{
"description": null,
"_filename": "example/Questionnaire-order-referral-form.json",
"package_name": "ch.fhir.ig.ch",
"subjectType": [ "Patient" ],
"date": "2022-01-06",
"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-extract", "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-populate" ]
},
"publisher": "HL7 Switzerland",
"jurisdiction": [ {
"coding": [ {
"code": "CH",
"system": "urn:iso:std:iso:3166"
} ]
} ],
"name": "OrderReferralForm",
"item": [ {
"item": [ {
"text": "Auftragsnummer des Auftraggebers",
"type": "string",
"linkId": "order.placerOrderIdentifier",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-servicerequest#ServiceRequest.identifier:placerOrderIdentifier.value"
}, {
"text": "Identifier Domain der Auftragsnummer des Auftraggebers",
"type": "string",
"linkId": "order.placerOrderIdentifierDomain",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ],
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-servicerequest#ServiceRequest.identifier:placerOrderIdentifier.system"
}, {
"text": "Auftragsnummer des Auftragsempfängers",
"type": "string",
"linkId": "order.fillerOrderIdentifier",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-servicerequest#ServiceRequest.identifier:fillerOrderIdentifier.value"
}, {
"text": "Identifier Domain der Auftragsnummer des Auftragsempfängers",
"type": "string",
"linkId": "order.fillerOrderIdentifierDomain",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ],
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-servicerequest#ServiceRequest.identifier:fillerOrderIdentifier.system"
}, {
"text": "Identifier des Vorgängerdokuments",
"type": "string",
"linkId": "order.precedentDocumentIdentifier",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ],
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-composition#Composition.extension:precedentDocument"
}, {
"item": [ {
"item": [ {
"text": "Titel",
"type": "string",
"linkId": "order.notificationContactDocument.practitioner.title",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.prefix"
}, {
"text": "Name",
"type": "string",
"linkId": "order.notificationContactDocument.practitioner.familyName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.family"
}, {
"text": "Vorname",
"type": "string",
"linkId": "order.notificationContactDocument.practitioner.givenName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.given"
}, {
"text": "Telefon",
"type": "string",
"linkId": "order.notificationContactDocument.practitioner.phone",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.telecom.value"
}, {
"text": "E-Mail",
"type": "string",
"linkId": "order.notificationContactDocument.practitioner.email",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.telecom.value"
} ],
"text": "Zu benachrichtigende Person",
"type": "group",
"linkId": "order.notificationContactDocument.practitioner",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole.practitioner"
} ],
"text": "Dringender Benachrichtigungskontakt für dieses Dokument",
"type": "group",
"linkId": "order.notificationContactDocument",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-composition#Composition.extension:urgentNoficationContactForThisDocument"
}, {
"item": [ {
"item": [ {
"text": "Titel",
"type": "string",
"linkId": "order.notificationContactDocumentResponse.practitioner.title",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.prefix"
}, {
"text": "Name",
"type": "string",
"linkId": "order.notificationContactDocumentResponse.practitioner.familyName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.family"
}, {
"text": "Vorname",
"type": "string",
"linkId": "order.notificationContactDocumentResponse.practitioner.givenName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.given"
}, {
"text": "Telefon",
"type": "string",
"linkId": "order.notificationContactDocumentResponse.practitioner.phone",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.telecom.value"
}, {
"text": "E-Mail",
"type": "string",
"linkId": "order.notificationContactDocumentResponse.practitioner.email",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.telecom.value"
} ],
"text": "Zu benachrichtigende Person",
"type": "group",
"linkId": "order.notificationContactDocumentResponse.practitioner",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole.practitioner"
} ],
"text": "Dringender Benachrichtigungskontakt für die Antwort auf dieses Dokument",
"type": "group",
"linkId": "order.notificationContactDocumentResponse",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-composition#Composition.extension:urgentNoficationContactForTheResponseToThisDocument"
}, {
"text": "Auftragspriorität",
"type": "choice",
"linkId": "order.priority",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-servicerequest#ServiceRequest.priority",
"answerOption": [ {
"valueCoding": {
"code": "routine",
"system": "http://hl7.org/fhir/request-priority",
"display": "Die Anfrage hat normale Priorität."
},
"initialSelected": true
}, {
"valueCoding": {
"code": "urgent",
"system": "http://hl7.org/fhir/request-priority",
"display": "Die Anfrage sollte dringend bearbeitet werden - höhere Priorität als normal."
