Da Vinci - Documentation Templates and Rules
2.2.0 - STU 2.2

Da Vinci - Documentation Templates and Rules, published by HL7 International / Clinical Decision Support. This guide is not an authorized publication; it is the continuous build for version 2.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-dtr/ and changes regularly. See the Directory of published versions

## Questionnaire: Referred Questionnaire for QuestionnaireResponse

Official URL: http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire | Version: 2.2.0 | Highlight text changes?
Standards status: Informative Active as of 2023-08-21 | Computable Name:

- Tree view
- Sample Rendering
- Form Logic

Structure

LinkID | Text | Cardinality | Type | Description & Constraints
--- | --- | --- | --- | ---
|  |  | Questionnaire | http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire#2.2.0
1 | Patient Information | 0..1 | group | Value Set:
1.1 | Last Name but Different This Time | 0..1 | text | Value Set:
1.2 | First Name | 0..1 | text | Value Set:
1.3 | Middle Initial | 0..1 | text | Value Set:
1.4 | Date Of Birth | 0..1 | date | Value Set:
1.5 | Gender | 0..1 | choice | Value Set: AdministrativeGender
1.6 | Medicare ID | 0..1 | text | Value Set:
2 | Provider who is performing face-to-face evaluation | 0..1 | group | Value Set:
2.1 | Last Name | 0..1 | text | Value Set:
2.2 | First Name | 0..1 | text | Value Set:
2.3 | Middle Initial | 0..1 | text | Value Set:
2.4 | NPI | 0..1 | text | Value Set:
2.5 | Date of Face-To-Face Evaluation | 0..1 | date | Value Set:
2.6 | Record | 1..1 | reference | Value Set:
3 | Coverage Requirements | 0..1 | group | Value Set:
3.1 | Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy) | 0..1 | choice | Value Set: Options: 2 options
3.2 | Arterial oxygen saturation (Patient on room air while at rest and awake when tested) | 0..1 | quantity | Value Set:
3.3 | Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested) | 0..1 | quantity | Value Set:
3.4 | Arterial oxygen saturation (Patient tested during exercise) | 0..1 | quantity | Value Set:
3.5 | Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise) | 0..1 | quantity | Value Set:
3.6 | Is there a documented improvement of hypoxemia during exercise with oxygen? | 0..1 | boolean | Value Set:
4 | Prescribed Use | 0..1 | group | Value Set:
4.1 | Start date | 0..1 | date | Value Set:
4.2 | Length of need: (months) (99 = lifetime) | 0..1 | quantity | Value Set:
4.3 | Peak Flow Rate | 0..1 | group | Value Set:
4.3.1 | LPM | 0..1 | quantity | Value Set:
4.3.2 | oxygen % | 0..1 | quantity | Value Set:
4.4 | Average Flow Rate | 0..1 | group | Value Set:
4.4.1 | LPM | 0..1 | quantity | Value Set:
4.4.2 | oxygen % | 0..1 | quantity | Value Set:
4.5 | Frequency of use (choose all that apply) | 0..1 | text | Value Set:
5 | Oxygen Supply Order Details | 0..1 | group | Value Set:
5.1 | Current Order Description | 0..1 | text | Value Set:
5.1b | Current Order Is For A Portable Device | 0..1 | boolean | Value Set:
5.2 | Type | 0..1 | choice | Value Set: Options: 3 options
5.3 | Means of oxygen delivery and accessories | 0..1 | choice | Value Set: Options: 7 options
Documentation for this format

Options Sets

Answer options for 3.1

- http://snomed.info/sct#313296004 ("Mild chronic obstructive pulmonary disease")
- http://snomed.info/sct#389087006 ("Hypoxemia (disorder)")

Answer options for 5.2

- http://example.org#121 ("Liquid")
- http://example.org#122 ("Compressed Gas")
- http://example.org#123 ("Concentrator")

