{
"description": null,
"_filename": "Questionnaire-2-pertussis.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-extract" ],
"versionId": "1",
"lastUpdated": "2019-04-01T22:17:53.340+02:00"
},
"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": "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
}, {
"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": "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"
}, {
"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": "Pertussis and Parapertussis DNA",
"type": "choice",
"linkId": "per",
"repeats": true,
"answerOption": [ {
"valueCoding": {
"code": "90441-7",
"system": "http://loinc.org",
"display": "B pert+parapert DNA Pnl Nph"
}
} ]
} ],
"text": "Mikrobiologie",
"type": "group",
"linkId": "microbiology"
}, {
"item": [ {
"text": "Manual Differential panel - Blood",
"type": "choice",
"linkId": "Blood-diff",
"repeats": true,
"answerOption": [ {
"valueCoding": {
"code": "24318-8",
"system": "http://loinc.org",
"display": "Manual diff Bld"
}
} ]
} ],
"text": "Hämatologie",
"type": "group",
"linkId": "hematology"
}, {
"item": [ {
"text": "C-reactive Protein",
"type": "choice",
"linkId": "crp",
"repeats": true,
"answerOption": [ {
"valueCoding": {
"code": "1988-5",
"system": "http://loinc.org",
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