{ "description": null, "_filename": "example/Questionnaire-5-biol-monit.json", "package_name": "ch.fhir.ig.ch-lab-order", "subjectType": [ "Patient" ], "date": "2020-12-17", "meta": { "profile": [ "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-questionnaire", "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire", "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-extr-smap" ], "versionId": "1", "lastUpdated": "2019-04-01T20:17:53.340+00:00" }, "publisher": "HL7 Switzerland", "jurisdiction": [ { "coding": [ { "code": "CH", "system": "urn:iso:std:iso:3166" } ] } ], "name": "LabOrderFormExample", "item": [ { "item": [ { "text": "Auftragsnummer des Auftraggebers", "type": "string", "linkId": "order.placerOrderIdentifier" }, { "text": "Identifier Domain der Auftragsnummer des Auftraggebers", "type": "string", "linkId": "order.placerOrderIdentifierDomain", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden", "valueBoolean": true } ] }, { "text": "Auftragsnummer des Auftragsempfängers", "type": "string", "linkId": "order.fillerOrderIdentifier" }, { "text": "Identifier Domain der Auftragsnummer des Auftragsempfängers", "type": "string", "linkId": "order.fillerOrderIdentifierDomain", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden", "valueBoolean": true } ] }, { "text": "Identifier des Vorgängerdokuments", "type": "string", "linkId": "order.precedentDocumentIdentifier", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden", "valueBoolean": true } ] }, { "item": [ { "item": [ { "text": "Titel", "type": "string", "linkId": "order.notificationContactDocument.practitioner.title" }, { "text": "Name", "type": "string", "linkId": "order.notificationContactDocument.practitioner.familyName" }, { "text": "Vorname", "type": "string", "linkId": "order.notificationContactDocument.practitioner.givenName" }, { "text": "Telefon", "type": "string", "linkId": "order.notificationContactDocument.practitioner.phone" }, { "text": "E-Mail", "type": "string", "linkId": "order.notificationContactDocument.practitioner.email" } ], "text": "Zu benachrichtigende Person", "type": "group", "linkId": "order.notificationContactDocument.practitioner" } ], "text": "Dringender Benachrichtigungskontakt für dieses Dokument", "type": "group", "linkId": "order.notificationContactDocument" }, { "item": [ { "item": [ { "text": "Titel", "type": "string", "linkId": "order.notificationContactDocumentResponse.practitioner.title" }, { "text": "Name", "type": "string", "linkId": "order.notificationContactDocumentResponse.practitioner.familyName" }, { "text": "Vorname", "type": "string", "linkId": "order.notificationContactDocumentResponse.practitioner.givenName" }, { "text": "Telefon", "type": "string", "linkId": "order.notificationContactDocumentResponse.practitioner.phone" }, { "text": "E-Mail", "type": "string", "linkId": "order.notificationContactDocumentResponse.practitioner.email" } ], "text": "Zu benachrichtigende Person", "type": "group", "linkId": "order.notificationContactDocumentResponse.practitioner" } ], "text": "Dringender Benachrichtigungskontakt für die Antwort auf dieses Dokument", "type": "group", "linkId": "order.notificationContactDocumentResponse" }, { "text": "Auftragspriorität", "type": "choice", "linkId": "order.priority", "answerOption": [ { "valueCoding": { "code": "routine", "system": "http://hl7.org/fhir/request-priority", "display": "Routine" }, "initialSelected": true }, { "valueCoding": { "code": "urgent", "system": "http://hl7.org/fhir/request-priority", "display": "Urgent" } }, { "valueCoding": { "code": "asap", "system": "http://hl7.org/fhir/request-priority", "display": "ASAP" } }, { "valueCoding": { "code": "stat", "system": "http://hl7.org/fhir/request-priority", "display": "STAT" } } ] } ], "text": "Auftrag", "type": "group", "linkId": "order", "required": true }, { "item": [ { "item": [ { "text": "Titel", "type": "string", "linkId": "receiver.practitioner.title" }, { "text": "Name", "type": "string", "linkId": "receiver.practitioner.familyName" }, { "text": "Vorname", "type": "string", "linkId": "receiver.practitioner.givenName" }, { "text": "GLN", "type": "string", "linkId": "receiver.practitioner.gln" }, { "text": "ZSR", "type": "string", "linkId": "receiver.practitioner.zsr" }, { "text": "Telefon", "type": "string", "linkId": "receiver.practitioner.phone" }, { "text": "E-Mail", "type": "string", "linkId": "receiver.practitioner.email" } ], "text": "Empfangende Person", "type": "group", "linkId": "receiver.practitioner" }, { "item": [ { "text": "Name der Organisation", "type": "string", "linkId": "receiver.organization.name" }, { "text": "GLN", "type": "string", "linkId": "receiver.organization.gln", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition-ch-core-organization-definitions.html#Organization.identifier:GLN" }, { "text": "Strasse, Hausnummer, Postfach etc.", "type": "string", "linkId": "receiver.organization.streetAddressLine", "repeats": true }, { "text": "PLZ", "type": "string", "linkId": "receiver.organization.postalCode" }, { "text": "Ort", "type": "string", "linkId": "receiver.organization.city" }, { "text": "Land", "type": "string", "linkId": "receiver.organization.country" } ], "text": "Empfangende Organisation", "type": "group", "linkId": "receiver.organization" } ], "text": "Empfänger", "type": "group", "linkId": "receiver" }, { "item": [ { "text": "Name", "type": "string", "linkId": "patient.familyName" }, { "text": "Ledigname", "type": "string", "linkId": "patient.maidenName" }, { "text": "Vorname", "type": "string", "linkId": "patient.givenName" }, { "text": "Lokale Patienten-ID", "type": "string", "linkId": "patient.localPid" }, { "text": "Geburtsdatum", "type": "date", "linkId": "patient.birthDate" }, { "text": "Geschlecht", "type": "choice", "linkId": "patient.gender", "answerOption": [ { "valueCoding": { "code": "male", "system": "http://hl7.org/fhir/administrative-gender", "display": "Male" }, "initialSelected": true }, { "valueCoding": { "code": "female", "system": "http://hl7.org/fhir/administrative-gender", "display": "Female" } }, { "valueCoding": { "code": "other", "system": "http://hl7.org/fhir/administrative-gender", "display": "Other" } } ] }, { "text": "Zivilstand", "type": "choice", "linkId": "patient.maritalStatus", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.maritalStatus", "answerOption": [ { "valueCoding": { "code": "1", "system": "http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus", "display": "ledig" } }, { "valueCoding": { "code": "2", "system": "http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus", "display": "verheiratet" } }, { "valueCoding": { "code": "3", "system": "http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus", "display": "verwitwet" } }, { "valueCoding": { "code": "4", "system": "http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus", "display": "geschieden" } }, { "valueCoding": { "code": "5", "system": "http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus", "display": "unverheiratet" } }, { "valueCoding": { "code": "6", "system": "http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus", "display": "in eingetragener Partnerschaft" } }, { "valueCoding": { "code": "7", "system": "http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus", "display": "aufgelöste Partnerschaft" } }, { "valueCoding": { "code": "9", "system": "http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus", "display": "unbekannt" } } ] }, { "text": "Telefon", "type": "string", "linkId": "patient.phone" }, { "text": "E-Mail", "type": "string", "linkId": "patient.email" }, { "text": "Strasse, Hausnummer, Postfach etc.", "type": "string", "linkId": "patient.streetAddressLine", "repeats": true }, { "text": "PLZ", "type": "string", "linkId": "patient.postalCode" }, { "text": "Ort", "type": "string", "linkId": "patient.city" }, { "text": "Land", "type": "string", "linkId": "patient.country" }, { "text": "Korrespondenssprache", "type": "choice", "linkId": "patient.languageOfCorrespondance", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.communication:languageOfCorrespondance", "answerValueSet": "http://fhir.ch/ig/ch-epr-term/ValueSet/DocumentEntry.languageCode" }, { "item": [ { "text": "Beziehung", "type": "string", "linkId": "patient.contactperson.relationship", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.contact.relationship.text" }, { "text": "Name", "type": "string", "linkId": "patient.contactperson.familyName", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.contact.name.family" }, { "text": "Vorname", "type": "string", "linkId": "patient.contactperson.givenName", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.contact.name.given" }, { "text": "Telefon", "type": "string", "linkId": "patient.contactperson.phone", "repeats": true, "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.contact.telecom.value" }, { "text": "E-Mail", "type": "string", "linkId": "patient.contactperson.email", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.contact.telecom.value" } ], "text": "Kontaktperson", "type": "group", "linkId": "patient.contactperson", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.contact" } ], "text": "Patient", "type": "group", "linkId": "patient", "required": true }, { "item": [ { "item": [ { "item": [ { "text": "Titel", "type": "string", "linkId": "sender.author.practitioner.title" }, { "text": "Name", "type": "string", "linkId": "sender.author.practitioner.familyName" }, { "text": "Vorname", "type": "string", "linkId": "sender.author.practitioner.givenName" }, { "text": "GLN", "type": "string", "linkId": "sender.author.practitioner.gln" }, { "text": "ZSR", "type": "string", "linkId": "sender.author.practitioner.zsr" }, { "text": "Telefon", "type": "string", "linkId": "sender.author.practitioner.phone" }, { "text": "E-Mail", "type": "string", "linkId": "sender.author.practitioner.email" } ], "text": "Verantwortliche Person", "type": "group", "linkId": "sender.author.practitioner" }, { "item": [ { "text": "Name der Organisation", "type": "string", "linkId": "sender.author.organization.name" }, { "text": "Strasse, Hausnummer, Postfach etc.", "type": "string", "linkId": "sender.author.organization.streetAddressLine", "repeats": true }, { "text": "PLZ", "type": "string", "linkId": "sender.author.organization.postalCode" }, { "text": "Ort", "type": "string", "linkId": "sender.author.organization.city" }, { "text": "Land", "type": "string", "linkId": "sender.author.organization.country" } ], "text": "Verantwortliche Organisation", "type": "group", "linkId": "sender.author.organization" } ], "text": "Verantwortlicher", "type": "group", "linkId": "sender.author", "required": true }, { "item": [ { "item": [ { "text": "Name", "type": "string", "linkId": "sender.dataenterer.practitioner.familyName" }, { "text": "Vorname", "type": "string", "linkId": "sender.dataenterer.practitioner.givenName" }, { "text": "Telefon", "type": "string", "linkId": "sender.dataenterer.practitioner.phone" }, { "text": "E-Mail", "type": "string", "linkId": "sender.dataenterer.practitioner.email" } ], "text": "Erfassende Person", "type": "group", "linkId": "sender.dataenterer.practitioner" } ], "text": "Erfasser", "type": "group", "linkId": "sender.dataenterer" } ], "text": "Absender", "type": "group", "linkId": "sender", "required": true }, { "item": [ { "item": [ { "item": [ { "text": "Titel", "type": "string", "linkId": "receiverCopy.practitionerRole.practitioner.title", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-humanname#HumanName.prefix" }, { "text": "Name", "type": "string", "linkId": "receiverCopy.practitionerRole.practitioner.familyName", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-humanname#HumanName.family" }, { "text": "Vorname", "type": "string", "linkId": "receiverCopy.practitionerRole.practitioner.givenName", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-humanname#HumanName.given" }, { "text": "Telefon", "type": "string", "linkId": "receiverCopy.practitionerRole.practitioner.phone", "definition": "http://hl7.org/fhir/StructureDefinition/ContactPoint#ContactPoint.value" }, { "text": "E-Mail", "type": "string", "linkId": "receiverCopy.practitionerRole.practitioner.email", "definition": "http://hl7.org/fhir/StructureDefinition/ContactPoint#ContactPoint.value" } ], "text": "Name