{
"description": null,
"_filename": "example/Questionnaire-home-o2-questionnaire-stu3.json",
"package_name": "hl7.fhir.us.davinci-dtr",
"subjectType": [ "Patient" ],
"date": "2019-03-11T00:00:00-04:00",
"meta": {
"profile": [ "http://hl7.org/fhir/us/davinci-dtr/STU3/StructureDefinition/dtr-questionnaire-stu3" ]
},
"publisher": "Da Vinci DTR",
"name": null,
"item": [ {
"item": [ {
"text": "Last Name",
"type": "string",
"linkId": "1.1",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "PatientLastName"
} ]
}, {
"text": "First Name",
"type": "string",
"linkId": "1.2",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "PatientFirstName"
} ]
}, {
"text": "Middle Initial",
"type": "string",
"linkId": "1.3",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "PatientMiddleInitial"
} ]
}, {
"text": "Date Of Birth",
"type": "date",
"linkId": "1.4",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "PatientDateOfBirth"
} ]
}, {
"text": "Gender",
"type": "choice",
"linkId": "1.5",
"options": {
"reference": "#gender"
},
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "PatientGender"
} ]
}, {
"text": "Medicare ID",
"type": "string",
"linkId": "1.6",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "PatientMedicareId"
} ]
} ],
"text": "Patient Information",
"type": "group",
"linkId": "1"
}, {
"item": [ {
"text": "Last Name",
"type": "string",
"linkId": "2.1",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "OrderingProviderLastName"
} ]
}, {
"text": "First Name",
"type": "string",
"linkId": "2.2",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "OrderingProviderFirstName"
} ]
}, {
"text": "Middle Initial",
"type": "string",
"linkId": "2.3",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "OrderingProviderMiddleInitial"
} ]
}, {
"text": "NPI",
"type": "string",
"linkId": "2.4",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "OrderingProviderNPI"
} ]
}, {
"text": "Date of Face-To-Face Evaluation",
"type": "date",
"linkId": "2.5",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "Today"
} ]
} ],
"text": "Provider who is performing face-to-face evaluation",
"type": "group",
"linkId": "2"
}, {
"item": [ {
"text": "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)",
"type": "open-choice",
"linkId": "3.1",
"option": [ {
"valueCoding": {
"code": "COPD"
}
}, {
"valueCoding": {
"code": "Bronchiectasis"
}
}, {
"valueCoding": {
"code": "Hypoxemia"
}
}, {
"valueCoding": {
"code": "Diffuse interstitial lung disease"
}
}, {
"valueCoding": {
"code": "Cystic fibrosis"
}
}, {
"valueCoding": {
"code": "Pulmonary neoplasm"
}
}, {
"valueCoding": {
"code": "Erythrocytosis"
}
}, {
"valueCoding": {
"code": "Pulmonary hypertension"
}
}, {
"valueCoding": {
"code": "Recurring CHF d/t Cor Pulmonale"
}
} ],
"repeats": true,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "RelevantDiagnoses"
} ]
}, {
"text": "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)",
"type": "quantity",
"linkId": "3.2",
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "ArterialOxygenSaturation"
} ]
}, {
"text": "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)",
"type": "quantity",
"linkId": "3.3",
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "ArterialPartialPressureOfOxygen"
} ]
}, {
"text": "Arterial oxygen saturation (Patient tested during exercise)",
"type": "quantity",
"linkId": "3.4",
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "ArterialOxygenSaturationExercise"
} ]
}, {
"text": "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)",
"type": "quantity",
"linkId": "3.5",
"required": false
}, {
"text": "Is there a documented improvement of hypoxemia during exercise with oxygen?",
"type": "boolean",
"linkId": "3.6",
"required": false
}, {
"text": "Is the patient mobile within the home?",
"type": "boolean",
"linkId": "3.7",
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "PatientMobile"
} ],
"enableWhen": [ {
"question": "5.1b",
"answerBoolean": true
} ]
}, {
"text": "Does the patient have dependent edema due to congestive heart failure?",
"type": "boolean",
"linkId": "3.8",
"required": false,
"enableWhen": [ {
"question": "3.2",
"answerQuantity": {
"unit": "%",
"value": 89
}
} ]
}, {
"text": "Does the patient have cor pulmonale or pulmonary hypertension documented by P pulmonale on an EKG or by an echocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement?",
"type": "boolean",
"linkId": "3.9",
"required": false,
"enableWhen": [ {
"question": "3.2",
"answerQuantity": {
"unit": "%",
"value": 89
}
} ]
}, {
"text": "Does the patient have a hematocrit greater than 56%?",
"type": "boolean",
"linkId": "3.10",
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "PatientHasHematocritThatIsGreaterThanThreshold"
} ],
"enableWhen": [ {
"question": "3.2",
"answerQuantity": {
"unit": "%",
"value": 89
}
} ]
}, {
"text": "Recent hematocrit result",
"type": "quantity",
"linkId": "3.11",
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "HematocritThatIsGreaterThanThreshold"
} ],
"enableWhen": [ {
