalTime", "valueCode" : "over-5min" }, { "url" : "clinicalTime", "valueCode" : "under-3min" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/estimated-completion-time" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/home-o2-std-questionnaire", "name" : "HomeOxygenTherapyStdQuestionnaire", "title" : "Home Oxygen Therapy Order Template", "status" : "draft", "subjectType" : ["Patient"], "date" : "2020-01-13T00:00:00+00:00", "publisher" : "Da Vinci DTR", "contact" : [{ "name" : "Example Author" }], "item" : [{ "linkId" : "1", "text" : "Patient Information", "type" : "group", "item" : [{ "linkId" : "1.1", "text" : "Last Name", "type" : "string", "required" : true }, { "linkId" : "1.2", "text" : "Fist Name", "type" : "string", "required" : true }, { "linkId" : "1.3", "text" : "Middle Name", "type" : "string", "required" : false }, { "linkId" : "1.gender", "definition" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-question-library#Demographics.sex", "text" : "What is this person's gender?", "type" : "choice", "required" : true, "answerValueSet" : "http://hl7.org/fhir/ValueSet/relatedperson-relationshiptype" }, { "linkId" : "1.4", "text" : "Date Of Birth", "type" : "date" }, { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/minValue", "valueDecimal" : 1 }, { "url" : "http://hl7.org/fhir/StructureDefinition/maxValue", "valueDecimal" : 400 }, { "url" : "http://hl7.org/fhir/StructureDefinition/maxDecimalPlaces", "valueInteger" : 2 }], "linkId" : "1.5", "text" : "Enter your weight in lb", "type" : "decimal" }, { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/mimeType", "valueCode" : "image/jpeg" }, { "url" : "http://hl7.org/fhir/StructureDefinition/maxSize", "valueDecimal" : 1048576 }], "linkId" : "1.6", "text" : "Attach latest x-ray", "type" : "attachment" }] }, { "linkId" : "2", "text" : "Calculation", "type" : "group", "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/alternativeExpression", "valueExpression" : { "language" : "application/elm+json", "expression" : "corresponding elm data" } }], "description" : "deadline for submission", "language" : "text/fhirpath", "expression" : "today() + 7 days" } }], "linkId" : "2.1", "text" : "Deadline for submission (7 days from now)", "type" : "date", "readOnly" : true }] }] } }, { "fullUrl" : "http://example.org/fhir/home-o2-questionnaireresponse", "resource" : { "resourceType" : "QuestionnaireResponse", "id" : "home-o2-questionnaireresponse", "meta" : { "profile" : ["http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaireresponse"] }, "language" : "en", "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-coverage", "valueReference" : { "reference" : "Coverage/CoverageExample" } }, { "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse", "valueCodeableConcept" : { "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-crd/CodeSystem/coverage-information-codes", "code" : "withorder", "display" : "Include with order" }] } }, { "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context", "valueReference" : { "reference" : "ServiceRequest/ServiceRequestExample" } }], "questionnaire" : "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire", "status" : "completed", "subject" : { "reference" : "Patient/examplepatient", "display" : "Vlad" }, "authored" : "2023-08-21", "item" : [{ "linkId" : "1", "text" : "Patient Information", "item" : [{ "linkId" : "1.1", "text" : "Last Name but Different This Time", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "override" }, { "extension" : [{ "url" : "role", "valueCodeableConcept" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/practitioner-role", "code" : "doctor", "display" : "Doctor" }] } }, { "url" : "practitioner", "valueReference" : { "reference" : "Practitioner/PractitionerExample", "display" : "Dr. Jane Doe" } }], "url" : "author" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueString" : "Quinton" }] }, { "linkId" : "1.2", "text" : "First Name", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueString" : "Vlad" }] }, { "linkId" : "1.3", "text" : "Middle Initial", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueString" : "A, N" }] }, { "linkId" : "1.4", "text" : "Date Of Birth", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueDate" : "1956-12-01" }] }, { "linkId" : "1.5", "text" : "Gender", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueCoding" : { "system" : "http://hl7.org/fhir/administrative-gender", "code" : "male", "display" : "Male" } }] }, { "linkId" : "1.6", "text" : "Medicare ID", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueString" : "10A3D58WH22" }] }] }, { "linkId" : "2", "text" : "Provider