Notice
- Important: This guidance is under active development by NHS England and content may be added or updated on a regular basis.
- This Implementation Guide is currently in Draft and SHOULD NOT be used for development or active implementation without express direction from the NHS England Genomics Unit.
QuestionnaireResponse-RoD-PheobeSmithamFather-Example
Example of a filled RoD Form.
| QuestionnaireResponse |
| id : QuestionnaireResponse-RoD-PheobeSmithamFather-Example |
| questionnaire : https://fhir.nhs.uk/Questionnaire/NHSDigital-Questionnaire-Genomics-Example |
| status : completed |
| basedOn |
| reference : ServiceRequest/ServiceRequest-WGSTestOrderFormUpdated-TrioTesting-Example |
| subject |
| reference : Patient/Patient-PheobeSmithamFather-Example |
| identifier |
| system : https://fhir.nhs.uk/Id/nhs-number |
| value : 9449307636 |
| authored : 2023-10-01 |
| author |
| identifier |
| system : https://fhir.nhs.uk/Id/sds-role-profile-id |
| value : 9999999996 |
| source |
| reference : Patient/Patient-PheobeSmithamFather-Example |
| identifier |
| system : https://fhir.nhs.uk/Id/nhs-number |
| value : 9449307636 |
| item |
| linkId : patientDetails |
| text : Patient Details |
| item |
| linkId : givenName |
| text : First Name |
| answer |
| value : James |
| item |
| linkId : familyName |
| text : Last Name |
| answer |
| value : Lawrence |
| item |
| linkId : nhs_Number |
| text : NHS number (or postcode if not not known) |
| answer |
| value : 9449307636 |
| item |
| linkId : birthDate |
| text : Date of Birth |
| answer |
| value : 1981-08-03 |
| item |
| linkId : declaration4 |
| text : Confirmation of Your Genomic Test and Research Choices |
| item |
| linkId : confirmation |
| text : I confirm that I have had the opportunity to discuss information about genomic testing, I agree to the genomic test, and my research choice is indicated below. |
| item |
| linkId : researchConfirmation1 |
| text : I have discussed taking part in the National Genomic Research Library. If your answer to A is NO then please ignore B and sign directly below |
| answer |
| value : True |
| item |
| linkId : researchConfirmation2 |
| text : I agree that my data and remainder sample may contribute to the National Genomic Research Library |
| answer |
| value : True |
| item |
| linkId : isRespondentAttorney |
| text : Are you completing this form on behalf of someone? |
| answer |
| value : False |
| item |
| linkId : patientValidation |
| text : Patient Validation |
| item |
| linkId : patientNamecombined |
| text : Patient Name |
| answer |
| value : James Lawrence |
| item |
| linkId : patientSignature |
| text : Signature |
| answer |
| value : JamesLawrence |
| item |
| linkId : datePatientCompletedForm |
| text : Date |
| answer |
| value : 2023-10-01 |
| item |
| linkId : declaration5 |
| text : Healthcare professional use only |
| item |
| linkId : healthcareProfessional |
| text : To be completed by the healthcare professional recording the patient’s choices. |
| item |
| linkId : patientCategory |
| text : Patient category |
| answer |
| value |
| system : https://fhir.nhs.uk/CodeSystem/patient-choice-category-genomics |
| code : AdultOwnChoice |
| display : Adult(made their own choice) |
| item |
| linkId : testType |
| text : Test type |
| answer |
| value |
| system : https://fhir.nhs.uk/CodeSystem/test-type-genomics |
| code : RID-WGS |
| display : Rare and Inherited Diseases - WGS |
| item |
| linkId : remoteConsent |
| text : Remote consent, recorded remotely by clinician, no patient signature |
| answer |
| value : True |
| item |
| linkId : responsibleClinician |
| text : Responsible clinician |
| answer |
| value : Dr. Eugene Smith |
| item |
| linkId : patientMRN |
| text : Hospital number |
| answer |
| value : NA |
| item |
| linkId : healthcareProfessionalName |
| text : Healthcare professional name |
| answer |
| value : Dr. Eugene Smith |
| item |
| linkId : healthcareProfessionalSignature |
| text : Signature |
| answer |
| value : Dr. Eugene Smith |
| item |
| linkId : datehealthcareProfessionalCompletedForm |
| text : Date |
| answer |
| value : 2023-10-01 |
