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

Last Name but Different This Time

  • linkId: 1.1

First Name

  • linkId: 1.2

Middle Initial

  • linkId: 1.3

Date Of Birth

  • linkId: 1.4

Gender

Medicare ID

  • linkId: 1.6

Provider who is performing face-to-face evaluation

  • linkId: 2

Last Name

  • linkId: 2.1

First Name

  • linkId: 2.2

Middle Initial

  • linkId: 2.3

NPI

  • linkId: 2.4

Date of Face-To-Face Evaluation

  • linkId: 2.5

Record*

  • linkId: 2.6

Coverage Requirements

  • linkId: 3

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

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

  • linkId: 3.3

Arterial oxygen saturation (Patient tested during exercise)

  • linkId: 3.4

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

  • linkId: 3.5

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

  • linkId: 3.6

Prescribed Use

  • linkId: 4

Start date

  • linkId: 4.1

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

  • linkId: 4.2

Peak Flow Rate

  • linkId: 4.3

LPM

  • linkId: 4.3.1

oxygen %

  • linkId: 4.3.2

Average Flow Rate

  • linkId: 4.4

LPM

  • linkId: 4.4.1

oxygen %

  • linkId: 4.4.2

Frequency of use (choose all that apply)

  • linkId: 4.5

Oxygen Supply Order Details

  • linkId: 5

Current Order Description

  • linkId: 5.1

Current Order Is For A Portable Device

  • linkId: 5.1b

Type

Means of oxygen delivery and accessories

LinkIDDescription & Constraintsdoco
.. 1
... 1.1
... 1.2
... 1.3
... 1.5 Value Set: AdministrativeGender
... 1.6
.. 2
... 2.1
... 2.2
... 2.3
... 2.4
... 2.5
... 2.6
.. 3
... 3.1 Options: 2 options
... 3.2
... 3.3
... 3.4
... 3.5
... 3.6
.. 4
... 4.1
... 4.2
... 4.3
.... 4.3.1
.... 4.3.2
... 4.4
.... 4.4.1
.... 4.4.2
... 4.5
.. 5
... 5.1
... 5.1b
... 5.2 Options: 3 options
... 5.3 Options: 7 options

doco Documentation for this format

Test this Questionnaire

Try this questionnaire out:

    Responses for this Questionnaire