}
}, {
"valueCoding": {
"code": "asap",
"system": "http://hl7.org/fhir/request-priority",
"display": "Die Anfrage sollte so schnell wie möglich bearbeitet werden - höhere Priorität als dringend."
}
}, {
"valueCoding": {
"code": "stat",
"system": "http://hl7.org/fhir/request-priority",
"display": "Die Anfrage sollte sofort bearbeitet werden - höchstmögliche Priorität. Z.B. bei einem Notfall."
}
} ]
} ],
"text": "Auftrag",
"type": "group",
"linkId": "order",
"required": true,
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-document#Bundle"
}, {
"item": [ {
"item": [ {
"text": "Titel",
"type": "string",
"linkId": "receiver.practitioner.title",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.prefix"
}, {
"text": "Name",
"type": "string",
"linkId": "receiver.practitioner.familyName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.family"
}, {
"text": "Vorname",
"type": "string",
"linkId": "receiver.practitioner.givenName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.given"
}, {
"text": "GLN",
"type": "string",
"linkId": "receiver.practitioner.gln",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.identifier:GLN.value"
}, {
"text": "ZSR",
"type": "string",
"linkId": "receiver.practitioner.zsr",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.identifier:ZSR.value"
}, {
"text": "Telefon",
"type": "string",
"linkId": "receiver.practitioner.phone",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.telecom.value"
}, {
"text": "E-Mail",
"type": "string",
"linkId": "receiver.practitioner.email",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.telecom.value"
} ],
"text": "Empfangende Person",
"type": "group",
"linkId": "receiver.practitioner",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole.practitioner"
}, {
"item": [ {
"text": "Name der Organisation",
"type": "string",
"linkId": "receiver.organization.name",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.name"
}, {
"text": "GLN",
"type": "string",
"linkId": "receiver.organization.gln",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.identifier:GLN"
}, {
"text": "Strasse, Hausnummer, Postfach etc.",
"type": "string",
"linkId": "receiver.organization.streetAddressLine",
"repeats": true,
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.address.line"
}, {
"text": "PLZ",
"type": "string",
"linkId": "receiver.organization.postalCode",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.address.postalCode"
}, {
"text": "Ort",
"type": "string",
"linkId": "receiver.organization.city",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.address.city"
}, {
"text": "Land",
"type": "string",
"linkId": "receiver.organization.country",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.address.country"
} ],
"text": "Empfangende Organisation",
"type": "group",
"linkId": "receiver.organization",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole.organization"
} ],
"text": "Empfänger",
"type": "group",
"linkId": "receiver",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-composition#Composition.extension:receiver"
}, {
"item": [ {
"text": "Name",
"type": "string",
"linkId": "patient.familyName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.name.family"
}, {
"text": "Ledigname",
"type": "string",
"linkId": "patient.maidenName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.name.family"
}, {
"text": "Vorname",
"type": "string",
"linkId": "patient.givenName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.name.given"
}, {
"text": "Lokale Patienten-ID",
"type": "string",
"linkId": "patient.localPid",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.identifier:LocalPid.value"
}, {
"text": "Lokale Patienten-ID Domain",
"type": "string",
"linkId": "patient.localPidDomain",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ],
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.identifier:LocalPid.system"
}, {
"text": "Geburtsdatum",
"type": "date",
"linkId": "patient.birthDate",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.birthDate"
}, {
"text": "Geschlecht",
"type": "choice",
"linkId": "patient.gender",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.gender",
"answerOption": [ {
"valueCoding": {
"code": "male",
"system": "http://hl7.org/fhir/administrative-gender",
"display": "Männlich"
},
"initialSelected": true
}, {
"valueCoding": {
"code": "female",
"system": "http://hl7.org/fhir/administrative-gender",
"display": "Weiblich"
}
}, {
"valueCoding": {
"code": "other",
"system": "http://hl7.org/fhir/administrative-gender",
"display": "Anderes"
}
} ]
}, {
"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",
"repeats": true,
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.telecom.value"
}, {
"text": "E-Mail",
"type": "string",
"linkId": "patient.email",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.telecom.value"
}, {
"text": "Strasse, Hausnummer, Postfach etc.",
"type": "string",
"linkId": "patient.streetAddressLine",
"repeats": true,
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.address.line"
}, {
"text": "PLZ",
"type": "string",
"linkId": "patient.postalCode",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.address.postalCode"
}, {
"text": "Ort",
"type": "string",
"linkId": "patient.city",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.address.city"