who is performing face-to-face evaluation", "item" : [{ "linkId" : "2.1", "text" : "Last Name", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueString" : "Doe" }] }, { "linkId" : "2.2", "text" : "First Name", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueString" : "Jane" }] }, { "linkId" : "2.3", "text" : "Middle Initial", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueString" : "B" }] }, { "linkId" : "2.4", "text" : "NPI", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueString" : "1122334455" }] }, { "linkId" : "2.5", "text" : "Date of Face-To-Face Evaluation", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "override" }, { "extension" : [{ "url" : "role", "valueCodeableConcept" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/practitioner-role", "code" : "doctor", "display" : "Doctor" }] } }, { "url" : "practitioner", "valueReference" : { "reference" : "Practitioner/PractitionerExample", "display" : "Dr. Jane Doe" } }], "url" : "author" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueDate" : "2019-07-18" }] }, { "linkId" : "2.6", "text" : "Record", "answer" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/containedReference", "valueBoolean" : false }], "valueReference" : { "reference" : "Patient/examplepatient", "display" : "Mr. Saul Moki" } }] }] }, { "linkId" : "3", "text" : "Coverage Requirements", "item" : [{ "linkId" : "3.1", "text" : "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueCoding" : { "system" : "http://snomed.info/sct", "code" : "313296004", "display" : "Mild chronic obstructive pulmonary disease" } }] }, { "linkId" : "3.2", "text" : "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueQuantity" : { "value" : 95, "system" : "http://unitsofmeasure.org", "code" : "mm[Hg]" } }] }, { "linkId" : "3.3", "text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueQuantity" : { "value" : 83, "system" : "http://unitsofmeasure.org", "code" : "mm[Hg]" } }] }, { "linkId" : "3.4", "text" : "Arterial oxygen saturation (Patient tested during exercise)", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueQuantity" : { "value" : 95, "system" : "http://unitsofmeasure.org", "code" : "mm[Hg]" } }] }, { "linkId" : "3.5", "text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueQuantity" : { "value" : 78, "system" : "http://unitsofmeasure.org", "code" : "mm[Hg]" } }] }, { "linkId" : "3.6", "text" : "Is there a documented improvement of hypoxemia during exercise with oxygen?", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueBoolean" : true }] }] }, { "linkId" : "4", "text" : "Prescribed Use", "item" : [{ "linkId" : "4.1", "text" : "Start date", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueDate" : "2019-07-18" }] }, { "linkId" : "4.2", "text" : "Length of need: (months) (99 = lifetime)", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueQuantity" : { "value" : 99 } }] }, { "linkId" : "4.3", "text" : "Peak Flow Rate", "item" : [{ "linkId" : "4.3.1", "text" : "LPM", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueQuantity" : { "value" : 2 } }] }, { "linkId" : "4.3.2", "text" : "oxygen %", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueQuantity" : { "value" : 98 } }] }] }, { "linkId" : "4.4", "text" : "Average Flow Rate", "item" : [{ "linkId" : "4.4.1", "text" : "LPM", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueQuantity" : { "value" : 2 } }] }, { "linkId" : "4.4.2", "text" : "oxygen %", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueQuantity" : { "value" : 97 } }] }] }, { "linkId" : "4.5", "text" : "Frequency of use (choose all that apply)", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueString" : "At rest and awake" }] }] }, { "linkId" : "5", "text" : "Oxygen Supply Order Details", "item" : [{ "linkId" : "5.1", "text" : "Current Order Description", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueString" : "HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental" }] }, { "linkId" : "5.1b", "text" : "Current Order Is For A Portable Device" }, { "linkId" : "5.2", "text" : "Type", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueCoding" : { "system" : "http://example.org", "code" : "122", "display" : "Compressed Gas" } }] }, { "linkId" : "5.3", "text" : "Means of oxygen delivery and accessories", "answer" : [{ "extension" : [{ "extension" : [{ "url" : "source", "valueCode" : "auto-client" }], "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin" }], "valueCoding" : { "system" : "http://example.org", "code" : "134", "display" : "Mask" } }] }] }] } }] } }] }