# Referred Questionnaire for QuestionnaireResponse - Da Vinci - Documentation Templates and Rules v2.2.0

## Questionnaire: Referred Questionnaire for QuestionnaireResponse 

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

### Test this Questionnaire

### Responses for this Questionnaire

* [An example [QuestionnaireResponse](StructureDefinition-dtr-questionnaireresponse.html) for Home Oxygen Therapy.](QuestionnaireResponse-home-o2-questionnaireresponse.md)



## Resource Content

```json
{
  "resourceType" : "Questionnaire",
  "id" : "referred-questionnaire",
  "url" : "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/referred-questionnaire",
  "version" : "2.2.0",
  "title" : "Referred Questionnaire for QuestionnaireResponse",
  "derivedFrom" : ["http://hl7.org/fhir/us/davinci-dtr/dtr-questionnaire"],
  "status" : "active",
  "subjectType" : ["Patient"],
  "date" : "2023-08-21T00:00:00+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 but Different This Time",
      "type" : "text"
    },
    {
      "linkId" : "1.2",
      "text" : "First Name",
      "type" : "text"
    },
    {
      "linkId" : "1.3",
      "text" : "Middle Initial",
      "type" : "text"
    },
    {
      "linkId" : "1.4",
      "text" : "Date Of Birth",
      "type" : "date"
    },
    {
      "linkId" : "1.5",
      "text" : "Gender",
      "type" : "choice",
      "answerValueSet" : "http://hl7.org/fhir/ValueSet/administrative-gender"
    },
    {
      "linkId" : "1.6",
      "text" : "Medicare ID",
      "type" : "text"
    }]
  },
  {
    "linkId" : "2",
    "text" : "Provider who is performing face-to-face evaluation",
    "type" : "group",
    "item" : [{
      "linkId" : "2.1",
      "text" : "Last Name",
      "type" : "text"
    },
    {
      "linkId" : "2.2",
      "text" : "First Name",
      "type" : "text"
    },
    {
      "linkId" : "2.3",
      "text" : "Middle Initial",
      "type" : "text"
    },
    {
      "linkId" : "2.4",
      "text" : "NPI",
      "type" : "text"
    },
    {
      "linkId" : "2.5",
      "text" : "Date of Face-To-Face Evaluation",
      "type" : "date"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource",
        "valueCode" : "Patient"
      }],
      "linkId" : "2.6",
      "text" : "Record",
      "type" : "reference",
      "required" : true
    }]
  },
  {
    "linkId" : "3",
    "text" : "Coverage Requirements",
    "type" : "group",
    "item" : [{
      "linkId" : "3.1",
      "text" : "Relevant Patient Diagnoses (conditions that might be expected to improve with oxygen therapy)",
      "type" : "choice",
      "answerOption" : [{
        "valueCoding" : {
          "system" : "http://snomed.info/sct",
          "code" : "313296004",
          "display" : "Mild chronic obstructive pulmonary disease"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://snomed.info/sct",
          "code" : "389087006",
          "display" : "Hypoxemia (disorder)"
        }
      }]
    },
    {
      "linkId" : "3.2",
      "text" : "Arterial oxygen saturation (Patient on room air while at rest and awake when tested)",
      "type" : "quantity"
    },
    {
      "linkId" : "3.3",
      "text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient on room air while at rest and awake when tested)",
      "type" : "quantity"
    },
    {
      "linkId" : "3.4",
      "text" : "Arterial oxygen saturation (Patient tested during exercise)",
      "type" : "quantity"
    },
    {
      "linkId" : "3.5",
      "text" : "Arterial Partial Pressure of Oxygen (PO2) (Patient tested during exercise)",
      "type" : "quantity"
    },
    {
      "linkId" : "3.6",
      "text" : "Is there a documented improvement of hypoxemia during exercise with oxygen?",
      "type" : "boolean"
    }]
  },
  {
    "linkId" : "4",
    "text" : "Prescribed Use",
    "type" : "group",
    "item" : [{
      "linkId" : "4.1",
      "text" : "Start date",
      "type" : "date"
    },
    {
      "linkId" : "4.2",
      "text" : "Length of need: (months) (99 = lifetime)",
      "type" : "quantity"
    },
    {
      "linkId" : "4.3",
      "text" : "Peak Flow Rate",
      "type" : "group",
      "item" : [{
        "linkId" : "4.3.1",
        "text" : "LPM",
        "type" : "quantity"
      },
      {
        "linkId" : "4.3.2",
        "text" : "oxygen %",
        "type" : "quantity"
      }]
    },
    {
      "linkId" : "4.4",
      "text" : "Average Flow Rate",
      "type" : "group",
      "item" : [{
        "linkId" : "4.4.1",
        "text" : "LPM",
        "type" : "quantity"
      },
      {
        "linkId" : "4.4.2",
        "text" : "oxygen %",
        "type" : "quantity"
      }]
    },
    {
      "linkId" : "4.5",
      "text" : "Frequency of use (choose all that apply)",
      "type" : "text"
    }]
  },
  {
    "linkId" : "5",
    "text" : "Oxygen Supply Order Details",
    "type" : "group",
    "item" : [{
      "linkId" : "5.1",
      "text" : "Current Order Description",
      "type" : "text"
    },
    {
      "linkId" : "5.1b",
      "text" : "Current Order Is For A Portable Device",
      "type" : "boolean"
    },
    {
      "linkId" : "5.2",
      "text" : "Type",
      "type" : "choice",
      "answerOption" : [{
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "121",
          "display" : "Liquid"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "122",
          "display" : "Compressed Gas"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "123",
          "display" : "Concentrator"
        }
      }]
    },
    {
      "linkId" : "5.3",
      "text" : "Means of oxygen delivery and accessories",
      "type" : "choice",
      "answerOption" : [{
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "131",
          "display" : "Nasal cannula"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "132",
          "display" : "Non-rebreather"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "133",
          "display" : "Ventilator"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "134",
          "display" : "Mask"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "135",
          "display" : "PAP bleed in"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "136",
          "display" : "Oxygen conserving device"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org",
          "code" : "137",
          "display" : "High flow oxygen therapy"
        }
      }]
    }]
  }]
}

```