}, {
"text": "Land",
"type": "string",
"linkId": "patient.country",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.address.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,
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-composition#Composition.subject"
}, {
"item": [ {
"text": "Voraussichtlich: Ambulant / Stationär / Notfall",
"type": "choice",
"linkId": "requestedEncounter.class",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-encounter#Encounter.class",
"answerOption": [ {
"valueCoding": {
"code": "AMB",
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"display": "Ambulant"
}
}, {
"valueCoding": {
"code": "IMP",
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"display": "Stationär"
}
}, {
"valueCoding": {
"code": "EMER",
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"display": "Notfall"
}
} ]
}, {
"text": "Zimmerkategorie",
"type": "choice",
"linkId": "requestedEncounter.desiredAccommodation",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-encounter#Encounter.extension:desiredAccommodation",
"answerOption": [ {
"valueCoding": {
"code": "1",
"system": "http://fhir.ch/ig/ch-core/CodeSystem/bfs-medstats-21-encountertype",
"display": "allgemein"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://fhir.ch/ig/ch-core/CodeSystem/bfs-medstats-21-encountertype",
"display": "halbprivat"
}
}, {
"valueCoding": {
"code": "3",
"system": "http://fhir.ch/ig/ch-core/CodeSystem/bfs-medstats-21-encountertype",
"display": "privat"
}
} ]
} ],
"text": "Patientenaufnahme",
"type": "group",
"linkId": "requestedEncounter",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-servicerequest#ServiceRequest.extension:requestedEncounterDetails"
}, {
"item": [ {
"item": [ {
"text": "AHV-Nr. des Patienten",
"type": "string",
"linkId": "coverage.beneficiary.ahvn13",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-patient#Patient.identifier:AHVN13"
} ],
"text": "Begünstigter (Patient)",
"type": "group",
"linkId": "coverage.beneficiary",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.beneficiary"
}, {
"item": [ {
"text": "Name der Versicherung",
"type": "string",
"linkId": "coverage.kvg.name",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.payor"
}, {
"text": "Kennnummer der Versichertenkarte",
"type": "string",
"linkId": "coverage.kvg.insuranceCardNumber",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.identifier"
} ],
"text": "Krankenkasse (nach KVG)",
"type": "group",
"linkId": "coverage.kvg",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.type"
}, {
"item": [ {
"text": "Name der Versicherung",
"type": "string",
"linkId": "coverage.uvg.name",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.payor"
}, {
"text": "Schadennummer",
"type": "string",
"linkId": "coverage.uvg.claimNumber",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.identifier"
} ],
"text": "Unfallversicherung (nach UVG)",
"type": "group",
"linkId": "coverage.uvg",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.type"
}, {
"item": [ {
"text": "Name der Versicherung",
"type": "string",
"linkId": "coverage.vvg.name",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.payor"
}, {
"text": "Kennnummer der Versichertenkarte",
"type": "string",
"linkId": "coverage.vvg.insuranceCardNumber",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.identifier"
} ],
"text": "Zusatzversicherung (nach VVG)",
"type": "group",
"linkId": "coverage.vvg",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.type"
}, {
"item": [ {
"text": "IV-Verfügungsnummer",
"type": "string",
"linkId": "coverage.iv.verfuegungsnummer",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.identifier"
} ],
"text": "Invalidenversicherung (IV)",
"type": "group",
"linkId": "coverage.iv",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.type"
}, {
"item": [ {
"text": "MV-Versichertennummer",
"type": "string",
"linkId": "coverage.mv.versichertennummer",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.identifier"
} ],
"text": "Militärversicherung (MV)",
"type": "group",
"linkId": "coverage.mv",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.type"
}, {
"item": [ {
"text": "Patient selbst",
"type": "boolean",
"linkId": "coverage.self.patient",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.payor"
}, {
"text": "Andere Person",
"type": "boolean",
"linkId": "coverage.self.patientRelatedPerson",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.payor",
"enableWhen": [ {
"operator": "=",
"question": "coverage.self.patient",
"answerBoolean": false
} ]
}, {
"item": [ {
"text": "Name",
"type": "string",
"linkId": "coverage.self.relatedPerson.familyName",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.name.family"
}, {
"text": "Vorname",
"type": "string",
"linkId": "coverage.self.relatedPerson.givenName",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.name.given"
}, {
"text": "Telefon",
"type": "string",
"linkId": "coverage.self.relatedPerson.phone",
"repeats": true,
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.telecom.value"
}, {
"text": "E-Mail",
"type": "string",
"linkId": "coverage.self.relatedPerson.email",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.telecom.value"
}, {
"text": "Strasse, Hausnummer, Postfach etc.",
