Medical records

Introduction

Questionnaire and QuestionnaireResponse are implemented as medical record templates and medical record notes in COSMIC. The questionnaire defines the questions (items/template) which should be responded to by the QuestionnaireResponse.

To enable a more detailed structure of diagnosis and action codes, the resources Condition and Procedure are supported as contained resources within a QuestionnaireResponse.

To manage the status of the QuestionnaireResponse, Provenance can be used to nullify a specific QuestionnaireResponse.

The user of these APIs can be either a healthcare professional or a patient. For further information about how the APIs should be used for healthcare professionals respective patients, see sections for QuestionnaireSeLite for searching for questionnaires, and QuestionnaireResponseSe for creating questionnaire responses. Invalidation is only intended for healthcare professional use.

Included Profiles

Resources included in the questionnaire use cases are Questionnaire, QuestionnaireResponse, Provenance, Procedure and Condition. Profiles for these are specified as following:

  • QuestionnaireSeLite - used to retrieve a list of Questionnaires with one or several codes. Includes descriptive attributes like title, description, useContext & code. Either healthcare professional Questionnaires or patient Questionnaires can be requested.

  • QuestionnaireSe - used to retrieve complete (full model) of one Questionnaire. In addition to attributes retrieved from QuestionnaireLiteSe, this profile includes all questions (items) and their types (string, decimal, choice etc.) of the Questionnaire.

  • QuestionnaireResponseSe - used to create a QuestionnaireResponse, which responds to the Questionnaire that has been retrieved earlier. In addition to the answers, this profile includes attributes like subject, encounter and author.

  • ProvenanceStatusSe - used to nullify a QuestionnaireResponse which means that the QuestionnaireResponse will no longer have completed status. Additional required information is a reason for nullifying (reason), responsible performer (agent) and the date (recorded) is required.

  • ConditionDiagnosisSe - used to handle diagnosis keywords in a QuestionnaireResponse. Includes attributes such as code, subject, encounter and recordedDate.

  • ProcedureKVALite - used to handle procedures in a QuestionnaireResponse. Includes attributes such as code, subject and performed.

  • PractitionerRoleLiteSe - used to represent a practitioner and the connected organization who documented the QuestionnaireResponse.

The relationship between the profiles is specified in the image below. Questionnaires reference model

Use Cases