{ "resourceType" : "Questionnaire", "id" : "MNACQuestionnaire", "language" : "en", "text" : { "status" : "extensions", "div" : "

Generated Narrative: Questionnaire MNACQuestionnaire

Structure\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
LinkIDTextCardinalityTypeDescription & Constraints\"doco\"
\".\"\".\" MNACQuestionnaireThis is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.Questionnairehttp://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire#2.0.0-cibuild
\".\"\".\"\".\" request-infoRequest Information0..1group
\".\"\".\"\".\"\".\" request-info|date-of-requestDATE OF REQUEST0..1date
\".\"\".\"\".\" diagnosis-infoDiagnosis Information0..1group
\".\"\".\"\".\"\".\" diagnosis-info|diagnosisDiagnosis0..1string
\".\"\".\"\".\" item-requestedItem Requested0..1group
\".\"\".\"\".\"\".\" item-requested|itemItem requested0..1string
\".\"\".\"\".\" uti-historyUTI History0..1group
\".\"\".\"\".\"\".\" uti-history|uti-last-yearThe patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing0..1boolean
\".\"\".\"\".\"\".\" uti-history|uti-datesDates of UTIs in the last year0..1stringEnable When: uti-history|uti-last-year = true
\".\"\".\"\".\"\".\" uti-history|antibiotics-usedAntibiotics used for UTIs in the last year0..1stringEnable When: uti-history|uti-last-year = true
\".\"\".\"\".\" symptoms-infoSymptoms Information0..1group
\".\"\".\"\".\"\".\" symptoms-info|symptomsCheck those that apply to your patient0..*choiceOptions: 7 options
\".\"\".\"\".\"\".\" symptoms-info|fever-temperatureIf fever, state temperature in degrees0..1decimalEnable When: symptoms-info|symptoms = Fever (MNACQuestionnaire-symptoms-info-symptoms#Fever)
\".\"\".\"\".\" catheterization-frequencyCatheterization Frequency0..1group
\".\"\".\"\".\"\".\" catheterization-frequency|frequencyHow many times per day does the patient catheterize?0..1choiceOptions: 4 options
\".\"\".\"\".\" additional-commentsAdditional Comments0..1group
\".\"\".\"\".\"\".\" additional-comments|commentsAdditional Comment0..1string
\".\"\".\"\".\" physician-infoPhysician Information0..1group
\".\"\".\"\".\"\".\" physician-info|namePhysician's Name0..1string
\".\"\".\"\".\"\".\" physician-info|mobileTelephone0..1string
\".\"\".\"\".\"\".\" physician-info|faxFAX0..1string
\".\"\".\"\".\"\".\" physician-info|signaturePhysician's Signature0..1attachment
\".\"\".\"\".\"\".\" physician-info|phone-referringReferring Physician Telephone0..1string
\".\"\".\"\".\"\".\" physician-info|dateDate0..1string

