# Home Oxygen Therapy Order Template - Da Vinci - Documentation Templates and Rules v2.2.0

## Questionnaire: Home Oxygen Therapy Order Template 

*  [Tree view](#tabs-tree) 
*  [Sample Rendering](#tabs-sample) 
*  [Form Logic](#tabs-logic) 

### Test this Questionnaire

### Responses for this Questionnaire

There are currently no QuestionnaireResponse instances for this Questionnaire defined in this IG.



## Resource Content

```json
{
  "resourceType" : "Questionnaire",
  "id" : "home-o2-std-questionnaire",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-std-questionnaire|2.2.0"]
  },
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/artifact-versionAlgorithm",
    "valueCoding" : {
      "system" : "http://hl7.org/fhir/version-algorithm",
      "code" : "semver"
    }
  },
  {
    "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/questionnaireAudience",
    "valueCode" : "clinical"
  },
  {
    "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/request-specific",
    "valueBoolean" : false
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/rendering-styleSensitive",
    "valueBoolean" : false
  },
  {
    "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-entryMode",
    "valueCode" : "sequential"
  },
  {
    "extension" : [{
      "url" : "totalTime",
      "valueCode" : "over-5min"
    },
    {
      "url" : "clinicalTime",
      "valueCode" : "under-3min"
    }],
    "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/estimated-completion-time"
  }],
  "url" : "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/home-o2-std-questionnaire",
  "version" : "2.2.0",
  "name" : "HomeOxygenTherapyStdQuestionnaire",
  "title" : "Home Oxygen Therapy Order Template",
  "status" : "draft",
  "subjectType" : ["Patient"],
  "date" : "2020-01-13T00:00:00+00:00",
  "publisher" : "HL7 International / Clinical Decision Support",
  "contact" : [{
    "name" : "HL7 International / Clinical Decision Support",
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/dss"
    }]
  }],
  "jurisdiction" : [{
    "coding" : [{
      "system" : "urn:iso:std:iso:3166",
      "code" : "US"
    }]
  }],
  "item" : [{
    "linkId" : "1",
    "text" : "Patient Information",
    "type" : "group",
    "item" : [{
      "linkId" : "1.1",
      "text" : "Last Name",
      "type" : "string",
      "required" : true
    },
    {
      "linkId" : "1.2",
      "text" : "Fist Name",
      "type" : "string",
      "required" : true
    },
    {
      "linkId" : "1.3",
      "text" : "Middle Name",
      "type" : "string",
      "required" : false
    },
    {
      "linkId" : "1.gender",
      "definition" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-question-library#Demographics.sex",
      "text" : "What is this person's gender?",
      "type" : "choice",
      "required" : true,
      "answerValueSet" : "http://hl7.org/fhir/ValueSet/relatedperson-relationshiptype"
    },
    {
      "linkId" : "1.4",
      "text" : "Date Of Birth",
      "type" : "date"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/minValue",
        "valueDecimal" : 1
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/maxValue",
        "valueDecimal" : 400
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/maxDecimalPlaces",
        "valueInteger" : 2
      }],
      "linkId" : "1.5",
      "text" : "Enter your weight in lb",
      "type" : "decimal"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/mimeType",
        "valueCode" : "image/jpeg"
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/maxSize",
        "valueDecimal" : 1048576
      }],
      "linkId" : "1.6",
      "text" : "Attach latest x-ray",
      "type" : "attachment"
    }]
  },
  {
    "linkId" : "2",
    "text" : "Calculation",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "extension" : [{
            "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/alternativeExpression",
            "valueExpression" : {
              "language" : "application/elm+json",
              "expression" : "corresponding elm data"
            }
          }],
          "description" : "deadline for submission",
          "language" : "text/fhirpath",
          "expression" : "today() + 7 days"
        }
      }],
      "linkId" : "2.1",
      "text" : "Deadline for submission (7 days from now)",
      "type" : "date",
      "readOnly" : true
    }]
  }]
}

```
