Generated Narrative: Questionnaire MNACQuestionnaire Structure LinkID Text Cardinality Type Description & Constraints MNACQuestionnaire This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. Questionnaire http://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire#2.0.0-cibuild #xD; request-info Request Information 0..1 group #xD; request-info|date-of-request DATE OF REQUEST 0..1 date #xD; diagnosis-info Diagnosis Information 0..1 group #xD; diagnosis-info|diagnosis Diagnosis 0..1 string #xD; item-requested Item Requested 0..1 group #xD; item-requested|item Item requested 0..1 string #xD; uti-history UTI History 0..1 group #xD; uti-history|uti-last-year 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 0..1 boolean #xD; uti-history|uti-dates Dates of UTIs in the last year 0..1 string Enable When: uti-history|uti-last-year = true #xD; uti-history|antibiotics-used Antibiotics used for UTIs in the last year 0..1 string Enable When: uti-history|uti-last-year = true #xD; symptoms-info Symptoms Information 0..1 group #xD; symptoms-info|symptoms Check those that apply to your patient 0..* choice Options: 7 options #xD; symptoms-info|fever-temperature If fever, state temperature in degrees 0..1 decimal Enable When: symptoms-info|symptoms = Fever (MNACQuestionnaire-symptoms-info-symptoms#Fever) #xD; catheterization-frequency Catheterization Frequency 0..1 group #xD; catheterization-frequency|frequency How many times per day does the patient catheterize? 0..1 choice Options: 4 options #xD; additional-comments Additional Comments 0..1 group #xD; additional-comments|comments Additional Comment 0..1 string #xD; physician-info Physician Information 0..1 group #xD; physician-info|name Physician's Name 0..1 string #xD; physician-info|mobile Telephone 0..1 string #xD; physician-info|fax FAX 0..1 string #xD; physician-info|signature Physician's Signature 0..1 attachment #xD; physician-info|phone-referring Referring Physician Telephone 0..1 string #xD; physician-info|date Date 0..1 string #xD; Documentation for this format Options Sets Answer options for symptoms-info|symptoms http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Fever ("Fever; state temperature in degree") http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#UrinaryUrgencyFrequency ("Change in urinary urgency, frequency, or incontinence") http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#AutonomicDysreflexia ("Appearance of new or increase in autonomic dysreflexia") http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#PhysicalSignsProstatitis ("Physical signs of prostatitis, epididymitis, orchitis") http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Immunosuppressed ("The patient is immunosuppressed") http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Pyuria ("Pyuria") http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#SystemicLeukocytosis ("Systemic leukocytosis") Answer options for catheterization-frequency|frequency http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#2-4Times ("2-4 times") http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#4-6Times ("4-6 times") http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#6-8Times ("6-8 times") http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#8TimesOrMore ("8 times or more") Contained Resources Metadata Type module-definition from http://terminology.hl7.org/CodeSystem/library-type Dependency Description: USCore model information Resource: US Core Model Informationversion: null6.1.0-derived) Canonical URL: http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived Dependency Description: FHIR model information Resource: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1 Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1 Parameters Parameter None Generated using version 0.5.3-cibuild of the sample-content-ig Liquid templates
The patient that is to be used to pre-populate the form
The ServiceRequest that is to be used to pre-populate the form
Example Medical Necessity For Authorization Of Catheters Questionnaire
HL7 International / Clinical Decision Support
This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.
This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf
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
Antibiotics used for UTIs in the last year
Change in urinary urgency, frequency, or incontinence
Appearance of new or increase in autonomic dysreflexia
Physical signs of prostatitis, epididymitis, orchitis
How many times per day does the patient catheterize?