\"doco\" Documentation for this format

Options Sets

Answer options for symptoms-info|symptoms

Answer options for catheterization-frequency|frequency

Contained Resources

\n \n \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n \n \n \n \n \n\n\n\n\n \n \n \n\n\n\n \n \n \n \n \n\n\n\n\n \n \n \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n \n\n\n \n
Metadata
Type\n module-definition from http://terminology.hl7.org/CodeSystem/library-type \n\n\n
Dependency\n \n Description: USCore model information\n \n
\n \n \n \n \n \n \n Resource: US Core Model Informationversion: null6.1.0-derived)\n
\n Canonical URL: http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived\n \n \n \n
Dependency\n \n Description: FHIR model information\n \n
\n \n \n \n \n \n \n Resource: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1\n
\n Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1\n \n \n \n
Parameters
ParameterNone
Generated using version 0.5.3-cibuild of the sample-content-ig Liquid templates
\n
" }, "contained" : [{ "resourceType" : "Library", "id" : "effective-data-requirements", "name" : "EffectiveDataRequirements", "status" : "active", "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/library-type", "code" : "module-definition" }] }, "relatedArtifact" : [{ "type" : "depends-on", "display" : "USCore model information", "resource" : "http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived" }, { "type" : "depends-on", "display" : "FHIR model information", "resource" : "http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1" }] }], "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/cqf-library", "valueCanonical" : "http://hl7.org/fhir/us/cql/Library/MNACInitialExpressions" }, { "extension" : [{ "url" : "name", "valueCoding" : { "system" : "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext", "code" : "patient", "display" : "Patient" } }, { "url" : "type", "valueCode" : "Patient" }, { "url" : "description", "valueString" : "The patient that is to be used to pre-populate the form" }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext" }, { "extension" : [{ "url" : "name", "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/additionalLaunchContext", "code" : "ServiceRequest", "display" : "ServiceRequest" } }, { "url" : "type", "valueCode" : "ServiceRequest" }, { "url" : "description", "valueString" : "The ServiceRequest that is to be used to pre-populate the form" }], "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext" }, { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg", "valueCode" : "cds" }, { "url" : "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements", "valueCanonical" : "#effective-data-requirements" }, { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status", "valueCode" : "informative", "_valueCode" : { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom", "valueCanonical" : "http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql" }] } }], "url" : "http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire", "version" : "2.0.0-cibuild", "name" : "MNACQuestionnaire", "title" : "Example Medical Necessity For Authorization Of Catheters Questionnaire", "status" : "active", "experimental" : true, "date" : "2024-01-17T00:00:00+00:00", "publisher" : "HL7 International / Clinical Decision Support", "contact" : [{ "telecom" : [{ "system" : "url", "value" : "http://www.hl7.org/Special/committees/dss" }] }], "description" : "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.", "jurisdiction" : [{ "coding" : [{ "system" : "urn:iso:std:iso:3166", "code" : "US", "display" : "United States of America" }] }], "copyright" : "This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf", "item" : [{ "linkId" : "request-info", "text" : "Request Information", "type" : "group", "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Date of Request" } }], "linkId" : "request-info|date-of-request", "text" : "DATE OF REQUEST", "type" : "date" }] }, { "linkId" : "diagnosis-info", "text" : "Diagnosis Information", "type" : "group", "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Diagnosis" } }], "linkId" : "diagnosis-info|diagnosis", "text" : "Diagnosis", "type" : "string" }] }, { "linkId" : "item-requested", "text" : "Item Requested", "type" : "group", "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Item Requested" } }], "linkId" : "item-requested|item", "text" : "Item requested", "type" : "string" }] }, { "linkId" : "uti-history", "text" : "UTI History", "type" : "group", "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "UTI in Last Year" } }], "linkId" : "uti-history|uti-last-year", "text" : "The patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing", "type" : "boolean" }, { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Dates of UTIs" } }], "linkId" : "uti-history|uti-dates", "text" : "Dates of UTIs in the last year", "type" : "string", "enableWhen" : [{ "question" : "uti-history|uti-last-year", "operator" : "=", "answerBoolean" : true }] }, { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Antibiotics Used" } }], "linkId" : "uti-history|antibiotics-used", "text" : "Antibiotics used for UTIs in the last year", "type" : "string", "enableWhen" : [{ "question" : "uti-history|uti-last-year", "operator" : "=", "answerBoolean" : true }] }] }, { "linkId" : "symptoms-info", "text" : "Symptoms Information", "type" : "group", "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Check Symptoms" } }], "linkId" : "symptoms-info|symptoms", "text" : "Check those that apply to your patient", "type" : "choice", "repeats" : true, "answerOption" : [{ "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms", "code" : "Fever", "display" : "Fever; state temperature in degree" } }, { "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms", "code" : "UrinaryUrgencyFrequency", "display" : "Change in urinary urgency, frequency, or incontinence" } }, { "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms", "code" : "AutonomicDysreflexia", "display" : "Appearance of new or increase in autonomic dysreflexia" } }, { "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms", "code" : "PhysicalSignsProstatitis", "display" : "Physical signs of prostatitis, epididymitis, orchitis" } }, { "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms", "code" : "Immunosuppressed", "display" : "The patient is immunosuppressed" } }, { "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms", "code" : "Pyuria", "display" : "Pyuria" } }, { "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms", "code" : "SystemicLeukocytosis", "display" : "Systemic leukocytosis" } }] }, { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Fever Temperature" } }, { "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unit", "valueCoding" : { "system" : "http://unitsofmeasure.org", "code" : "deg", "display" : "deg" } }], "linkId" : "symptoms-info|fever-temperature", "text" : "If fever, state temperature in degrees", "type" : "decimal", "enableWhen" : [{ "question" : "symptoms-info|symptoms", "operator" : "=", "answerCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms", "code" : "Fever" } }] }] }, { "linkId" : "catheterization-frequency", "text" : "Catheterization Frequency", "type" : "group", "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Catheterization Frequency" } }], "linkId" : "catheterization-frequency|frequency", "text" : "How many times per day does the patient catheterize?", "type" : "choice", "answerOption" : [{ "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency", "code" : "2-4Times", "display" : "2-4 times" } }, { "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency", "code" : "4-6Times", "display" : "4-6 times" } }, { "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency", "code" : "6-8Times", "display" : "6-8 times" } }, { "valueCoding" : { "system" : "http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency", "code" : "8TimesOrMore", "display" : "8 times or more" } }] }] }, { "linkId" : "additional-comments", "text" : "Additional Comments", "type" : "group", "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Additional Comment" } }], "linkId" : "additional-comments|comments", "text" : "Additional Comment", "type" : "string" }] }, { "linkId" : "physician-info", "text" : "Physician Information", "type" : "group", "item" : [{ "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Physician Name" } }], "linkId" : "physician-info|name", "text" : "Physician's Name", "type" : "string" }, { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Physician Telephone" } }], "linkId" : "physician-info|mobile", "text" : "Telephone", "type" : "string" }, { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Physician Fax" } }], "linkId" : "physician-info|fax", "text" : "FAX", "type" : "string" }, { "linkId" : "physician-info|signature", "text" : "Physician's Signature", "type" : "attachment" }, { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Referring Physician Telephone" } }], "linkId" : "physician-info|phone-referring", "text" : "Referring Physician Telephone", "type" : "string" }, { "extension" : [{ "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression", "valueExpression" : { "language" : "text/cql-identifier", "expression" : "Date" } }], "linkId" : "physician-info|date", "text" : "Date", "type" : "string" }] }] }