MNACQuestionnaire
type: Questionnaire
node role: treeRoot
id:
  v: MNACQuestionnaire
language:
  v: en
text:
  status:
    v: extensions
  div:
    v: Generated Narrative: Questionnaire MNACQuestionnaire Structure LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> MNACQuestionnaire This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. Questionnaire http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire#2.0.0-ballot #xD; request-info Request Information 0..1 group #xD; request-info|date-of-request DATE OF REQUEST 0..1 date #xD; diagnosis-info Diagnosis Information 0..1 group #xD; diagnosis-info|diagnosis Diagnosis 0..1 string #xD; item-requested Item Requested 0..1 group #xD; item-requested|item Item requested 0..1 string #xD; uti-history UTI History 0..1 group #xD; uti-history|uti-last-year The patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing 0..1 boolean #xD; uti-history|uti-dates Dates of UTIs in the last year 0..1 string Enable When: uti-history|uti-last-year = true #xD; uti-history|antibiotics-used Antibiotics used for UTIs in the last year 0..1 string Enable When: uti-history|uti-last-year = true #xD; symptoms-info Symptoms Information 0..1 group #xD; symptoms-info|symptoms Check those that apply to your patient 0..* choice Options: 7 options #xD; symptoms-info|fever-temperature If fever, state temperature in degrees 0..1 decimal Enable When: symptoms-info|symptoms = Fever (MNACQuestionnaire-symptoms-info-symptoms#Fever) #xD; catheterization-frequency Catheterization Frequency 0..1 group #xD; catheterization-frequency|frequency How many times per day does the patient catheterize? 0..1 choice Options: 4 options #xD; additional-comments Additional Comments 0..1 group #xD; additional-comments|comments Additional Comment 0..1 string #xD; physician-info Physician Information 0..1 group #xD; physician-info|name Physician's Name 0..1 string #xD; physician-info|…
contained: Library
  id:
    v: effective-data-requirements
  name:
    v: EffectiveDataRequirements
  status:
    v: active
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/library-type
        l: library-type
      code:
        v: module-definition
  related artifact:
    type:
      v: depends-on
    display:
      v: USCore model information
    resource:
      v: http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived
      l: http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo
  related artifact:
    type:
      v: depends-on
    display:
      v: FHIR model information
    resource:
      v: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1
      l: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/cqf-library
    l: cqf-library
  value: Canonical
    v: http://hl7.org/fhir/us/cql/Library/MNACInitialExpressions
    l: MNACInitialExpressions
extension:
  extension:
    url:
      v: name
      l: name
    value: Coding
      system:
        v: http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext
        l: launchContext
      code:
        v: patient
      display:
        v: Patient
  extension:
    url:
      v: type
      l: type
    value: Code
      v: Patient
  extension:
    url:
      v: description
      l: description
    value: String
      v: The patient that is to be used to pre-populate the form
  url:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext
    l: sdc-questionnaire-launchContext
extension:
  extension:
    url:
      v: name
      l: name
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/additionalLaunchContext
        l: additionalLaunchContext
      code:
        v: ServiceRequest
      display:
        v: ServiceRequest
  extension:
    url:
      v: type
      l: type
    value: Code
      v: ServiceRequest
  extension:
    url:
      v: description
      l: description
    value: String
      v: The ServiceRequest that is to be used to pre-populate the form
  url:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext
    l: sdc-questionnaire-launchContext
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/structuredefinition-wg
    l: structuredefinition-wg
  value: Code
    v: cds
extension:
  url:
    v: http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements
    l: crmi-effectiveDataRequirements
  value: Canonical
    v: #effective-data-requirements
    l: effective-data-requirements
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status
    l: structuredefinition-standards-status
  value: Code
    v: informative
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom
        l: structuredefinition-conformance-derivedFrom
      value: Canonical
        v: http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql
        l: hl7.fhir.us.cql
url:
  v: http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire
  l: MNACQuestionnaire
version:
  v: 2.0.0-ballot
name:
  v: MNACQuestionnaire
title:
  v: Example Medical Necessity For Authorization Of Catheters Questionnaire
status:
  v: active
experimental:
  v: true
date:
  v: 2024-01-17T00:00:00+00:00
publisher:
  v: HL7 International / Clinical Decision Support
contact:
  telecom:
    system:
      v: url
    value:
      v: http://www.hl7.org/Special/committees/dss
description:
  v: This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.
jurisdiction:
  coding:
    system:
      v: urn:iso:std:iso:3166
      l: 3166
    code:
      v: US
    display:
      v: United States of America
copyright:
  v: This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf
item:
  link id:
    v: request-info
  text:
    v: Request Information
  type:
    v: group
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: request-info|date-of-request
    text:
      v: DATE OF REQUEST
    type:
      v: date
item:
  link id:
    v: diagnosis-info
  text:
    v: Diagnosis Information
  type:
    v: group
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: diagnosis-info|diagnosis
    text:
      v: Diagnosis

