{
  "description": null,
  "_filename": "example/Questionnaire-referred-questionnaire.json",
  "package_name": "hl7.fhir.us.davinci-dtr.r4",
  "subjectType": [ "Patient" ],
  "date": "2023-08-21T00:00:00+00:00",
  "publisher": "HL7 International / Clinical Decision Support",
  "jurisdiction": [ {
    "coding": [ {
      "code": "US",
      "system": "urn:iso:std:iso:3166"
    } ]
  } ],
  "derivedFrom": [ "http://hl7.org/fhir/us/davinci-dtr/dtr-questionnaire" ],
  "name": null,
  "item": [ {
    "item": [ {
      "text": "Last Name but Different This Time",
      "type": "text",
      "linkId": "1.1"
    }, {
      "text": "First Name",
      "type": "text",
      "linkId": "1.2"
    }, {
      "text": "Middle Initial",
      "type": "text",
      "linkId": "1.3"
    }, {
      "text": "Date Of Birth",
      "type": "date",
      "linkId": "1.4"
    }, {
      "text": "Gender",
      "type": "choice",
      "linkId": "1.5",
      "answerValueSet": "http://hl7.org/fhir/ValueSet/administrative-gender"
    }, {
      "text": "Medicare ID",
      "type": "text",
      "linkId": "1.6"
    } ],
    "text": "Patient Information",
    "type": "group",
    "linkId": "1"
  }, {
    "item": [ {
      "text": "Last Name",
      "type": "text",
      "linkId": "2.1"
    }, {
      "text": "First Name",
      "type": "text",
      "linkId": "2.2"
    }, {
      "text": "Middle Initial",
      "type": "text",
      "linkId": "2.3"
    }, {
      "text": "NPI",
      "type": "text",
      "linkId": "2.4"
    }, {
      "text": "Date of Face-To-Face Evaluation",
      "type": "date",
      "linkId": "2.5"
    }, {
      "text": "Record",
      "type": "reference",
      "linkId": "2.6",
      "required": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
        "valueCode": "Patient"
      } ]
    } ],
    "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": "choice",
      "linkId": "3.1",
      "answerOption": [ {
        "valueCoding": {
          "code": "313296004",
          "system": "http://snomed.info/sct",
          "display": "Mild chronic obstructive pulmonary disease"
        }
      }, {
        "valueCoding": {
          "code": "389087006",
          "system": "http://snomed.info/sct",
          "display": "Hypoxemia (disorder)"
        }
      } ]
    }, {
      "text": "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)",
      "type": "quantity",
      "linkId": "3.2"
    }, {
      "text": "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)",
      "type": "quantity",
      "linkId": "3.3"
    }, {
      "text": "Arterial oxygen saturation (Patient tested during exercise)",
      "type": "quantity",
      "linkId": "3.4"
    }, {
      "text": "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)",
      "type": "quantity",
      "linkId": "3.5"
    }, {
      "text": "Is there a documented improvement of hypoxemia during exercise with oxygen?",
      "type": "boolean",
      "linkId": "3.6"
    } ],
    "text": "Coverage Requirements",
    "type": "group",
    "linkId": "3"
  }, {
    "item": [ {
      "text": "Start date",
      "type": "date",
      "linkId": "4.1"
    }, {
      "text": "Length of need: (months) (99 = lifetime)",
      "type": "quantity",
      "linkId": "4.2"
    }, {
      "item": [ {
        "text": "LPM",
        "type": "quantity",
        "linkId": "4.3.1"
      }, {
        "text": "oxygen %",
        "type": "quantity",
        "linkId": "4.3.2"
      } ],
      "text": "Peak Flow Rate",
      "type": "group",
      "linkId": "4.3"
    }, {
      "item": [ {
        "text": "LPM",
        "type": "quantity",
        "linkId": "4.4.1"
      }, {
        "text": "oxygen %",
        "type": "quantity",
        "linkId": "4.4.2"
      } ],
      "text": "Average Flow Rate",
      "type": "group",
      "linkId": "4.4"
    }, {
      "text": "Frequency of use (choose all that apply)",
      "type": "text",
      "linkId": "4.5"
    } ],
    "text": "Prescribed Use",
    "type": "group",
    "linkId": "4"
  }, {
    "item": [ {
      "text": "Current Order Description",
      "type": "text",
      "linkId": "5.1"
    }, {
      "text": "Current Order Is For A Portable Device",
      "type": "boolean",
      "linkId": "5.1b"
    }, {
      "text": "Type",
      "type": "choice",
      "linkId": "5.2",
      "answerOption": [ {
        "valueCoding": {
          "code": "121",
          "system": "http://example.org",
          "display": "Liquid"
        }
      }, {
        "valueCoding": {
          "code": "122",
          "system": "http://example.org",
          "display": "Compressed Gas"
        }
      }, {
        "valueCoding": {
          "code": "123",
          "system": "http://example.org",
          "display": "Concentrator"
        }
      } ]
    }, {
      "text": "Means of oxygen delivery and accessories",
      "type": "choice",
      "linkId": "5.3",
      "answerOption": [ {
        "valueCoding": {
          "code": "131",
          "system": "http://example.org",
          "display": "Nasal cannula"
        }
      }, {
        "valueCoding": {
          "code": "132",
          "system": "http://example.org",
          "display": "Non-rebreather"
        }
      }, {
        "valueCoding": {
          "code": "133",
          "system": "http://example.org",
          "display": "Ventilator"
        }
      }, {
        "valueCoding": {
          "code": "134",
          "system": "http://example.org",
          "display": "Mask"
        }
      }, {
        "valueCoding": {
          "code": "135",
          "system": "http://example.org",
          "display": "PAP bleed in"
        }
      }, {
        "valueCoding": {
          "code": "136",
          "system": "http://example.org",
          "display": "Oxygen conserving device"
        }
      }, {
        "valueCoding": {
          "code": "137",
          "system": "http://example.org",
          "display": "High flow oxygen therapy"
        }
      } ]
    } ],
    "text": "Oxygen Supply Order Details",
    "type": "group",
    "linkId": "5"
  } ],
  "type": null,
  "experimental": null,
  "resourceType": "Questionnaire",
  "title": "Referred Questionnaire for QuestionnaireResponse",
  "package_version": "2.2.0-ballot",
  "status": "active",
  "id": "6bd27850-3c18-484d-aa42-3e3f2b7e9d6e",
  "kind": null,
  "url": "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire",
  "version": "2.2.0-ballot",
  "contact": [ {
    "name": "HL7 International / Clinical Decision Support",
    "telecom": [ {
      "value": "http://www.hl7.org/Special/committees/dss",
      "system": "url"
    } ]
  } ]
}