{ "resourceType": "QuestionnaireResponse", "id": "QuestionnaireResponse-RoD-PheobeSmithamFather-Example", "questionnaire": "https://fhir.nhs.uk/Questionnaire/NHSDigital-Questionnaire-Genomics-Example", "status": "completed", "basedOn": [ { "reference": "ServiceRequest/ServiceRequest-WGSTestOrderFormUpdated-TrioTesting-Example" } ], "subject": { "reference": "Patient/Patient-PheobeSmithamFather-Example", "identifier": { "system": "https://fhir.nhs.uk/Id/nhs-number", "value": "9449307636" } }, "authored": "2023-10-01", "author": { "identifier": { "system": "https://fhir.nhs.uk/Id/sds-role-profile-id", "value": "9999999996" } }, "source": { "reference": "Patient/Patient-PheobeSmithamFather-Example", "identifier": { "system": "https://fhir.nhs.uk/Id/nhs-number", "value": "9449307636" } }, "item": [ { "linkId": "patientDetails", "text": "Patient Details", "item": [ { "linkId": "givenName", "text": "First Name", "answer": [ { "valueString": "James" } ] }, { "linkId": "familyName", "text": "Last Name", "answer": [ { "valueString": "Lawrence" } ] }, { "linkId": "nhs_Number", "text": "NHS number (or postcode if not not known)", "answer": [ { "valueString": "9449307636" } ] }, { "linkId": "birthDate", "text": "Date of Birth", "answer": [ { "valueDate": "1981-08-03" } ] } ] }, { "linkId": "declaration4", "text": "Confirmation of Your Genomic Test and Research Choices", "item": [ { "linkId": "confirmation", "text": "I confirm that I have had the opportunity to discuss information about genomic testing, I agree to the genomic test, and my research choice is indicated below.", "item": [ { "linkId": "researchConfirmation1", "text": "I have discussed taking part in the National Genomic Research Library. If your answer to A is NO then please ignore B and sign directly below", "answer": [ { "valueBoolean": true } ] }, { "linkId": "researchConfirmation2", "text": "I agree that my data and remainder sample may contribute to the National Genomic Research Library", "answer": [ { "valueBoolean": true } ] } ] } ] }, { "linkId": "isRespondentAttorney", "text": "Are you completing this form on behalf of someone?", "answer": [ { "valueBoolean": false } ] }, { "linkId": "patientValidation", "text": "Patient Validation", "item": [ { "linkId": "patientNamecombined", "text": "Patient Name", "answer": [ { "valueString": "James Lawrence" } ] }, { "linkId": "patientSignature", "text": "Signature", "answer": [ { "valueString": "JamesLawrence" } ] }, { "linkId": "datePatientCompletedForm", "text": "Date", "answer": [ { "valueDateTime": "2023-10-01" } ] } ] }, { "linkId": "declaration5", "text": "Healthcare professional use only", "item": [ { "linkId": "healthcareProfessional", "text": "To be completed by the healthcare professional recording the patient’s choices.", "item": [ { "linkId": "patientCategory", "text": "Patient category", "answer": [ { "valueCoding": { "system": "https://fhir.nhs.uk/CodeSystem/patient-choice-category-genomics", "code": "AdultOwnChoice", "display": "Adult(made their own choice)" } } ] }, { "linkId": "testType", "text": "Test type", "answer": [ { "valueCoding": { "system": "https://fhir.nhs.uk/CodeSystem/test-type-genomics", "code": "RID-WGS", "display": "Rare and Inherited Diseases - WGS" } } ] }, { "linkId": "remoteConsent", "text": "Remote consent, recorded remotely by clinician, no patient signature", "answer": [ { "valueBoolean": true } ] }, { "linkId": "responsibleClinician", "text": "Responsible clinician", "answer": [ { "valueString": "Dr. Eugene Smith" } ] }, { "linkId": "patientMRN", "text": "Hospital number", "answer": [ { "valueString": "NA" } ] }, { "linkId": "healthcareProfessionalName", "text": "Healthcare professional name", "answer": [ { "valueString": "Dr. Eugene Smith" } ] }, { "linkId": "healthcareProfessionalSignature", "text": "Signature", "answer": [ { "valueString": "Dr. Eugene Smith" } ] }, { "linkId": "datehealthcareProfessionalCompletedForm", "text": "Date", "answer": [ { "valueDateTime": "2023-10-01" } ] } ] } ] } ] }