der Organisation", "type": "string", "linkId": "receiverCopy.organization.name", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole.practitioner" }, { "item": [ { "text": "Name der Organisation", "type": "string", "linkId": "receiverCopy.practitionerRole.organization.name", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.name" }, { "text": "Strasse, Hausnummer, Postfach etc.", "type": "string", "linkId": "receiverCopy.practitionerRole.organization.streetAddressLine", "repeats": true, "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-address#Address.line" }, { "text": "PLZ", "type": "string", "linkId": "receiverCopy.practitionerRole.organization.postalCode", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-address#Address.postalCode" }, { "text": "Ort", "type": "string", "linkId": "receiverCopy.practitionerRole.organization.city", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-address#Address.city" }, { "text": "Land", "type": "string", "linkId": "receiverCopy.practitionerRole.organization.country", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-address#Address.country" } ], "text": "Titel", "type": "string", "linkId": "receiverCopy.title", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole.organization" }, { "text": "Name", "type": "string", "linkId": "receiverCopy.familyName" }, { "text": "Vorname", "type": "string", "linkId": "receiverCopy.givenName" }, { "text": "Telefon", "type": "string", "linkId": "receiverCopy.phone" }, { "text": "E-Mail", "type": "string", "linkId": "receiverCopy.email" }, { "text": "Strasse, Hausnummer, Postfach etc.", "type": "string", "linkId": "receiverCopy.streetAddressLine", "repeats": true }, { "text": "PLZ", "type": "string", "linkId": "receiverCopy.postalCode" }, { "text": "Ort", "type": "string", "linkId": "receiverCopy.city" }, { "text": "Land", "type": "string", "linkId": "receiverCopy.country" } ], "text": "Kopieempfangende Organisation oder Person", "type": "group", "linkId": "receiverCopy", "repeats": true, "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole" }, { "text": "Patient selbst", "type": "boolean", "linkId": "receiverCopy.patient", "definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient" }, { "item": [ { "text": "Name", "type": "string", "linkId": "receiverCopy.relatedPerson.familyName", "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.name.family" }, { "text": "Vorame", "type": "string", "linkId": "receiverCopy.relatedPerson.givenName", "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.name.given" }, { "text": "Telefon", "type": "string", "linkId": "receiverCopy.relatedPerson.phone", "repeats": true, "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.telecom.value" }, { "text": "E-Mail", "type": "string", "linkId": "receiverCopy.relatedPerson.email", "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.telecom.value" }, { "text": "Strasse, Hausnummer, Postfach etc.", "type": "string", "linkId": "receiverCopy.relatedPerson.streetAddressLine", "repeats": true, "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.address.line" }, { "text": "PLZ", "type": "string", "linkId": "receiverCopy.relatedPerson.postalCode", "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.address.postalCode" }, { "text": "Ort", "type": "string", "linkId": "receiverCopy.relatedPerson.city", "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.address.city" }, { "text": "Land", "type": "string", "linkId": "receiverCopy.relatedPerson.country", "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.address.country" } ], "text": "Andere Person", "type": "group", "linkId": "receiverCopy.relatedPerson", "repeats": true, "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson" } ], "text": "Kopieempfänger", "type": "group", "linkId": "receiverCopies" }, { "item": [ { "text": "Einverständnis des Patienten zur Behandlung", "type": "string", "linkId": "consent.treatment" }, { "text": "Einverständnis