New Zealand Rheumatic Fever FHIR Implementation Guide - Local Development build (v0.4.8) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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: Medications and Follow-up Guidance Questionnaire - XML Representation

Draft as of 2023-11-10

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<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="MedicationsAndFollowUpGuidanceQuestionnaire"/>
  <url
       value="https://fhir-ig.digital.health.nz/rheumatic-fever/Questionnaire/MedicationsAndFollowUpGuidanceQuestionnaire"/>
  <identifier>
    <use value="official"/>
    <value value="MedicationsAndFollowUpGuidanceQuestionnaire"/>
    <period>
      <start value="2023-10-16"/>
    </period>
  </identifier>
  <version value="1.0.0"/>
  <name value="MedicationsAndFollowUpGuidanceQuestionnaire"/>
  <title value="Medications and Follow-up Guidance Questionnaire"/>
  <status value="draft"/>
  <experimental value="false"/>
  <subjectType value="Patient"/>
  <date value="2023-11-10"/>
  <publisher value="Te Whatu Ora"/>
  <contact>
    <name value="Te Whatu Ora"/>
    <telecom>
      <system value="url"/>
      <value value="https://www.tewhatuora.govt.nz/"/>
    </telecom>
  </contact>
  <contact>
    <name value="David Grainger"/>
    <telecom>
      <system value="email"/>
      <value value="david.grainger@middleware.co.nz"/>
      <use value="work"/>
    </telecom>
  </contact>
  <description
               value="Gathers information in secondary prophylaxis planning which guides subsequent medication appointments and follow-up"/>
  <purpose
           value="Gathers information in secondary prophylaxis planning which guides subsequent medication appointments and follow-up"/>
  <item>
    <linkId value="page1"/>
    <prefix value="page1"/>
    <text
          value="Please complete this questionnaire to guide practitioners carrying out rheumatic fever secondary prophylaxis."/>
    <type value="display"/>
  </item>
  <item>
    <linkId value="SourceOfOralMedications"/>
    <prefix value="1)"/>
    <text value="Source of oral medications? (choose one)"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerOption>
      <valueString value="GP prescription"/>
    </answerOption>
    <answerOption>
      <valueString value="3 monthly visit from a nurse"/>
    </answerOption>
    <answerOption>
      <valueString value="Monthly visit from a nurse"/>
    </answerOption>
    <answerOption>
      <valueString value="Pick-up from a pharmacy"/>
    </answerOption>
    <answerOption>
      <valueString value="Other"/>
    </answerOption>
  </item>
  <item>
    <linkId value="CaseOnWarfarin"/>
    <prefix value="2)"/>
    <text value="Case on warfarin? (Yes/No/Unknown)"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerValueSet
                    value="https://fhir-ig.digital.health.nz/rheumatic-fever/ValueSet/nz-questionnaireresponse-qualifiedyesno-code"/>
  </item>
  <item>
    <linkId value="WarfarinSupervisionService"/>
    <prefix value="2.1)"/>
    <text value="Warfarin supervision service (choose one)"/>
    <type value="choice"/>
    <enableWhen>
      <question value="CaseOnWarfarin"/>
      <operator value="="/>
      <answerCoding>
        <system value="http://snomed.info/sct"/>
        <code value="373066001"/>
        <display value="Yes (qualifier value)"/>
      </answerCoding>
    </enableWhen>
    <required value="true"/>
    <repeats value="false"/>
    <answerOption>
      <valueString value="GP"/>
    </answerOption>
    <answerOption>
      <valueString value="Pharmacy"/>
    </answerOption>
    <answerOption>
      <valueString value="Hospital service"/>
    </answerOption>
    <answerOption>
      <valueString value="Patient"/>
    </answerOption>
    <answerOption>
      <valueString value="Whanau"/>
    </answerOption>
  </item>
  <item>
    <linkId value="MonitoringResultSource"/>
    <prefix value="3)"/>
    <text
          value="International normalised ratio (INR) monitoring result source (choose one)"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerOption>
      <valueString value="Patient"/>
    </answerOption>
    <answerOption>
      <valueString value="Parent"/>
    </answerOption>
    <answerOption>
      <valueString value="Éclair"/>
    </answerOption>
    <answerOption>
      <valueString value="GP"/>
    </answerOption>
    <answerOption>
      <valueString value="Pharmacy"/>
    </answerOption>
    <answerOption>
      <valueString value="INROnline"/>
    </answerOption>
    <answerOption>
      <valueString value="Other"/>
    </answerOption>
  </item>
  <item>
    <linkId value="FollowUpClinicalService"/>
    <prefix value="4)"/>
    <text value="Follow-up clinical service? (choose one)"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerOption>
      <valueString value="Specialist"/>
    </answerOption>
    <answerOption>
      <valueString value="GP"/>
    </answerOption>
    <answerOption>
      <valueString value="To be determined"/>
    </answerOption>
  </item>
  <item>
    <linkId value="PrescribingMethod"/>
    <prefix value="5)"/>
    <text value="Method of prescribing (choose one)"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerOption>
      <valueString value="Community Medication Authority"/>
    </answerOption>
    <answerOption>
      <valueString value="Standing Order (local)"/>
    </answerOption>
    <answerOption>
      <valueString value="Standing Order (national)"/>
    </answerOption>
    <answerOption>
      <valueString value="Individual prescription"/>
    </answerOption>
  </item>
</Questionnaire>