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4.7 4.26 Resource Questionnaire - Content

Patient Care Work Group

Maturity Level : 2

Compartments : Not linked to any defined compartments

A structured set of questions and their intended to guide the collection of answers. The Questionnaire may contain questions, answers or both. The questions are ordered and grouped into coherent subsets, corresponding to the structure of the grouping of the underlying questions.

This resource is referenced by questionnaireresponse

4.7.4 4.26.4 Resource Content

 

Alternate definitions: Schema / Schematron , Resource Profile ( XML , JSON ), Questionnaire

4.7.4.1 4.26.4.1 Terminology Bindings

Questionnaire.name Questionnaire.group.name Questionnaire.group.question.name

Path	Definition	Type	Reference
Questionnaire.status	Lifecycle status of the questionnaire questionnaire.	Fixed Required	http://hl7.org/fhir/questionnaire-status QuestionnaireStatus
Questionnaire.subjectType	One of the resource types defined as part of FHIR.	Required	http://hl7.org/fhir/valueset/resource-types ResourceType
Questionnaire.group.concept	Structured names Codes for forms groupings of questionnaire questions.	Example	http://hl7.org/fhir/vs/questionnaire-name Questionnaire Question Codes
Questionnaire.group.question.concept	Structured names for (sub)sections of forms Codes corresponding to individual questions.	Example	http://hl7.org/fhir/vs/questionnaire-group-name Questionnaire Question Codes
Questionnaire.group.question.type	The expected format of an answer.	Required	AnswerFormat
Questionnaire.group.question.option	Structured names for questions on the form Allowed values to answer questions.	Example	http://hl7.org/fhir/vs/questionnaire-question-name Questionnaire Answer Codes

4.7.4.2 4.26.4.2 Constraints

• Inv-3 que-1 : On Questionnaire.group: Groups may either contain questions or groups but not both (xpath on f:Questionnaire/f:group: not(exists(f:group) and exists(f:question)) )
• Inv-1 que-2 : On Questionnaire.group.question: Must supply either a simple answer, a choice, data or nothing (xpath on f:Questionnaire/f:group/f:question: The link ids for groups and questions must be unique within the questionnaire (xpath: count(f:data) + count(f:choice) + count(f:answer) <= 1 count(descendant::f:linkId/@value)=count(distinct-values(descendant::f:linkId/@value)) )
• Inv-2 que-3 : If root group must be "required" (xpath: f:group/f:required/@value=true() )
• que-4 : On Questionnaire.group.question: Must supply a name, a question's text A question must use either option or options, not both (xpath on f:Questionnaire/f:group/f:question: count(f:name) + count(f:text) >= 1 not(f:options and f:option) )

4.7.5 4.26.5 Notes:

• Questionnaires can be authored by clinicians, the patient his/herself or a patients relatives (or even owner in the case of animals). Clinicians may author questionnaires, where the answers are provided by others on behalf of the patient his/herself. Additionally, information gathered for the purpose of a patient may be about the patient's relatives (e.g. in family anamnesis). Therefore, Questionnaire makes a distinction between the author, the subject and the source of information. Questionnaires may be used to represent predefined forms, named using Questionnaire.name. Questionnaires.identifier identify a specific set of answers to the questions on these forms. If a Questionnaire is used to just represent a predefined form forms or "template", the Questionnaire need not contain answers (Question.answer, Question.data and Questionnaire.question.choice are empty). panels, referenced using Questionnaire.group.concept.
• A Questionnaire's contents are placed inside its single nested Group, which may contain Questions or subgroups with Questions. These may or may not correspond to the structure of the original form. If they do correspond,
• Groups and Questions may be named, so answers on a Questionnaire can refer to a corresponding sections of a form. Likewise, answers to Questionnaires can be named to refer to the have linkIds allowing groups and question on answers captured in a form. It is also possible QuestionnaireResponse to include textual content on the form in Questionnaire (see below). Since sections and questions may be answered multiple times, the same Group.name and Question.name may appear multiple times. associated with their corresponding group or question.
• Questionnaire allows for flexible naming and structuring of its contents to reflect the flexible and varying nature of forms and questionnaires. It explicitly does not try to standardize or streamline exchange of its contents outside its context of use, although exchanging partners may further constrain its structure and flexibility using profiles to define standardized, reusable forms.
• Because of the lack of explicit support for Questionnaires in HL7v3, HL7 v3 , CDA Documents frequently used named sections with Observations to model Questionnaires. Such use cases should now utilize the Questionnaire Resource instead.
• The Questionnaire's encounter element can be used to link to the encounter during which the Questionnaire was taken. This can be relevant since the encounter gives context to the answers and can be used to relate information in the Questionnaire to orders and observations that were done during the same Encounter. The order of questions within groups, groups withing within groups and groups withing within questions in is relevant and must be retained for display and capture.