des Patienten zum Datenschutz", "type": "string", "linkId": "consent.patientPrivacy" }, { "text": "Einverständnis des Patienten zur Forschung", "type": "string", "linkId": "consent.research" }, { "text": "Patientenverfügung", "type": "string", "linkId": "consent.advancedCareDirective" } ], "text": "Einverständniserklärung", "type": "group", "linkId": "consent", "definition": "http://fhir.ch/ig/ch-lab-order/StructureDefinition/ch-lab-order-servicerequest#ServiceRequest.supportingInfo" }, { "item": [ { "text": "Unfallversicherung (nach UVG)", "type": "string", "linkId": "coverage.uvg" }, { "text": "Grundversicherung (nach KVG)", "type": "string", "linkId": "coverage.kvg" }, { "text": "Zusatzversicherung (nach VVG)", "type": "string", "linkId": "coverage.vvg" }, { "text": "Andere (nach VVG)", "type": "string", "linkId": "coverage.vvgOther" } ], "text": "Kostenträger", "type": "group", "linkId": "coverage", "definition": "http://fhir.ch/ig/ch-lab-order/StructureDefinition/ch-lab-order-servicerequest#ServiceRequest.insurance" }, { "item": [ { "text": "Untersuchungsresultat", "type": "string", "linkId": "previousResult.result", "repeats": true } ], "text": "Vorheriges Untersuchungsresultat", "type": "group", "linkId": "previousResult", "definition": "http://fhir.ch/ig/ch-lab-order/StructureDefinition/ch-lab-order-servicerequest#ServiceRequest.supportingInfo" }, { "item": [ { "text": "Laborwerte", "type": "choice", "linkId": "lab", "repeats": true, "answerOption": [ { "valueCoding": { "code": "24360-0", "system": "http://loinc.org", "display": "Hemoglobin and Hematocrit panel - Blood" } }, { "valueCoding": { "code": "43113-0", "system": "http://loinc.org", "display": "Hemoglobin electrophoresis panel in Blood" } }, { "valueCoding": { "code": "57021-8", "system": "http://loinc.org", "display": "CBC W Auto Differential panel - Blood" } }, { "valueCoding": { "code": "58410-2", "system": "http://loinc.org", "display": "CBC panel - Blood by Automated count" } }, { "valueCoding": { "code": "57023-4", "system": "http://loinc.org", "display": "Auto Differential panel - Blood" } } ] } ], "text": "Hematology", "type": "group", "linkId": "hematology" }, { "item": [ { "text": "Toxic Content", "type": "choice", "linkId": "tox", "repeats": true, "answerOption": [ { "valueCoding": { "code": "29587-3", "system": "http://loinc.org", "display": "Toxicology panel - Blood" } }, { "valueCoding": { "code": "54454-4", "system": "http://loinc.org", "display": "Arsenic fractions panel - Urine" } }, { "valueCoding": { "code": "29589-9", "system": "http://loinc.org", "display": "Heavy metals panel - Urine" } } ] } ], "text": "Toxicology", "type": "group", "linkId": "toxicology" } ], "copyright": "CC0-1.0", "type": null, "experimental": null, "resourceType": "Questionnaire", "title": "Lab Order Form Example 5-biol-monit", "package_version": "2.0.0-ballot", "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-targetStructureMap", "valueCanonical": "http://fhir.ch/ig/ch-orf/StructureMap/OrfQrToBundle" }, { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-sourceStructureMap", "valueCanonical": "http://fhir.ch/ig/ch-orf/StructureMap/OrfPrepopBundleToQr" }, { "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" } }, { "url": "type", "valueCode": "Patient" } ] }, { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext", "extension": [ { "url": "name", "valueCoding": { "code": "user", "system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext", "display": "User" } }, { "url": "type", "valueCode": "Practitioner" }, { "url": "description", "valueString": "The practitioner that is to be used to pre-populate the form" } ] } ], "status": "active", "id": "6cd4921b-6598-4a05-9056-6e8a605fe38b", "kind": null, "url": "http://fhir.ch/ig/ch-lab-order/Questionnaire/5-biol-monit", "version": "2.0.0-ballot", "contact": [ { "name": "HL7 Switzerland", "telecom": [ { "value": "https://www.hl7.ch", "system": "url" } ] }, { "name": "Marcel Hanselmann", "telecom": [ { "use": "work", "value": "laborprojektgruppe@gmail.com", "system": "email" } ] } ] }