{
  "description": "Clinical response questionnaire at baseline (first doctors' visit)",
  "_filename": "Questionnaire-ClinicalResponseBaseline.json",
  "package_name": "hl7.fhir.uv.ichom-breast-cancer",
  "date": "2023-08-21T17:02:15+00:00",
  "publisher": "HL7 International - Clinical Interoperability Council Group",
  "jurisdiction": [ {
    "coding": [ {
      "code": "001",
      "system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
      "display": "World"
    } ]
  } ],
  "name": "ClinicalResponseBaseline",
  "item": [ {
    "item": [ {
      "text": "What is the patient's medical record number?",
      "type": "string",
      "linkId": "NA-Clinical",
      "required": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/fhirpath",
          "expression": "%patient.id"
        }
      } ]
    }, {
      "text": "What is the patient's last name?",
      "type": "string",
      "linkId": "LastName-Clinical",
      "required": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/fhirpath",
          "expression": "%patient.name.first().family.first()"
        }
      } ]
    } ],
    "text": "General information",
    "type": "group",
    "linkId": "General-Information-Clinical",
    "required": true
  }, {
    "item": [ {
      "text": "Indicate the sex of the patient at birth:",
      "type": "choice",
      "linkId": "Sex",
      "required": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/variable",
        "valueExpression": {
          "name": "expandedGender",
          "language": "application/x-fhir-query",
          "expression": "ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/administrative-gender"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/fhirpath",
          "expression": "%expandedGender.expansion.contains.where(code=%patient.gender)"
        }
      } ],
      "answerValueSet": "http://hl7.org/fhir/ValueSet/administrative-gender"
    }, {
      "text": "In what year was the patient born?",
      "type": "integer",
      "linkId": "YearOfBirth",
      "required": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/fhirpath",
          "expression": "%patient.birthDate.substring(0,4)"
        }
      } ],
      "maxLength": 4
    } ],
    "text": "Demographic factors",
    "type": "group",
    "linkId": "Demographics",
    "required": true
  }, {
    "item": [ {
      "code": [ {
        "code": "8302-2",
        "system": "http://loinc.org",
        "display": "Body height"
      } ],
      "text": "Indicate the patient's body height",
      "type": "quantity",
      "linkId": "Height",
      "required": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-observationLinkPeriod",
        "valueDuration": {
          "code": "a",
          "value": 300,
          "system": "http://unitsofmeasure.org"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-observationExtract",
        "valueBoolean": true
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "cm",
          "system": "http://unitsofmeasure.org",
          "display": "cm"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-minQuantity",
        "valueQuantity": {
          "code": "cm",
          "value": 10,
          "system": "http://unitsofmeasure.org"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-maxQuantity",
        "valueQuantity": {
          "code": "cm",
          "value": 320,
          "system": "http://unitsofmeasure.org"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "[in_i]",
          "system": "http://unitsofmeasure.org",
          "display": "[in_i]"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-minQuantity",
        "valueQuantity": {
          "code": "[in_i]",
          "value": 3.94,
          "system": "http://unitsofmeasure.org"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-maxQuantity",
        "valueQuantity": {
          "code": "[in_i]",
          "value": 126,
          "system": "http://unitsofmeasure.org"
        }
      } ]
    }, {
      "code": [ {
        "code": "29463-7",
        "system": "http://loinc.org",
        "display": "Body weight"
      }, {
        "code": "3141-9",
        "system": "http://loinc.org",
        "display": "Body weight Measured"
      }, {
        "code": "27113001",
        "system": "http://snomed.info/sct",
        "display": "Body weight"
      } ],
      "text": "Indicate the patient's weight.",
      "type": "quantity",
      "linkId": "Weight",
