{
  "description": "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.",
  "_filename": "Questionnaire-MNACQuestionnaire.json",
  "package_name": "hl7.fhir.us.cql.r4",
  "date": "2024-01-17T00:00:00+00:00",
  "publisher": "HL7 International / Clinical Decision Support",
  "jurisdiction": [ {
    "coding": [ {
      "code": "US",
      "system": "urn:iso:std:iso:3166",
      "display": "United States of America"
    } ]
  } ],
  "name": "MNACQuestionnaire",
  "item": [ {
    "item": [ {
      "text": "DATE OF REQUEST",
      "type": "date",
      "linkId": "request-info|date-of-request",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Date of Request"
        }
      } ]
    } ],
    "text": "Request Information",
    "type": "group",
    "linkId": "request-info"
  }, {
    "item": [ {
      "text": "Diagnosis",
      "type": "string",
      "linkId": "diagnosis-info|diagnosis",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Diagnosis"
        }
      } ]
    } ],
    "text": "Diagnosis Information",
    "type": "group",
    "linkId": "diagnosis-info"
  }, {
    "item": [ {
      "text": "Item requested",
      "type": "string",
      "linkId": "item-requested|item",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Item Requested"
        }
      } ]
    } ],
    "text": "Item Requested",
    "type": "group",
    "linkId": "item-requested"
  }, {
    "item": [ {
      "text": "The patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing",
      "type": "boolean",
      "linkId": "uti-history|uti-last-year",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "UTI in Last Year"
        }
      } ]
    }, {
      "text": "Dates of UTIs in the last year",
      "type": "string",
      "linkId": "uti-history|uti-dates",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Dates of UTIs"
        }
      } ],
      "enableWhen": [ {
        "operator": "=",
        "question": "uti-history|uti-last-year",
        "answerBoolean": true
      } ]
    }, {
      "text": "Antibiotics used for UTIs in the last year",
      "type": "string",
      "linkId": "uti-history|antibiotics-used",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Antibiotics Used"
        }
      } ],
      "enableWhen": [ {
        "operator": "=",
        "question": "uti-history|uti-last-year",
        "answerBoolean": true
      } ]
    } ],
    "text": "UTI History",
    "type": "group",
    "linkId": "uti-history"
  }, {
    "item": [ {
      "text": "Check those that apply to your patient",
      "type": "choice",
      "linkId": "symptoms-info|symptoms",
      "repeats": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Check Symptoms"
        }
      } ],
      "answerOption": [ {
        "valueCoding": {
          "code": "Fever",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "display": "Fever; state temperature in degree"
        }
      }, {
        "valueCoding": {
          "code": "UrinaryUrgencyFrequency",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "display": "Change in urinary urgency, frequency, or incontinence"
        }
      }, {
        "valueCoding": {
          "code": "AutonomicDysreflexia",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "display": "Appearance of new or increase in autonomic dysreflexia"
        }
      }, {
        "valueCoding": {
          "code": "PhysicalSignsProstatitis",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "display": "Physical signs of prostatitis, epididymitis, orchitis"
        }
      }, {
        "valueCoding": {
          "code": "Immunosuppressed",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "display": "The patient is immunosuppressed"
        }
      }, {
        "valueCoding": {
          "code": "Pyuria",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "display": "Pyuria"
        }
      }, {
        "valueCoding": {
          "code": "SystemicLeukocytosis",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms",
          "display": "Systemic leukocytosis"
        }
      } ]
    }, {
      "text": "If fever, state temperature in degrees",
      "type": "decimal",
      "linkId": "symptoms-info|fever-temperature",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Fever Temperature"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
        "valueCoding": {
          "code": "deg",
          "system": "http://unitsofmeasure.org",
          "display": "deg"
        }
      } ],
      "enableWhen": [ {
        "operator": "=",
        "question": "symptoms-info|symptoms",
        "answerCoding": {
          "code": "Fever",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms"
        }
      } ]
    } ],
    "text": "Symptoms Information",
    "type": "group",
    "linkId": "symptoms-info"
  }, {
    "item": [ {
      "text": "How many times per day does the patient catheterize?",
      "type": "choice",
      "linkId": "catheterization-frequency|frequency",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Catheterization Frequency"
        }
      } ],
      "answerOption": [ {
        "valueCoding": {
          "code": "2-4Times",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
          "display": "2-4 times"
        }
      }, {
        "valueCoding": {
          "code": "4-6Times",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
          "display": "4-6 times"
        }
      }, {
        "valueCoding": {
          "code": "6-8Times",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
          "display": "6-8 times"
        }
      }, {
        "valueCoding": {
          "code": "8TimesOrMore",
          "system": "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency",
          "display": "8 times or more"
        }
      } ]
    } ],
    "text": "Catheterization Frequency",
    "type": "group",
    "linkId": "catheterization-frequency"
  }, {
    "item": [ {
      "text": "Additional Comment",
      "type": "string",
      "linkId": "additional-comments|comments",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Additional Comment"
        }
      } ]
    } ],
    "text": "Additional Comments",
    "type": "group",
    "linkId": "additional-comments"
  }, {
    "item": [ {
      "text": "Physician's Name",
      "type": "string",
      "linkId": "physician-info|name",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Physician Name"
        }
      } ]
    }, {
      "text": "Telephone",
      "type": "string",
      "linkId": "physician-info|mobile",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Physician Telephone"
        }
      } ]
    }, {
      "text": "FAX",
      "type": "string",
      "linkId": "physician-info|fax",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Physician Fax"
        }
      } ]
    }, {
      "text": "Physician's Signature",
      "type": "attachment",
      "linkId": "physician-info|signature"
    }, {
      "text": "Referring Physician Telephone",
      "type": "string",
      "linkId": "physician-info|phone-referring",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Referring Physician Telephone"
        }
      } ]
    }, {
      "text": "Date",
      "type": "string",
      "linkId": "physician-info|date",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Date"
        }
      } ]
    } ],
    "text": "Physician Information",
    "type": "group",
    "linkId": "physician-info"
  } ],
  "copyright": "This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf",
  "type": null,
  "experimental": "true",
  "resourceType": "Questionnaire",
  "title": "Example Medical Necessity For Authorization Of Catheters Questionnaire",
  "package_version": "1.0.0",
  "extension": [ {
    "url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
    "valueCanonical": "http://hl7.org/fhir/us/cql/Library/MNACInitialExpressions"
  }, {
    "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": "The patient that is to be used to pre-populate the form"
    } ]
  }, {
    "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext",
    "extension": [ {
      "url": "name",
      "valueCoding": {
        "code": "ServiceRequest",
        "system": "http://example.org/fhir/CodeSystem/additionalLaunchContext",
        "display": "ServiceRequest"
      }
    }, {
      "url": "type",
      "valueCode": "ServiceRequest"
    }, {
      "url": "description",
      "valueString": "The ServiceRequest that is to be used to pre-populate the form"
    } ]
  }, {
    "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode": "cds"
  }, {
    "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/us/cql/ImplementationGuide/hl7.fhir.us.cql"
      } ]
    }
  } ],
  "status": "active",
  "id": "7697cbd6-631a-46fc-85d3-ee61cccc8d97",
  "kind": null,
  "url": "http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire",
  "version": "1.0.0",
  "contact": [ {
    "telecom": [ {
      "value": "http://www.hl7.org/Special/committees/dss",
      "system": "url"
    } ]
  } ]
}