Questionnaire Example: questionnaire-example-bluebook

Narrative

Birth details - To be completed by health professional Name of child: ____________________________________ Sex: __

Neonatal Information Birth Weight (kg): ___________ Birth Length (cm): ___________ Vitamin K given : __ 1st dose: ___________ 2nd dose: ___________ Hep B given : __ Date given : ___________ Abnormalities noted at birth: _______________________________________________

Example XML

<?xml version="1.0" encoding="UTF-8"?>

<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="bb"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">

      <pre>

        <b>Birth details - To be completed by health professional</b>
  Name of child: ____________________________________
            Sex: __

  Neonatal Information
    Birth Weight (kg): ___________
    Birth Length (cm): ___________
    Vitamin K given  : __
             1st dose: ___________
             2nd dose: ___________
    Hep B given      : __
      Date given     : ___________
    Abnormalities noted at birth:
      _______________________________________________

      </pre>

    </div>
  </text>
  <url value="http://hl7.org/fhir/Questionnaire/bb"/>
  <identifier>
    <system value="urn:ietf:rfc:3986"/>
    <value value="urn:oid:2.16.840.1.113883.4.642.20.4"/>
  </identifier>
  <name value="NSWGovernmentMyPersonalHealthRecord"/>
  <title value="NSW Government My Personal Health Record"/>
  <status value="draft"/>
  <subjectType value="Patient"/>
  <date value="2013-02-19"/>
  <publisher value="New South Wales Department of Health"/>
  <description value="NSW Government My Personal Health Record"/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="AU"/>
    </coding>
  </jurisdiction>
  <item>
    <linkId value="birthDetails"/>
    <text value="Birth details - To be completed by health professional"/>
    <type value="group"/>
    <item>
      <linkId value="group"/>
      <type value="group"/>
      <item>
        <linkId value="nameOfChild"/>
        <text value="Name of child"/>
        <type value="string"/>
      </item>
      <item>
        <linkId value="sex"/>
        <text value="Sex"/>
        <type value="coding"/>
        <answerOption>
          <valueCoding>
            <code value="F"/>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <code value="M"/>
          </valueCoding>
        </answerOption>
      </item>
    </item>
    <item>
      <linkId value="neonatalInformation"/>
      <text value="Neonatal Information"/>
      <type value="group"/>
      <item>
        <linkId value="birthWeight"/>
        <text value="Birth weight (kg)"/>
        <type value="decimal"/>
      </item>
      <item>
        <linkId value="birthLength"/>
        <text value="Birth length (cm)"/>
        <type value="decimal"/>
      </item>
      <item>
        <linkId value="vitaminKgiven"/>
        <text value="Vitamin K given"/>
        <type value="coding"/>
        <answerOption>
          <valueCoding>
            <code value="INJECTION"/>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <code value="INTRAVENOUS"/>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <code value="ORAL"/>
          </valueCoding>
        </answerOption>
        <item>
          <linkId value="vitaminKgivenDoses"/>
          <type value="group"/>
          <enableWhen>
            <question value="vitaminKgiven"/>
            <operator value="exists"/>
            <answerBoolean value="true"/>
          </enableWhen>
          <item>
            <linkId value="vitaminKDose1"/>
            <text value="1st dose"/>
            <type value="dateTime"/>
          </item>
          <item>
            <linkId value="vitaminKDose2"/>
            <text value="2nd dose"/>
            <type value="dateTime"/>
          </item>
        </item>
      </item>
      <item>
        <linkId value="hepBgiven"/>
        <text value="Hep B given y / n"/>
        <type value="boolean"/>
        <item>
          <linkId value="hepBgivenDate"/>
          <text value="Date given"/>
          <type value="date"/>
        </item>
      </item>
      <item>
        <linkId value="abnormalitiesAtBirth"/>
        <text value="Abnormalities noted at birth"/>
        <type value="string"/>
      </item>
    </item>
  </item>
</Questionnaire>