"type": "string",
"linkId": "coverage.self.relatedPerson.streetAddressLine",
"repeats": true,
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.address.line"
}, {
"text": "PLZ",
"type": "string",
"linkId": "coverage.self.relatedPerson.postalCode",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.address.postalCode"
}, {
"text": "Ort",
"type": "string",
"linkId": "coverage.self.relatedPerson.city",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.address.city"
}, {
"text": "Land",
"type": "string",
"linkId": "coverage.self.relatedPerson.country",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#RelatedPerson.address.country"
} ],
"text": "Andere Person",
"type": "group",
"linkId": "coverage.self.relatedPerson",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.payor",
"enableWhen": [ {
"operator": "=",
"question": "coverage.self.patientRelatedPerson",
"answerBoolean": true
} ]
} ],
"text": "Selbstzahler",
"type": "group",
"linkId": "coverage.self",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.type"
}, {
"item": [ {
"text": "Name des Kostenträgers",
"type": "string",
"linkId": "coverage.other.name",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.payor"
}, {
"text": "Beliebige ID",
"type": "string",
"linkId": "coverage.other.id",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.identifier"
}, {
"text": "Bemerkung zur ID",
"type": "string",
"linkId": "coverage.other.id.note",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.identifier.type.text"
} ],
"text": "Anderer Kostenträger",
"type": "group",
"linkId": "coverage.other",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-coverage#Coverage.type"
} ],
"text": "Kostenträger",
"type": "group",
"linkId": "coverage",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-servicerequest#ServiceRequest.insurance"
}, {
"item": [ {
"item": [ {
"item": [ {
"text": "Titel",
"type": "string",
"linkId": "sender.author.practitioner.title",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.prefix"
}, {
"text": "Name",
"type": "string",
"linkId": "sender.author.practitioner.familyName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.family"
}, {
"text": "Vorname",
"type": "string",
"linkId": "sender.author.practitioner.givenName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.given"
}, {
"text": "GLN",
"type": "string",
"linkId": "sender.author.practitioner.gln",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.identifier:GLN.value"
}, {
"text": "ZSR",
"type": "string",
"linkId": "sender.author.practitioner.zsr",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.identifier:ZSR.value"
}, {
"text": "Telefon",
"type": "string",
"linkId": "sender.author.practitioner.phone",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.telecom.value"
}, {
"text": "E-Mail",
"type": "string",
"linkId": "sender.author.practitioner.email",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.telecom.value"
} ],
"text": "Verantwortliche Person",
"type": "group",
"linkId": "sender.author.practitioner",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole.practitioner"
}, {
"item": [ {
"text": "Name der Organisation",
"type": "string",
"linkId": "sender.author.organization.name",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.name"
}, {
"text": "GLN",
"type": "string",
"linkId": "sender.author.organization.gln",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.identifier:GLN"
}, {
"text": "Strasse, Hausnummer, Postfach etc.",
"type": "string",
"linkId": "sender.author.organization.streetAddressLine",
"repeats": true,
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.address.line"
}, {
"text": "PLZ",
"type": "string",
"linkId": "sender.author.organization.postalCode",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.address.postalCode"
}, {
"text": "Ort",
"type": "string",
"linkId": "sender.author.organization.city",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.address.city"
}, {
"text": "Land",
"type": "string",
"linkId": "sender.author.organization.country",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-organization#Organization.address.country"
} ],
"text": "Verantwortliche Organisation",
"type": "group",
"linkId": "sender.author.organization",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole.organization"
} ],
"text": "Verantwortlicher",
"type": "group",
"linkId": "sender.author",
"required": true,
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-composition#Composition.author"
}, {
"item": [ {
"item": [ {
"text": "Name",
"type": "string",
"linkId": "sender.dataenterer.practitioner.familyName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.family"
}, {
"text": "Vorname",
"type": "string",
"linkId": "sender.dataenterer.practitioner.givenName",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.name.given"
}, {
"text": "Telefon",
"type": "string",
"linkId": "sender.dataenterer.practitioner.phone",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.telecom.value"
}, {
"text": "E-Mail",
"type": "string",
"linkId": "sender.dataenterer.practitioner.email",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitioner#Practitioner.telecom.value"
} ],
"text": "Erfassende Person",
"type": "group",
