Da Vinci - Documentation Templates and Rules
2.2.0 - STU 2.2 United States of America flag

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
Standards status: Informative Active as of 2023-08-21 Computable Name:

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. 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:
.... 4.1 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

doco 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

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)

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

Means of oxygen delivery and accessories

LinkIDDescription & Constraintsdoco
.. 1 Value Set:
... 1.1 Value Set:
... 1.2 Value Set:
... 1.3 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

doco Documentation for this format

Test this Questionnaire

Try this questionnaire out:

Responses for this Questionnaire