      "required": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-observationLinkPeriod",
        "valueDuration": {
          "code": "a",
          "value": 300,
          "system": "http://unitsofmeasure.org"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-observationExtract",
        "valueBoolean": true
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "kg",
          "system": "http://unitsofmeasure.org",
          "display": "kg"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-minQuantity",
        "valueQuantity": {
          "code": "kg",
          "value": 0.1,
          "system": "http://unitsofmeasure.org"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-maxQuantity",
        "valueQuantity": {
          "code": "kg",
          "value": 750,
          "system": "http://unitsofmeasure.org"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "[lb_av]",
          "system": "http://unitsofmeasure.org",
          "display": "[lb_av]"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-minQuantity",
        "valueQuantity": {
          "code": "[lb_av]",
          "value": 0.22,
          "system": "http://unitsofmeasure.org"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-maxQuantity",
        "valueQuantity": {
          "code": "[lb_av]",
          "value": 1653.47,
          "system": "http://unitsofmeasure.org"
        }
      } ]
    }, {
      "text": "Indicate the laterality of breast cancer",
      "type": "choice",
      "linkId": "LATERAL",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/LateralityVS"
    }, {
      "text": "Indicate if this is the first breast cancer",
      "type": "choice",
      "linkId": "FIRSTBC",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/NoYesUnknownVS"
    }, {
      "text": "Indicate if this is a new cancer on contralateral or ipsilateral breast",
      "type": "choice",
      "linkId": "NewBC",
      "required": true,
      "enableWhen": [ {
        "operator": "=",
        "question": "FIRSTBC",
        "answerCoding": {
          "code": "N",
          "system": "http://terminology.hl7.org/CodeSystem/v2-0532"
        }
      } ],
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/LateralityNewCancerVS"
    } ],
    "text": "Clinical factors",
    "type": "group",
    "linkId": "Clinical-Factors",
    "required": true
  }, {
    "item": [ {
      "text": "Is the date of histological diagnosis known?",
      "type": "boolean",
      "linkId": "HistologicalDateKnown",
      "required": true
    }, {
      "text": "Indicate the initial date of histological diagnosis:",
      "type": "date",
      "linkId": "HistologicalDiagnosisDate",
      "required": true,
      "enableWhen": [ {
        "operator": "=",
        "question": "HistologicalDateKnown",
        "answerBoolean": true
      } ]
    }, {
      "text": "Indicate the histologic type of the tumor (select all that apply)",
      "type": "choice",
      "linkId": "HISTOTYPE",
      "repeats": true,
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/HistologicalTypeVS"
    }, {
      "text": "Indicate if the patient carries a germline mutation predisposing breast cancer",
      "type": "choice",
      "linkId": "MUTBC",
      "repeats": true,
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/GermlineMutationVS"
    }, {
      "text": "Indicate the grade of the invasive component of tumor",
      "type": "choice",
      "linkId": "GRADEINV",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/GradingVS"
    }, {
      "text": "Indicate the tumor grade of DCIS component of tumor",
      "type": "choice",
      "linkId": "GRADEDCIS",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/GradingVS"
    }, {
      "text": "Indicate the clinical tumor stage (per AJCC 8th Ed.):",
      "type": "choice",
      "linkId": "TNMCT_BREAST",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/TNMPrimaryTumorVS"
    }, {
      "text": "Indicate the clinical nodal stage (per AJCC 8th Ed.):",
      "type": "choice",
      "linkId": "TNMCN_BREAST",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/TNMRegionalNodesVS"
    }, {
      "text": "Indicate the clinical distant metastasis (per AJCC 8th Ed.):",
      "type": "choice",
      "linkId": "TNMCM_BREAST",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/TNMDistantMetastasesVS"
    }, {
      "text": "Indicate if the estrogen receptor status is positive:",