"linkId": "sender.dataenterer.practitioner",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole.practitioner"
} ],
"text": "Erfasser",
"type": "group",
"linkId": "sender.dataenterer",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-composition#Composition.extension: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": "Gesundheitsfachperson",
"type": "group",
"linkId": "receiverCopy.practitionerRole.practitioner",
"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": "Gesundheitsorganisatiton",
"type": "group",
"linkId": "receiverCopy.practitionerRole.organization",
"definition": "http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-practitionerrole#PractitionerRole.organization"
} ],
"text": "Gesundheitsfachperson oder -organisation",
"type": "group",
"linkId": "receiverCopy.practitionerRole",
"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 (Kopie dieses Auftrags und aller daraus resultierenden Resultate)",
"type": "group",
"linkId": "receiverCopy",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-composition#Composition.extension:copyReceiver"
}, {
"item": [ {
"item": [ {
"text": "Name",
"type": "string",
"linkId": "appointment.location.name",
"required": true,
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-location#Location.name"
}, {
"text": "Telefon",
"type": "string",
"linkId": "appointment.location.phone",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-location#Location.telecom.value"
}, {
"text": "E-Mail",
"type": "string",
"linkId": "appointment.location.email",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-location#Location.telecom.value"
}, {
"text": "Strasse, Hausnummer, Postfach etc.",
"type": "string",
"linkId": "appointment.location.streetAddressLine",
"repeats": true,
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-location#Location.address.line"
}, {
"text": "PLZ",
"type": "string",
"linkId": "appointment.location.postalCode",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-location#Location.address.postalCode"
}, {
"text": "Ort",
"type": "string",
"linkId": "appointment.location.city",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-location#Location.address.city"
}, {
"text": "Land",
"type": "string",
"linkId": "appointment.location.country",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-location#Location.address.country"
} ],
"text": "Ort der Durchführung",
"type": "group",
"linkId": "appointment.location",
"required": true,
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-appointment#Appointment.participant.actor"
}, {
"item": [ {
"text": "Von",
"type": "dateTime",
"linkId": "appointment.requestedPeriod.start",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-appointment#Appointment.requestedPeriod.start"
}, {
"text": "Bis",
"type": "dateTime",
"linkId": "appointment.requestedPeriod.end",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-appointment#Appointment.requestedPeriod.end"
} ],
"text": "Datum und Zeit, wann der Termin bevorzugt geplant werden soll",
"type": "group",
"linkId": "appointment.requestedPeriod",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-appointment#Appointment.requestedPeriod"
}, {
"text": "Status",
"type": "choice",
"linkId": "appointment.status",
"required": true,
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-appointment#Appointment.status",
"answerOption": [ {
"valueCoding": {
"code": "proposed",
"system": "http://hl7.org/fhir/appointmentstatus",
"display": "Wunsch des Patienten (vorgeschlagen)"
},
"initialSelected": true
}, {
"valueCoding": {
"code": "pending",
"system": "http://hl7.org/fhir/appointmentstatus",
"display": "Vom Patienten bestätigt, aber vom Leistungserbringer noch nicht (ausstehend)"
}
}, {
"valueCoding": {
"code": "booked",
"system": "http://hl7.org/fhir/appointmentstatus",
"display": "Vom Patienten und Leistungserbringer bestätigt (gebucht)"
}
} ]
}, {
"text": "Patienteninformation für diesen Termin",
"type": "string",
"linkId": "appointment.patientInstruction",
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-appointment#Appointment.patientInstruction"
} ],
"text": "Ort und Zeit der Durchführung der angeforderten Leistung",
"type": "group",
"linkId": "appointment",
"repeats": true,
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-servicerequest#ServiceRequest.extension:locationAndTime"
}, {
"item": [ {
"text": "Kommentar",
"type": "string",
"linkId": "note.text",
"required": true,
"definition": "http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-servicerequest#ServiceRequest.note.text"
} ],
"text": "Bemerkungen",
"type": "group",
"linkId": "note",
"repeats": true
} ],
"copyright": "CC-BY-SA-4.0",
"type": null,
"experimental": null,
"resourceType": "Questionnaire",
"title": "Order-Referral-Form",
"package_version": "orf-1.0.0",
"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",
"valueId": "Bundle"
}, {
"url": "type",
"valueCode": "Bundle"
}, {
"url": "description",
"valueString": "The Bundle that is to be used to pre-populate the form"
} ]
} ],
"status": "active",
"id": "9a194efb-1a37-489e-919d-b636213c69a2",
"kind": null,
"url": "http://fhir.ch/ig/ch-orf/Questionnaire/order-referral-form",
"version": "1.0.0",
"contact": [ {
"name": "HL7 Switzerland",
"telecom": [ {
"value": "https://www.hl7.ch/",
"system": "url"
} ]
} ]
}