Answer options for 5.3

- http://example.org#131 ("Nasal cannula")
- http://example.org#132 ("Non-rebreather")
- http://example.org#133 ("Ventilator")
- http://example.org#134 ("Mask")
- http://example.org#135 ("PAP bleed in")
- http://example.org#136 ("Oxygen conserving device")
- http://example.org#137 ("High flow oxygen therapy")

Patient Information

- linkId: 1
- Answers:

Last Name but Different This Time

- linkId: 1.1
- Answers:

First Name

- linkId: 1.2
- Answers:

Middle Initial

- linkId: 1.3
- Answers:

Date Of Birth

- linkId: 1.4
- Answers:

Gender

- linkId: 1.5
- Answers: AdministrativeGender

Medicare ID

- linkId: 1.6
- Answers:

Provider who is performing face-to-face evaluation

- linkId: 2
- Answers:

Last Name

- linkId: 2.1
- Answers:

First Name

- linkId: 2.2
- Answers:

Middle Initial

- linkId: 2.3
- Answers:

NPI

- linkId: 2.4
- Answers:

Date of Face-To-Face Evaluation

- linkId: 2.5
- Answers:

Record*

- linkId: 2.6
- Answers:

Coverage Requirements

- linkId: 3
- Answers:

Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)

- linkId: 3.1
- Answers:
- Answers: 2 options

Arterial oxygen saturation (Patient on room air while at rest and awake when tested)

- linkId: 3.2
- Answers:

Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)

- linkId: 3.3
- Answers:

Arterial oxygen saturation (Patient tested during exercise)

- linkId: 3.4
- Answers:

Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)

- linkId: 3.5
- Answers:

Is there a documented improvement of hypoxemia during exercise with oxygen?

- linkId: 3.6
- Answers:

Prescribed Use

- linkId: 4
- Answers:

Start date

- linkId: 4.1
- Answers:

Length of need: (months) (99 = lifetime)

- linkId: 4.2
- Answers:

Peak Flow Rate

- linkId: 4.3
- Answers:

LPM

- linkId: 4.3.1
- Answers:

oxygen %

- linkId: 4.3.2
- Answers:

Average Flow Rate

- linkId: 4.4
- Answers:

LPM

- linkId: 4.4.1
- Answers:

oxygen %

- linkId: 4.4.2
- Answers:

Frequency of use (choose all that apply)

- linkId: 4.5
- Answers:

Oxygen Supply Order Details

- linkId: 5
- Answers:

Current Order Description

- linkId: 5.1
- Answers:

Current Order Is For A Portable Device

- linkId: 5.1b
- Answers:

Type

- linkId: 5.2
- Answers:
- Answers: 3 options

Means of oxygen delivery and accessories

- linkId: 5.3
- Answers:
- Answers: 7 options

LinkID | Description & Constraints
--- | ---
1 | Value Set:
1.1 | Value Set:
1.2 | Value Set:
1.3 | Value Set:
1.4 | Value Set:
1.5 | Value Set: AdministrativeGender
1.6 | Value Set:
2 | Value Set:
2.1 | Value Set:
2.2 | Value Set:
2.3 | Value Set:
2.4 | Value Set:
2.5 | Value Set:
2.6 | Value Set:
3 | Value Set:
3.1 | Value Set: Options: 2 options
3.2 | Value Set:
3.3 | Value Set:
3.4 | Value Set:
3.5 | Value Set:
3.6 | Value Set:
4 | Value Set:
4.1 | Value Set:
4.2 | Value Set:
4.3 | Value Set:
4.3.1 | Value Set:
4.3.2 | Value Set:
4.4 | Value Set:
4.4.1 | Value Set:
4.4.2 | Value Set:
4.5 | Value Set:
5 | Value Set:
5.1 | Value Set:
5.1b | Value Set:
5.2 | Value Set: Options: 3 options
5.3 | Value Set: Options: 7 options
Documentation for this format

### Test this Questionnaire

Try this questionnaire out:

- NLM Forms Library

### Responses for this Questionnaire

- An example [QuestionnaireResponse](StructureDefinition-dtr-questionnaireresponse.html) for Home Oxygen Therapy.