# home-o2-adaptive-questionnaireresponse - Da Vinci - Documentation Templates and Rules v2.2.0

## Example QuestionnaireResponse: home-o2-adaptive-questionnaireresponse

Language: en

Profile: [DTR Questionnaire Response for adaptive form](StructureDefinition-dtr-questionnaireresponse-adapt.md)

* [LinkID](https://hl7.org/fhir/R4/formats.html#table): home-o2-adaptive-questionnaireresponse
  * [Text](https://hl7.org/fhir/R4/formats.html#table): 
  * [Definition](https://hl7.org/fhir/R4/formats.html#table): 
  * [Answer](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): Questionnaire:#home-o2-adaptive-questionnaire
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)1
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)
  * [Definition](https://hl7.org/fhir/R4/formats.html#table): 
  * [Answer](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): diagnosis
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](icon-q-string.png)2
  * [Text](https://hl7.org/fhir/R4/formats.html#table): Order Reason
  * [Definition](https://hl7.org/fhir/R4/formats.html#table): 
  * [Answer](https://hl7.org/fhir/R4/formats.html#table)![](data:image/png;base64, ): example.org: 4 (Replacement)
* [LinkID](https://hl7.org/fhir/R4/formats.html#table): ![](data:image/png;base64, ) Documentation for this format

#### Contained resources



## Resource Content

```json
{
  "resourceType" : "QuestionnaireResponse",
  "id" : "home-o2-adaptive-questionnaireresponse",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaireresponse-adapt"]
  },
  "language" : "en",
  "contained" : [{
    "resourceType" : "Questionnaire",
    "id" : "home-o2-adaptive-questionnaire",
    "meta" : {
      "profile" : ["http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaire-adapt"]
    },
    "text" : {
      "status" : "generated",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Example adaptive questionnaire contained in a QuestionnaireResposne</div>"
    },
    "extension" : [{
      "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive",
      "valueUrl" : "http://example.com/fhir/R4"
    },
    {
      "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/request-specific",
      "valueBoolean" : false
    }],
    "url" : "http://example.com/fhir/questionnaire",
    "name" : "HomeOxygenTherapyAdaptiveQuestionnaire",
    "title" : "Adaptive Home Oxygen Therapy Order Template",
    "derivedFrom" : ["http://hl7.org/fhir/us/davinci-dtr/dtr-questionnaire"],
    "status" : "draft",
    "subjectType" : ["Patient"],
    "date" : "2020-01-16T00:00:00+00:00",
    "publisher" : "Da Vinci DTR",
    "contact" : [{
      "name" : "Example Author"
    }],
    "item" : [{
      "linkId" : "1",
      "text" : "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)",
      "type" : "text",
      "required" : true
    },
    {
      "linkId" : "2",
      "text" : "Order Reason",
      "type" : "choice",
      "required" : true,
      "answerOption" : [{
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "1",
          "display" : "Initial or original order for certification"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "2",
          "display" : "Change in status"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "3",
          "display" : "Revision or change in equipment"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "4",
          "display" : "Replacement"
        }
      }]
    }]
  }],
  "extension" : [{
    "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-coverage",
    "valueReference" : {
      "reference" : "Coverage/CoverageExample"
    }
  },
  {
    "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse",
    "valueCodeableConcept" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/davinci-crd/CodeSystem/coverage-information-codes",
        "code" : "withorder",
        "display" : "Include with order"
      }]
    }
  },
  {
    "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context",
    "valueReference" : {
      "reference" : "ServiceRequest/ServiceRequestExample"
    }
  }],
  "questionnaire" : "#home-o2-adaptive-questionnaire",
  "status" : "completed",
  "subject" : {
    "reference" : "Patient/examplepatient",
    "display" : "Vlad"
  },
  "authored" : "2022-01-26T20:36:57.544Z",
  "item" : [{
    "linkId" : "1",
    "text" : "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)",
    "answer" : [{
      "extension" : [{
        "extension" : [{
          "url" : "source",
          "valueCode" : "auto-server"
        }],
        "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
      }],
      "valueString" : "diagnosis"
    }]
  },
  {
    "linkId" : "2",
    "text" : "Order Reason",
    "answer" : [{
      "extension" : [{
        "extension" : [{
          "url" : "source",
          "valueCode" : "auto-server"
        }],
        "url" : "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin"
      }],
      "valueCoding" : {
        "system" : "http://example.org",
        "code" : "4",
        "display" : "Replacement"
      }
    }]
  }]
}

```