"question": "3.10",
"answerBoolean": true
} ]
} ],
"text": "Coverage Requirements",
"type": "group",
"linkId": "3"
}, {
"item": [ {
"text": "Start date",
"type": "date",
"linkId": "4.1",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "Today"
} ]
}, {
"text": "Length of need: (months) (99 = lifetime)",
"type": "integer",
"linkId": "4.2",
"required": false
}, {
"item": [ {
"text": "LPM",
"type": "integer",
"linkId": "4.4.1",
"required": true
}, {
"text": "oxygen %",
"type": "integer",
"linkId": "4.4.2",
"required": true
} ],
"text": "Peak Flow Rate",
"type": "group",
"linkId": "4.4"
}, {
"text": "Since > 4 LPM prescribed, enter arterial oxygen saturation or PO2 while patient was on 4 LPM in stable state.",
"type": "quantity",
"linkId": "4.4b",
"required": true,
"enableWhen": [ {
"question": "4.4.1",
"answerInteger": 4
} ]
}, {
"item": [ {
"text": "LPM",
"type": "integer",
"linkId": "4.5.1",
"required": true
}, {
"text": "oxygen %",
"type": "integer",
"linkId": "4.5.2",
"required": true
} ],
"text": "Average Flow Rate",
"type": "group",
"linkId": "4.5"
}, {
"text": "Frequency of use (choose all that apply)",
"type": "open-choice",
"linkId": "4.6",
"option": [ {
"valueCoding": {
"code": "At rest and awake"
}
}, {
"valueCoding": {
"code": "During exertion"
}
}, {
"valueCoding": {
"code": "During sleep"
}
} ],
"repeats": true,
"required": true
} ],
"text": "Prescribed Use",
"type": "group",
"linkId": "4"
}, {
"item": [ {
"text": "Current Order Description",
"type": "string",
"linkId": "5.1",
"readOnly": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "DeviceRequestDescription"
} ]
}, {
"text": "Current Order Is For A Portable Device",
"type": "boolean",
"linkId": "5.1b",
"readOnly": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-calculatedValue",
"valueString": "DeviceRequestedIsPortable"
} ]
}, {
"text": "Type",
"type": "choice",
"linkId": "5.2",
"option": [ {
"valueCoding": {
"code": "Liquid"
}
}, {
"valueCoding": {
"code": "Compressed Gas"
}
}, {
"valueCoding": {
"code": "Concentrator"
}
} ],
"required": true
}, {
"text": "Means of oxygen delivery and accessories",
"type": "open-choice",
"linkId": "5.3",
"option": [ {
"valueCoding": {
"code": "Nasal cannula"
}
}, {
"valueCoding": {
"code": "Non-rebreather"
}
}, {
"valueCoding": {
"code": "Ventilator"
}
}, {
"valueCoding": {
"code": "Mask"
}
}, {
"valueCoding": {
"code": "PAP bleed in"
}
}, {
"valueCoding": {
"code": "Oxygen conserving device"
}
}, {
"valueCoding": {
"code": "High flow oxygen therapy"
}
} ],
"repeats": true,
"required": true
}, {
"text": "Type of order",
"type": "choice",
"linkId": "5.4",
"option": [ {
"valueCoding": {
"code": "Initial or original order for certification"
}
}, {
"valueCoding": {
"code": "Change in status"
}
}, {
"valueCoding": {
"code": "Revision or change in equipment"
}
}, {
"valueCoding": {
"code": "Replacement"
}
} ],
"required": true
}, {
"text": "Reason for Change in Status",
"type": "open-choice",
"linkId": "5.5",
"option": [ {
"valueCoding": {
"code": "Patient relocated"
}
}, {
"valueCoding": {
"code": "Different supplier"
}
} ],
"required": true,
"enableWhen": [ {
"question": "5.4",
"answerCoding": {
"code": "Change in status"
}
} ]
}, {
"text": "Reason for Revision or change in equipment",
"type": "open-choice",
"linkId": "5.6",
"option": [ {
"valueCoding": {
"code": "New Physician order"
}
}, {
"valueCoding": {
"code": "Beneficiary requested upgrade with signed ABN"
}
} ],
"required": true,
"enableWhen": [ {
"question": "5.4",
"answerCoding": {
"code": "Revision or change in equipment"
}
} ]
}, {
"text": "Reason for Replacement",
"type": "open-choice",
"linkId": "5.7",
"option": [ {
"valueCoding": {
"code": "Lost or stolen"
}
}, {
"valueCoding": {
"code": "End of lifetime"
}
}, {
"valueCoding": {
"code": "Repair exceeds 60% of cost"
}
} ],
"required": true,
"enableWhen": [ {
"question": "5.4",
"answerCoding": {
"code": "Replacement"
}
} ]
} ],
"text": "Oxygen Supply Order Details",
"type": "group",
"linkId": "5"
} ],
"type": null,
"experimental": null,
"resourceType": "Questionnaire",
"title": "Home Oxygen Therapy",
"package_version": "3.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqif-library",
"valueReference": {
"reference": "#library-oxygen-therapy-prepopulate"
}
} ],
"contained": [ {
"id": "gender",
"name": "Gender",
"status": "draft",
"compose": {
"include": [ {
"system": "http://hl7.org/fhir/ValueSet/administrative-gender",
"concept": [ {
"code": "male",
"display": "Male"
}, {
"code": "female",
"display": "Female"
}, {
"code": "other",
"display": "Other"
} ]
} ]
},
"description": "Gender",
"resourceType": "ValueSet"
}, {
"id": "library-oxygen-therapy-prepopulate",
"type": {
"coding": [ {
"code": "logic-library"
} ]
},
"status": "active",
"resourceType": "Library"
} ],
"status": "draft",
"id": "31b8898c-d29e-4a54-b6a9-1435485054be",
"kind": null,
"url": "http://hl7.org/fhir/us/davinci-dtr/STU3/Questionnaire/home-o2-questionnaire-stu3",
"version": "3.0.1",
"contact": [ {
"name": "example author"
} ]
}