4.7.5.1 4.26.5.1 Using Questionnaires versus using Resources

There is considerable overlap between the information covered by Questionnaires and other Resources (especially FamilyHistory, MedicationStatement, Observation, Procedure, FamilyMemberHistory , MedicationStatement , Observation , Procedure , etc.): Questionnaire's flexible structure can easily be misused to capture any data, even data that should be captured as separate Resources. The choice between using Questionnaires or separate Resources may be dictated by the procedure of collection and recording. E.g. recording; e.g. if the data is captured as a physician-agreed (electronic) form, it might be impossible or undesirable to distill separate resources from it, it and capturing the data in a Questionnaire SHALL would be stored and communicated as a whole. most appropriate.

However, data captured only in Questionnaires can be difficult to query after-the-fact: queries after-the-fact. Queries against other Resources will not return data captured only in Questionnaires, Questionnaires , and querying against Questionnaires directly may not find all desired data, depending on how the questions may have been phrased or encoded over time or by different clinicians. Moreover, interoperability of such Questionnaires is limited as interpretation of its contents is only known to the circle of parties that were involved in its definition: encoding data from such Questionnaires using other, more specific, Resources increases the ability and consistency with which it can be understood and queried.

To facilitate better standardization of the information on a form, Questionnaire has the capacity (Using a Question's It is entirely possible for data element) to allow systems to communicate (part of) the answers exist in the form both QuestionnaireResponse and in other resources. For example, data may be captured in QuestionnaireResponse as part of structured FHIR data. This provides an upgrade path to intake questionnaire. That data may then be propagated into the questionnaire designer Patient resource (demographics), FamilyMemberHistory , AllergyIntolerance , MedicationStatement and communicating systems, where capable systems may use FHIR data to answer (sets of) questions, whereas other systems can simply continue Observation resources to supply the direct answers as input by allow the user. 4.7.5.2 Providing Questions and/or Answers The Questionnaire has been specifically designed data to be able to contain both a form's questions queried and answers. analyzed. The Group and Question construct has elements to carry textual data of the form like headings, explanatory text, actual question text and the text of (multiple)choice options. As such, the Questionnaire original QuestionnaireResponse instance can be used to: only contain answers (in which case the actual layout and questions of the form is defined in some external way, and the name elements are used to relate the answers to the questions) contain retained for traceability purposes. For example, if a combination of questions and answers (e.g. when it is deemed important to keep the actual questionnaire question text with the answer) or only contain the Questions, asks "what is your weight", that can then result in which case the Questionnaire represents an empty, predefined form This third case can be useful to make Questionnaire serve as a kind creation of form "template", where FHIR clients receive the empty form, display it to the user, get answers from the users and then return an Observation with the combined questions appropriate Observation.code and answers to the server. The questionnaire core extensions provide additional means for control over repeating sections and expected specified answer format. as the Observation.valueQuantity .

4.7.5.3 4.26.5.2 Structure of the Questionnaire

A Questionnaire is built out of three components:

• The main component is Questionnaire, which holds information about the Questionnaire, like the subject, identifier, publisher, date authored etcetera. authored, etc. The Questionnaire contains one "main" "root" Group, which contains all the content of the questionnaire. This "root" group contains elements that apply to the entire questionnaire - the title for the questionnaire, the concept that represents the meaning of the overall questionnaire (e.g. a code for "family history"), the text to display at the top of the questionnaire, etc. (In most cases, required would be 'true' and repeats would be false for the root group
• This Group, Group can contain either nested Groups (to represent sections and subsections on a questionnaire form) or Questions. This way, any form containing sections or subsections can be represented, down to the actual questions.
• The Questions themselves may be simple questions with a promp prompt text and one expected answer, but they may also contain nested groups, each containing sets of nested questions. This way, one can model "panels" of questions which would only be relevant (and thus would only be displayed) depending on the answers of a parent question, question; e.g. a Question question "Did the patient receive treatment in the past six months?", months?" would contain a nested group of questions asking for further details about the treatment. See an example from the Australian NSW New South Wales blue book
• Specific controls on dynamic display of groups, questions, etc. based on the answers to other questions is outside the scope of the base resource and are expected to be introduced as extensions.

4.26.5.3 Identifiers within Questionnaire

There are three different "identifying" elements within Questionnaire: identifier , id and linkId . Each serves very distinct purposes:

• identifier is used to reference the overall questionnaire in business terms. It is the number printed across the top of the form or listed beside the form when making a choice between alternate forms.
• The id attribute supported on each element is used for references within a resource, for example linking narrative to discrete elements
• The linkId element on questions and groups establishes a link between elements in a QuestionnaireAnsers and their definition inside a Questionnaire. This is the only way to link between the groups and questions in a Questionnaire and QuestionnaireResponse

4.7.6 4.26.5.4 Question Definitions

Questionnaires can be crafted using any questions the author can conceive phrased in whatever manner is appropriate or convenient. However, standardization of questions and the constraints enforced on the accompanying answers increases the ability to compare data gathered across questionnaires. There are two mechanisms defined in the specification for linking a Question (or Group) to a standardized definition:

• The concept element on both Group and Question allows an individual question, a group of questions or even the questionnaire as a whole to be associated with a pre-defined terminology of questions and question groups such as LOINC
• The deReference extension allows a question or group to be associated with the DataElement (DE) resource that formally defines the data element.

