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: DTR Home Oxygen Therapy QuestionnaireResponse - R4 - XML Representation

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<QuestionnaireResponse xmlns="http://hl7.org/fhir">
  <id value="home-o2-questionnaireresponse"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaireresponse-r4"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p>This completed form contains all of the information collected from the provider on Home Oxygen Therapy.</p></div>
  </text>
  <contained>
    <Patient>
      <id value="example1"/>
      <gender value="male"/>
      <birthDate value="1996-12-23"/>
      <address>
        <use value="home"/>
        <type value="both"/>
        <state value="MA"/>
      </address>
    </Patient>
  </contained>
  <questionnaire value="#Questionnaire/q045"/>
  <status value="completed"/>
  <subject>
    <reference value="#example1"/>
    <display value="Vlad"/>
  </subject>
  <authored value="2019-07-18"/>
  <item>
    <linkId value="1"/>
    <text value="Patient Information"/>
    <item>
      <linkId value="1.1"/>
      <text value="Last Name but Different This Time"/>
      <answer>
        <valueString value="Quinton"/>
      </answer>
    </item>
    <item>
      <linkId value="1.2"/>
      <text value="First Name"/>
      <answer>
        <valueString value="Vlad"/>
      </answer>
    </item>
    <item>
      <linkId value="1.3"/>
      <text value="Middle Initial"/>
      <answer>
        <valueString value="A, N"/>
      </answer>
    </item>
    <item>
      <linkId value="1.4"/>
      <text value="Date Of Birth"/>
      <answer>
        <valueDate value="1956-12-01"/>
      </answer>
    </item>
    <item>
      <linkId value="1.5"/>
      <text value="Gender"/>
      <answer>
        <valueCoding>
          <system value="http://hl7.org/fhir/administrative-gender"/>
          <code value="male"/>
          <display value="Male"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="1.6"/>
      <text value="Medicare ID"/>
      <answer>
        <valueString value="10A3D58WH22"/>
      </answer>
    </item>
  </item>
  <item>
    <linkId value="2"/>
    <text value="Provider who is performing face-to-face evaluation"/>
    <item>
      <linkId value="2.1"/>
      <text value="Last Name"/>
      <answer>
        <valueString value="Doe"/>
      </answer>
    </item>
    <item>
      <linkId value="2.2"/>
      <text value="First Name"/>
      <answer>
        <valueString value="Jane"/>
      </answer>
    </item>
    <item>
      <linkId value="2.3"/>
      <text value="Middle Initial"/>
      <answer>
        <valueString value="B"/>
      </answer>
    </item>
    <item>
      <linkId value="2.4"/>
      <text value="NPI"/>
      <answer>
        <valueString value="1122334455"/>
      </answer>
    </item>
    <item>
      <linkId value="2.5"/>
      <text value="Date of Face-To-Face Evaluation"/>
      <answer>
        <valueDate value="2019-07-18"/>
      </answer>
    </item>
  </item>
  <item>
    <linkId value="3"/>
    <text value="Coverage Requirements"/>
    <item>
      <linkId value="3.1"/>
      <text
            value="Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)"/>
      <answer>
        <valueCoding>
          <system value="http://snomed.info/sct"/>
          <code value="313296004"/>
          <display value="Mild chronic obstructive pulmonary disease"/>
        </valueCoding>
      </answer>
      <answer>
        <valueCoding>
          <system value="http://snomed.info/sct"/>
          <code value="389087006"/>
          <display value="Hypoxemia (disorder)"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="3.2"/>
      <text
            value="Arterial oxygen saturation (Patient on room air while at rest and awake when tested)"/>
    </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)"/>
    </item>
    <item>
      <linkId value="3.4"/>
      <text value="Arterial oxygen saturation (Patient tested during exercise)"/>
    </item>
    <item>
      <linkId value="3.5"/>
      <text
            value="Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)"/>
    </item>
    <item>
      <linkId value="3.6"/>
      <text
            value="Is there a documented improvement of hypoxemia during exercise with oxygen?"/>
    </item>
  </item>
  <item>
    <linkId value="4"/>
    <text value="Prescribed Use"/>
    <item>
      <linkId value="4.1"/>
      <text value="Start date"/>
      <answer>
        <valueDate value="2019-07-18"/>
      </answer>
    </item>
    <item>
      <linkId value="4.2"/>
      <text value="Length of need: (months) (99 = lifetime)"/>
      <answer>
        <valueInteger value="99"/>
      </answer>
    </item>
    <item>
      <linkId value="4.4"/>
      <text value="Peak Flow Rate"/>
      <item>
        <linkId value="4.4.1"/>
        <text value="LPM"/>
        <answer>
          <valueInteger value="2"/>
        </answer>
      </item>
      <item>
        <linkId value="4.4.2"/>
        <text value="oxygen %"/>
        <answer>
          <valueInteger value="98"/>
        </answer>
      </item>
    </item>
    <item>
      <linkId value="4.5"/>
      <text value="Average Flow Rate"/>
      <item>
        <linkId value="4.5.1"/>
        <text value="LPM"/>
        <answer>
          <valueInteger value="2"/>
        </answer>
      </item>
      <item>
        <linkId value="4.5.2"/>
        <text value="oxygen %"/>
        <answer>
          <valueInteger value="97"/>
        </answer>
      </item>
    </item>
    <item>
      <linkId value="4.6"/>
      <text value="Frequency of use (choose all that apply)"/>
      <answer>
        <valueCoding>
          <code value="At rest and awake"/>
          <display value="At rest and awake"/>
        </valueCoding>
      </answer>
    </item>
  </item>
  <item>
    <linkId value="5"/>
    <text value="Oxygen Supply Order Details"/>
    <item>
      <linkId value="5.1"/>
      <text value="Current Order Description"/>
      <answer>
        <valueString
                     value="HCPCS E0424 - Stationary Compressed Gaseous Oxygen System, Rental"/>
      </answer>
    </item>
    <item>
      <linkId value="5.1b"/>
      <text value="Current Order Is For A Portable Device"/>
    </item>
    <item>
      <linkId value="5.2"/>
      <text value="Type"/>
      <answer>
        <valueCoding>
          <code value="E0424"/>
          <display value="Compressed Gas"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="5.3"/>
      <text value="Means of oxygen delivery and accessories"/>
      <answer>
        <valueCoding>
          <code value="Mask"/>
          <display value="Mask"/>
        </valueCoding>
      </answer>
      <answer>
        <valueCoding>
          <code value="Ventilator"/>
          <display value="Ventilator"/>
        </valueCoding>
      </answer>
    </item>
    <item>
      <linkId value="5.4"/>
      <text value="Type of order"/>
      <answer>
        <valueCoding>
          <code value="Initial or original order for certification"/>
          <display value="Initial or original order for certification"/>
        </valueCoding>
      </answer>
    </item>
  </item>
</QuestionnaireResponse>