New Zealand Rheumatic Fever FHIR Implementation Guide - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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: Recurrence Diagnosis Questionnaire - XML Representation

Draft as of 2024-01-01

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<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="RecurrenceDiagnosisQuestionnaire"/>
  <url
       value="https://fhir-ig.digital.health.nz/rheumatic-fever/Questionnaire/RecurrenceDiagnosisQuestionnaire"/>
  <identifier>
    <use value="official"/>
    <value value="RecurrenceDiagnosisQuestionnaire"/>
    <period>
      <start value="2024-01-01"/>
    </period>
  </identifier>
  <version value="1.0.0"/>
  <name value="RecurrenceDiagnosisQuestionnaire"/>
  <title value="Recurrence Diagnosis Questionnaire"/>
  <status value="draft"/>
  <experimental value="false"/>
  <subjectType value="Patient"/>
  <date value="2024-01-01"/>
  <publisher value="Te Whatu Ora"/>
  <contact>
    <name value="Te Whatu Ora"/>
    <telecom>
      <system value="url"/>
      <value value="https://www.tewhatuora.govt.nz/"/>
    </telecom>
    <telecom>
      <system value="email"/>
      <value value="integration@tewhatuora.govt.nz"/>
    </telecom>
  </contact>
  <contact>
    <name value="HNZ Integration Team"/>
    <telecom>
      <system value="email"/>
      <value value="integration@tewhatuora.govt.nz"/>
      <use value="work"/>
    </telecom>
  </contact>
  <description
               value="Gathers information about prophylaxis and recurrence details for acute rheumatic fever diagnosis"/>
  <purpose
           value="Gathers information about prophylaxis and recurrence details for acute rheumatic fever diagnosis"/>
  <item>
    <linkId value="page1"/>
    <prefix value="page1"/>
    <text
          value="Please complete this questionnaire to assess recurrence and prophylaxis details for rheumatic fever diagnosis."/>
    <type value="display"/>
  </item>
  <item>
    <linkId value="ReceivingAntibioticProphylaxis"/>
    <prefix value="1)"/>
    <text value="Was the patient receiving antibiotic prophylaxis?"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerOption>
      <valueString value="Yes"/>
    </answerOption>
    <answerOption>
      <valueString value="No - Completed Treatment"/>
    </answerOption>
    <answerOption>
      <valueString value="No - Discontinued Prematurely"/>
    </answerOption>
    <answerOption>
      <valueString value="No - Other"/>
    </answerOption>
    <answerOption>
      <valueString value="Unknown"/>
    </answerOption>
  </item>
  <item>
    <linkId value="TypeOfProphylaxis"/>
    <prefix value="2)"/>
    <text value="Type of Prophylaxis"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerOption>
      <valueString value="Benzathine Penicillin"/>
    </answerOption>
    <answerOption>
      <valueString value="Amoxicillin"/>
    </answerOption>
    <answerOption>
      <valueString value="Penicillin V"/>
    </answerOption>
    <answerOption>
      <valueString value="Erythromycin"/>
    </answerOption>
    <answerOption>
      <valueString value="Roxithromycin"/>
    </answerOption>
    <answerOption>
      <valueString value="Other"/>
    </answerOption>
    <answerOption>
      <valueString value="Unknown"/>
    </answerOption>
    <answerOption>
      <valueString value="None"/>
    </answerOption>
  </item>
  <item>
    <linkId value="OtherProphylaxis"/>
    <prefix value="3)"/>
    <text value="Other Prophylaxis"/>
    <type value="text"/>
    <enableWhen>
      <question value="TypeOfProphylaxis"/>
      <operator value="="/>
      <answerString value="Other"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="MedicationRoute"/>
    <prefix value="4)"/>
    <text value="Medication Route"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerOption>
      <valueString value="Intramuscular Injection"/>
    </answerOption>
    <answerOption>
      <valueString value="Subcutaneous Injection"/>
    </answerOption>
    <answerOption>
      <valueString value="Oral"/>
    </answerOption>
  </item>
  <item>
    <linkId value="PrescribedFrequency"/>
    <prefix value="5)"/>
    <text value="Prescribed Frequency"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="false"/>
    <answerOption>
      <valueString value="28 Days"/>
    </answerOption>
    <answerOption>
      <valueString value="21 Days"/>
    </answerOption>
    <answerOption>
      <valueString value="Daily"/>
    </answerOption>
    <answerOption>
      <valueString value="10 Weeks"/>
    </answerOption>
    <answerOption>
      <valueString value="13 Weeks"/>
    </answerOption>
    <answerOption>
      <valueString value="Other"/>
    </answerOption>
  </item>
  <item>
    <linkId value="OtherPrescribedFrequency"/>
    <prefix value="6)"/>
    <text value="Other Prescribed Frequency"/>
    <type value="text"/>
    <enableWhen>
      <question value="PrescribedFrequency"/>
      <operator value="="/>
      <answerString value="Other"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="ProphylaxisAdherence"/>
    <prefix value="7)"/>
    <text
          value="What was the patient's adherence to prophylaxis in the last 12 months?"/>
    <type value="text"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="ProphylaxisProvider"/>
    <prefix value="8)"/>
    <text value="Who was providing the prophylaxis at the time?"/>
    <type value="text"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="LastDocumentedDose"/>
    <prefix value="9)"/>
    <text
          value="Date of last documented secondary prophylaxis benzathine dose?"/>
    <type value="date"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="RiskFactorsRecurrence"/>
    <prefix value="10)"/>
    <text value="Risk Factors for Recurrence?"/>
    <type value="text"/>
    <required value="true"/>
  </item>
</Questionnaire>