<QuestionnaireResponse xmlns="http://hl7.org/fhir"> <id value="QuestionnaireResponse-RoD-PheobeSmithamFather-Example" /> <basedOn> <reference value="ServiceRequest/ServiceRequest-WGSTestOrderFormUpdated-TrioTesting-Example" /> </basedOn> <questionnaire value="https://fhir.nhs.uk/Questionnaire/NHSDigital-Questionnaire-Genomics-Example" /> <status value="completed" /> <subject> <reference value="Patient/Patient-PheobeSmithamFather-Example" /> <identifier> <system value="https://fhir.nhs.uk/Id/nhs-number" /> <value value="9449307636" /> </identifier> </subject> <authored value="2023-10-01" /> <author> <identifier> <system value="https://fhir.nhs.uk/Id/sds-role-profile-id" /> <value value="9999999996" /> </identifier> </author> <source> <reference value="Patient/Patient-PheobeSmithamFather-Example" /> <identifier> <system value="https://fhir.nhs.uk/Id/nhs-number" /> <value value="9449307636" /> </identifier> </source> <item> <linkId value="patientDetails" /> <text value="Patient Details" /> <item> <linkId value="givenName" /> <text value="First Name" /> <answer> <valueString value="James" /> </answer> </item> <item> <linkId value="familyName" /> <text value="Last Name" /> <answer> <valueString value="Lawrence" /> </answer> </item> <item> <linkId value="nhs_Number" /> <text value="NHS number (or postcode if not not known)" /> <answer> <valueString value="9449307636" /> </answer> </item> <item> <linkId value="birthDate" /> <text value="Date of Birth" /> <answer> <valueDate value="1981-08-03" /> </answer> </item> </item> <item> <linkId value="declaration4" /> <text value="Confirmation of Your Genomic Test and Research Choices" /> <item> <linkId value="confirmation" /> <text value="I confirm that I have had the opportunity to discuss information about genomic testing, I agree to the genomic test, and my research choice is indicated below." /> <item> <linkId value="researchConfirmation1" /> <text value="I have discussed taking part in the National Genomic Research Library. If your answer to A is NO then please ignore B and sign directly below" /> <answer> <valueBoolean value="true" /> </answer> </item> <item> <linkId value="researchConfirmation2" /> <text value="I agree that my data and remainder sample may contribute to the National Genomic Research Library" /> <answer> <valueBoolean value="true" /> </answer> </item> </item> </item> <item> <linkId value="isRespondentAttorney" /> <text value="Are you completing this form on behalf of someone?" /> <answer> <valueBoolean value="false" /> </answer> </item> <item> <linkId value="patientValidation" /> <text value="Patient Validation" /> <item> <linkId value="patientNamecombined" /> <text value="Patient Name" /> <answer> <valueString value="James Lawrence" /> </answer> </item> <item> <linkId value="patientSignature" /> <text value="Signature" /> <answer> <valueString value="JamesLawrence" /> </answer> </item> <item> <linkId value="datePatientCompletedForm" /> <text value="Date" /> <answer> <valueDateTime value="2023-10-01" /> </answer> </item> </item> <item> <linkId value="declaration5" /> <text value="Healthcare professional use only" /> <item> <linkId value="healthcareProfessional" /> <text value="To be completed by the healthcare professional recording the patient’s choices." /> <item> <linkId value="patientCategory" /> <text value="Patient category" /> <answer> <valueCoding> <system value="https://fhir.nhs.uk/CodeSystem/patient-choice-category-genomics" /> <code value="AdultOwnChoice" /> <display value="Adult(made their own choice)" /> </valueCoding> </answer> </item> <item> <linkId value="testType" /> <text value="Test type" /> <answer> <valueCoding> <system value="https://fhir.nhs.uk/CodeSystem/test-type-genomics" /> <code value="RID-WGS" /> <display value="Rare and Inherited Diseases - WGS" /> </valueCoding> </answer> </item> <item> <linkId value="remoteConsent" /> <text value="Remote consent, recorded remotely by clinician, no patient signature" /> <answer> <valueBoolean value="true" /> </answer> </item> <item> <linkId value="responsibleClinician" /> <text value="Responsible clinician" /> <answer> <valueString value="Dr. Eugene Smith" /> </answer> </item> <item> <linkId value="patientMRN" /> <text value="Hospital number" /> <answer> <valueString value="NA" /> </answer> </item> <item> <linkId value="healthcareProfessionalName" /> <text value="Healthcare professional name" /> <answer> <valueString value="Dr. Eugene Smith" /> </answer> </item> <item> <linkId value="healthcareProfessionalSignature" /> <text value="Signature" /> <answer> <valueString value="Dr. Eugene Smith" /> </answer> </item> <item> <linkId value="datehealthcareProfessionalCompletedForm" /> <text value="Date" /> <answer> <valueDateTime value="2023-10-01" /> </answer> </item> </item> </item> </QuestionnaireResponse>