{
  "description": null,
  "_filename": "Questionnaire-1-tvt.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": "Titel",
      "type": "string",
      "linkId": "order.title"
    }, {
      "text": "Typ",
      "type": "choice",
      "linkId": "order.type",
      "answerValueSet": "http://fhir.ch/ig/ch-epr-term/ValueSet/DocumentEntry.typeCode"
    }, {
      "text": "Kategorie",
      "type": "choice",
      "linkId": "order.category",
      "answerValueSet": "http://fhir.ch/ig/ch-epr-term/ValueSet/DocumentEntry.classCode"
    }, {
      "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": "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": "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": "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": "Patient",
    "type": "group",
    "linkId": "patient"
  }, {
    "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": "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": [ {
        "text": "Name der Organisation",
        "type": "string",
        "linkId": "receiverCopy.organization.name"
      }, {
        "text": "Titel",
        "type": "string",
        "linkId": "receiverCopy.title"
      }, {
        "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
    } ],
    "text": "Kopieempfänger",
    "type": "group",
    "linkId": "receiverCopies"
  }, {
    "item": [ {
      "text": "Hämatologie Subset",
      "type": "choice",
      "linkId": "hemato-subset",
      "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": "D-Dimer",
      "type": "choice",
      "linkId": "d-dimer",
      "repeats": true,
      "answerOption": [ {
        "valueCoding": {
          "code": "55398-2",
          "system": "http://loinc.org",
          "display": "Short Fibrin D-dimer FEU and DDU panel - Platelet poor plasma"
        }
      } ]
    } ],
    "text": "Coagulation",
    "type": "group",
    "linkId": "coagulation"
  }, {
    "item": [ {
      "text": "CRP",
      "type": "choice",
      "linkId": "crp",
      "repeats": true,
      "answerOption": [ {
        "valueCoding": {
          "code": "1988-5",
          "system": "http://loinc.org",
          "display": "C reactive protein [Mass/Volume] in Serum or Plasma"
        },
        "initialSelected": true
      }, {
        "valueCoding": {
          "code": "76485-2",
          "system": "http://loinc.org",
          "display": "C reactive protein [Moles/volume] in Serum or Plasma"
        }
      }, {
        "valueCoding": {
          "code": "30522-7",
          "system": "http://loinc.org",
          "display": "C reactive protein [Mass/volume] in Serum or Plasma by High sensitivity method"
        }
      }, {
        "valueCoding": {
          "code": "76486-0",
          "system": "http://loinc.org",
          "display": "C reactive protein [Moles/volume] in Serum or Plasma by High sensitivity method"
        }
      } ]
    } ],
    "text": "clinical chemistry",
    "type": "group",
    "linkId": "cc"
  }, {
    "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"
  } ],
  "copyright": "CC-BY-SA-4.0",
  "type": null,
  "experimental": null,
  "resourceType": "Questionnaire",
  "title": "Lab Order Form Example",
  "package_version": "0.1.0",
  "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": "c83ed17f-0419-4a83-a319-646387ae4742",
  "kind": null,
  "url": "http://fhir.ch/ig/ch-lab-order/Questionnaire/1-tvt",
  "version": "0.1.0",
  "contact": [ {
    "name": "HL7 Switzerland",
    "telecom": [ {
      "value": "https://www.hl7.ch/",
      "system": "url"
    } ]
  }, {
    "name": "Marcel Hanselmann",
    "telecom": [ {
      "value": "marcel.hanselmann@bluewin.ch",
      "system": "email"
    } ]
  } ]
}