      "type": "choice",
      "linkId": "ERSTATUS",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/EstrogenStatusVS"
    }, {
      "text": "Indicate if the progesterone receptor status is positive:",
      "type": "choice",
      "linkId": "PRSTATUS",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/ProgesteroneStatusVS"
    }, {
      "text": "Indicate if the HER2 receptor status is positive:",
      "type": "choice",
      "linkId": "HER2STATUS",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/HER2ReceptorStatusVS"
    }, {
      "text": "Indicate if a molecular profiling tool was used. If so, which one?",
      "type": "choice",
      "linkId": "MolecularProfiling",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/MolecularProfilingStatusVS"
    }, {
      "text": "Indicate the mammaprint score on a scale of 0.000 to 1.000",
      "type": "decimal",
      "linkId": "Mammaprint",
      "required": true,
      "enableWhen": [ {
        "operator": "=",
        "question": "MolecularProfiling",
        "answerCoding": {
          "code": "mammaprint",
          "system": "http://hl7.org/fhir/uv/ichom-breast-cancer/CodeSystem/MolecularProfilingCodeSystem"
        }
      } ]
    }, {
      "text": "Indicate the oncotype score on a scale of 0 to 100",
      "type": "decimal",
      "linkId": "Oncotype",
      "required": true,
      "enableWhen": [ {
        "operator": "=",
        "question": "MolecularProfiling",
        "answerCoding": {
          "code": "oncotype",
          "system": "http://hl7.org/fhir/uv/ichom-breast-cancer/CodeSystem/MolecularProfilingCodeSystem"
        }
      } ]
    }, {
      "text": "Indicate the endopredict score on a scale of 1.1 to 6.2",
      "type": "decimal",
      "linkId": "Endopredict",
      "required": true,
      "enableWhen": [ {
        "operator": "=",
        "question": "MolecularProfiling",
        "answerCoding": {
          "code": "endopredict",
          "system": "http://hl7.org/fhir/uv/ichom-breast-cancer/CodeSystem/MolecularProfilingCodeSystem"
        }
      } ]
    } ],
    "text": "Tumor factors",
    "type": "group",
    "linkId": "Tumor-Factors",
    "required": true
  }, {
    "item": [ {
      "text": "Indicate if a multidisciplinary meeting was conducted",
      "type": "choice",
      "linkId": "MultMeet",
      "required": true,
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/NoYesUnknownVS"
    }, {
      "text": "Which treatments did the multidisciplinary team recommend (select all that apply)?",
      "type": "choice",
      "linkId": "MultRecTreatments",
      "repeats": true,
      "required": true,
      "enableWhen": [ {
        "operator": "=",
        "question": "MultMeet",
        "answerCoding": {
          "code": "Y",
          "system": "http://terminology.hl7.org/CodeSystem/v2-0532"
        }
      } ],
      "answerValueSet": "http://hl7.org/fhir/uv/ichom-breast-cancer/ValueSet/RecommendedTreatmentTypeVS"
    } ],
    "text": "Treatment variables",
    "type": "group",
    "linkId": "Treatment-Variables",
    "required": true
  } ],
  "type": null,
  "experimental": "true",
  "resourceType": "Questionnaire",
  "title": "Clinical response questionnaire at baseline",
  "package_version": "1.0.0",
  "extension": [ {
    "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext",
    "extension": [ {
      "url": "name",
      "valueCoding": {
        "code": "patient",
        "system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
        "display": "Patient"
      }
    }, {
      "url": "type",
      "valueCode": "Patient"
    }, {
      "url": "description",
      "valueString": "Patient information to pre-populate the form with"
    } ]
  }, {
    "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode": "informative",
    "_valueCode": {
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical": "http://hl7.org/fhir/uv/ichom-breast-cancer/ImplementationGuide/hl7.fhir.uv.ichom-breast-cancer"
      } ]
    }
  } ],
  "status": "draft",
  "id": "2c98c9ab-1db1-4dcc-8e2f-a4b60468b695",
  "kind": null,
  "url": "http://hl7.org/fhir/uv/ichom-breast-cancer/Questionnaire/ClinicalResponseBaseline",
  "version": "1.0.0",
  "contact": [ {
    "name": "HL7 International - Clinical Interoperability Council Group",
    "telecom": [ {
      "value": "http://www.hl7.org/Special/committees/cic",
      "system": "url"
    } ]
  } ]
}