Linking to formal definitions of a question allows data captured by distinct questionnaires to be compared. If systems have the necessary mappings to the formal definition, linkages to formal definitions may also be used to automatically pre-populate or extract data from a corresponding QuestionnaireResponse resource.

NOTE: Even if standard question definitions are referenced using concept or the deReference extension, information such as the question text, data type and value set SHOULD still be declared for the question. Systems processing the questionnaire may not have access to or support the ability to look up the question definitions from external sources. If the information is not included in-line within the questionnaire, other systems may not be able to to render or use the Questionnaire.

If an external reference ( concept or deReference extension) is included along with question information such as question text, data type or value set, it is expected that the content for the question and the referenced definition would be in alignment. However, FHIR does not dictate what degree of alignment is required; e.g. Does the question text need to match exactly? Is it legitimate for a question to constrain the allowed value set of possible answers? These rules will need to be established within implementation environments.

4.26.5.5 Question types

The codes for the data type for each question are slightly different than the data types allowed in the QuestionnaireResponse resource. Where the names are the same (ignoring case), the "answer" must use the specified type. Where the names are different, the mappings are as follows:

Questionnaire AnswerFormat code	QuestionnaireResponse data type
text	string
url	uri
choice	Coding
open-choice	Coding

4.26.5.6 Permitted values for questions

Many questionnaires place constraints on the allowed list of values for a given question. FHIR supports this notion through the ...question.choices element. However, rather than listing the choices directly, the choices element points to a ValueSet resource. This approach adds complexity for questionnaires having a simple list of strings as choices for a question, but provides several benefits:

• Questionnaires that reference codes from externally defined code systems have a means of doing so
• Answer sets can be shared across questions (and there are many questionnaires where this capability is useful)
• The full capability of value sets can be brought into play, including the ability to use ConceptMap to link and translate from questionnaire-specific codes to other codes, the use of multiple display names (e.g. different languages), the ability to use coded ordinals, the ability to allow choices from larger value sets (e.g. "all SNOMED CT procedure codes")
• etc.

In many cases, the set of code choices will be specific to a given questionnaire and should be maintained as part of the questionnaire. In this case, the referenced ValueSet can be included as a contained resource. All contained ValueSets are listed together and then are referenced by the individual questions as necessary.

4.26.5.7 Useful Value Sets

Many questions have a set of possible codes for their answer. These value sets may be useful to help, and when referenced by full URL, do not need to be provided as part of the questionnaire:

• Yes | No | Don't Know : http://hl7.org/fhir/ValueSet/yesnodontknow

4.26.5.8 Questions with multiple answer types

In some questionnaires, it may be possible to respond to a question with multiple types of answers. For example, capturing a coded answer plus free text, capturing a coded value plus a numeric priority, etc. In FHIR, this is handled through nested questions. Each question has a single data type. However, each question can have nested child questions. These nested child questions can have text (e.g. "Please specify") or can have no text at all if the appropriate guidance is provided by the parent question or group.

4.26.5.9 Questionnaires with Math

While not defined (yet) at the international level, extensions may be defined to perform mathematical functions on questionnaire responses. For example, tabulating scores. One extension that is defined that may be useful in this process is the Ordinal extension. This allows a numeric value to be associated with a coded data element. There are two extensions defined - one for defining the numeric weighting of a code defined in a value set - valueset-ordinalValue and the other is a code that can appear within a Coding itself - iso21090-CO-value .

4.26.5.10 Extensions for Additional capabilities

The core elements defined in the questionnaire resource are sufficient for simple questionnaires. For more sophisticated capabilities, a number of "common" extensions are defined in the Questionnaire Core extensions and the Element extensions profiles. For example, strict control over allowed number of conditions, conditional display of questionnaire content, etc. The conditional display extension [enable-when] can be used to enable groups nested beneath a question based on the selection of a specific answer, giving the behavior of "questions under answers" where this sort of more sophisticated behavior is needed.

4.26.6 Search Parameters

Search parameters for this resource. The standard common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name	Type	Description	Paths
_id token The logical resource id associated with the resource (must be supported by all servers) _language code	token	The language of the resource author reference The author of A code that corresponds to the questionnaire or one of its groups	Questionnaire.author ( Patient , Practitioner , RelatedPerson ) Questionnaire.group.concept
authored date	date	When the questionnaire was authored last changed	Questionnaire.authored Questionnaire.date
encounter identifier	reference token	Encounter during which An identifier for the questionnaire was authored	Questionnaire.encounter ( Encounter ) Questionnaire.identifier
identifier publisher	token string	An identifier for The author of the questionnaire	Questionnaire.identifier Questionnaire.publisher
name status	token	Name The status of the questionnaire	Questionnaire.name Questionnaire.status
status title	token string	The status All or part of the name of the questionnaire (title for the root group of the questionnaire)	Questionnaire.status Questionnaire.group.title
subject version	reference string	The subject business version of the questionnaire	Questionnaire.subject ( Patient , RelatedPerson ) Questionnaire.version