v: text/cql-identifier

v: Date of Request

v: text/cql-identifier

v: Diagnosis

v: string

link id:
  v: item-requested
text:
  v: Item Requested
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Item Requested
  link id:
    v: item-requested|item
  text:
    v: Item requested
  type:
    v: string

link id:
  v: uti-history
text:
  v: UTI History
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: UTI in Last Year
  link id:
    v: uti-history|uti-last-year
  text:
    v: The patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing
  type:
    v: boolean
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Dates of UTIs
  link id:
    v: uti-history|uti-dates
  text:
    v: Dates of UTIs in the last year
  type:
    v: string
  enable when:
    question:
      v: uti-history|uti-last-year
    operator:
      v: =
    answer: Boolean
      v: true
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Antibiotics Used
  link id:
    v: uti-history|antibiotics-used
  text:
    v: Antibiotics used for UTIs in the last year
  type:
    v: string
  enable when:
    question:
      v: uti-history|uti-last-year
    operator:
      v: =
    answer: Boolean
      v: true

link id:
  v: symptoms-info
text:
  v: Symptoms Information
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Check Symptoms
  link id:
    v: symptoms-info|symptoms
  text:
    v: Check those that apply to your patient
  type:
    v: choice
  repeats:
    v: true
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms
        l: MNACQuestionnaire-symptoms-info-symptoms
      code:
        v: Fever
      display:
        v: Fever; state temperature in degree
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms
        l: MNACQuestionnaire-symptoms-info-symptoms
      code:
        v: UrinaryUrgencyFrequency
      display:
        v: Change in urinary urgency, frequency, or incontinence
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms
        l: MNACQuestionnaire-symptoms-info-symptoms
      code:
        v: AutonomicDysreflexia
      display:
        v: Appearance of new or increase in autonomic dysreflexia
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms
        l: MNACQuestionnaire-symptoms-info-symptoms
      code:
        v: PhysicalSignsProstatitis
      display:
        v: Physical signs of prostatitis, epididymitis, orchitis
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms
        l: MNACQuestionnaire-symptoms-info-symptoms
      code:
        v: Immunosuppressed
      display:
        v: The patient is immunosuppressed
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms
        l: MNACQuestionnaire-symptoms-info-symptoms
      code:
        v: Pyuria
      display:
        v: Pyuria
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms
        l: MNACQuestionnaire-symptoms-info-symptoms
      code:
        v: SystemicLeukocytosis
      display:
        v: Systemic leukocytosis
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Fever Temperature
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/questionnaire-unit
      l: questionnaire-unit
    value: Coding
      system:
        v: http://unitsofmeasure.org
        l: unitsofmeasure.org
      code:
        v: deg
      display:
        v: deg
  link id:
    v: symptoms-info|fever-temperature
  text:
    v: If fever, state temperature in degrees
  type:
    v: decimal
  enable when:
    question:
      v: symptoms-info|symptoms
    operator:
      v: =
    answer: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms
        l: MNACQuestionnaire-symptoms-info-symptoms
      code:
        v: Fever

link id:
  v: catheterization-frequency
text:
  v: Catheterization Frequency
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Catheterization Frequency
  link id:
    v: catheterization-frequency|frequency
  text:
    v: How many times per day does the patient catheterize?
  type:
    v: choice
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency
        l: MNACQuestionnaire-catheterization-frequency-frequency
      code:
        v: 2-4Times
      display:
        v: 2-4 times
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency
        l: MNACQuestionnaire-catheterization-frequency-frequency
      code:
        v: 4-6Times
      display:
        v: 4-6 times
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency
        l: MNACQuestionnaire-catheterization-frequency-frequency
      code:
        v: 6-8Times
      display:
        v: 6-8 times
  answer option:
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency
        l: MNACQuestionnaire-catheterization-frequency-frequency
      code:
        v: 8TimesOrMore
      display:
        v: 8 times or more

link id:
  v: additional-comments
text:
  v: Additional Comments
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Additional Comment
  link id:
    v: additional-comments|comments
  text:
    v: Additional Comment
  type:
    v: string

link id:
  v: physician-info
text:
  v: Physician Information
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Physician Name
  link id:
    v: physician-info|name
  text:
    v: Physician's Name
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Physician Telephone
  link id:
    v: physician-info|mobile
  text:
    v: Telephone
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Physician Fax
  link id:
    v: physician-info|fax
  text:
    v: FAX
  type:
    v: string
item:
  link id:
    v: physician-info|signature
  text:
    v: Physician's Signature
  type:
    v: attachment
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Referring Physician Telephone
  link id:
    v: physician-info|phone-referring
  text:
    v: Referring Physician Telephone
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Date
  link id:
    v: physician-info|date
  text:
    v: Date
  type:
    v: string