NHS North West Genomics
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Questionnaire: Deafness (R67) Ask At Order Entry Questions

Official URL: https://fhir.nwgenomics.nhs.uk/Questionnaire/DeafnessR67AskAtOrderEntry Version: 2.2.0
Unknown as of 2026-09-20 Computable Name:

For analysis purposes only - not an active or planned project.

Ask At Order Entry Questions for the Deafness Testing Proforma (R67 Non-Syndromic Hearing Loss), used alongside the common core order form - see Order Entry Questions. The test code (R67) is fixed by the choice of form rather than entered - the proforma instead exists to capture the clinical detail (audiogram, syndromic features, risk factors) that supports the R67 eligibility criteria.

This Questionnaire is compared against Genomic Test Order - see NW GLH Paper Test Request Forms - but does not yet declare derivedFrom/extends it: unlike the Ask At Order Entry Questionnaires that originated from an existing digital order-entry screen (see Order Entry Questions), this one hasn't yet been processed into the specific electronic Ask At Order Entry shape that relationship implies for use in an actual order. It structures the Deafness Testing Proforma (R67 Non-Syndromic Hearing Loss) - see NW Genomics paper test request forms for how this compares to the other paper forms.

Source form: Deafness Testing Proforma - R67 Non-Syndromic Hearing Loss (PDF)

Summary

Item Paper Form Field FHIR
Name Free text (single field) Patient.name
Date of birth/Gender Free text Patient.birthDate / Patient.gender
Address/Postcode Free text Patient.address
Hospital Number/NHS no Free text Patient.identifier:MedicalRecordNumber / Patient.identifier:nhsNumber
Referring Clinician (Referring clinician, Address, Email) Free text PractitionerRole
Family history/pedigree Free text ServiceRequest.note
Audiogram findings Findings, severity (per ear), progression Observation.valueString / valueQuantity
Suspected syndromic diagnosis Pendred/Usher/Jervell-Lange Nielsen/Waardenburg/Branchio-oto-renal/Wolfram (tick boxes) ServiceRequest.reasonCode, repeating
Risk factors Prematurity/Hyperbilirubinemia/Prolonged NNU stay/Ototoxic medication (tick boxes) Observation.valueCodeableConcept, repeating
MRI performed / findings Yes/no + free text Observation.valueBoolean / valueString

Unlike most of the other paper forms, the test code (R67) is fixed by the choice of form rather than entered - the proforma exists purely to capture the clinical detail supporting R67 eligibility. No Order Placer Number, Account Number/Hospital Spell Identifier, Specimen Identifier, or clinician professional identifier (GMC/GMP) field is present on the paper form - it accompanies a separate DNA request card that is assumed to carry the specimen identifier.

Profile: Questionnaire

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. **For analysis purposes only - not an active or planned project.** **Ask At Order Entry Questions** for the **Deafness Testing Proforma (R67 Non-Syndromic Hearing Loss)**, used alongside the [common core order form](Questionnaire-GenomicTestOrder.html) - see [Order Entry Questions](Questionnaire-GenomicTestOrder.html#order-entry-questions). The test code (R67) is fixed by the choice of form rather than entered - the proforma instead exists to capture the clinical detail (audiogram, syndromic features, risk factors) that supports the R67 eligibility criteria. Questionnaire https://fhir.nwgenomics.nhs.uk/Questionnaire/DeafnessR67AskAtOrderEntry#2.2.0
... Patient Patient Details 0..1 group Definition: Patient
Value Set:
.... NOS/PatientName Name 0..1 string Definition: Patient.name
Value Set:
..... NOS/PatientName-designNote Single free-text Name field on this form, unlike the Surname/Forename split most other paper forms use. 0..1 display Value Set:
.... LN/21112-8 Date of birth 0..1 date Definition: Patient.birthDate
Value Set:
.... LN/46098-0 Gender 0..1 choice Definition: Patient.gender
Value Set: AdministrativeGender
.... LN/56799-0 Address 0..1 string Definition: Patient.address.line
Value Set:
.... LN/45401-7 Postcode 0..1 string Definition: Patient.address.postalCode
Value Set:
.... LN/76435-7 Hospital Number 0..1 string Definition: Patient.identifier:MedicalRecordNumber
Value Set:
.... LN/89061-6 NHS no 0..1 string Definition: Patient.identifier:nhsNumber
Value Set:
... HealthcareProfessional Referring Clinician 0..1 group Definition: PractitionerRole
Value Set:
.... LN/18705-4 Referring clinician 0..1 string Definition: PractitionerRole.practitioner.display
Value Set:
.... NOS/DepartmentAddress Address 0..1 string Definition: PractitionerRole.organization.display
Value Set:
.... LN/89058-2 Email 0..1 string Definition: PractitionerRole.telecom.value
Value Set:
... AskAtOrderEntry Ask At Order Entry Questions 0..1 group Value Set:
.... NOS/FamilyHistoryPedigree Family history/pedigree: other affected individuals, parental consanguinity, ethnicity 0..1 string Definition: ServiceRequest.note
Value Set:
.... Audiogram Audiogram 0..1 group Value Set:
..... NOS/AudiogramFindings Audiogram findings (serial if relevant) 0..1 string Definition: Observation.valueString
Value Set:
..... NOS/AudiogramSeverityRight Severity - right ear 0..1 integer Definition: Observation.valueQuantity
Value Set:
..... NOS/AudiogramSeverityLeft Severity - left ear 0..1 integer Definition: Observation.valueQuantity
Value Set:
..... NOS/AudiogramProgression Progression 0..1 string Definition: Observation.valueString
Value Set:
.... NOS/SuspectedSyndromicDiagnosis Clinically suspected syndromic diagnosis 0..* choice Definition: ServiceRequest.reasonCode
Value Set:
Options: 6 options
.... NOS/DeafnessRiskFactors Risk factors 0..* choice Definition: Observation.valueCodeableConcept
Value Set:
Options: 4 options
.... SNM/113091000-mri MRI performed? 0..1 boolean Definition: Observation.valueBoolean
Value Set:
.... NOS/MRIFindings MRI findings 0..1 string Definition: Observation.valueString
Enable When: SNM/113091000-mri = true
Value Set:

doco Documentation for this format

Options Sets

Answer options for NOS/SuspectedSyndromicDiagnosis

  • https://fhir.nwgenomics.nhs.uk/CodeSystem/NWGMSA#DeafnessSyndromePendred
  • https://fhir.nwgenomics.nhs.uk/CodeSystem/NWGMSA#DeafnessSyndromeUsher
  • https://fhir.nwgenomics.nhs.uk/CodeSystem/NWGMSA#DeafnessSyndromeJervellLangeNielsen
  • https://fhir.nwgenomics.nhs.uk/CodeSystem/NWGMSA#DeafnessSyndromeWaardenburg
  • https://fhir.nwgenomics.nhs.uk/CodeSystem/NWGMSA#DeafnessSyndromeBranchioOtoRenal
  • https://fhir.nwgenomics.nhs.uk/CodeSystem/NWGMSA#DeafnessSyndromeWolfram

Answer options for NOS/DeafnessRiskFactors

  • https://fhir.nwgenomics.nhs.uk/CodeSystem/NWGMSA#DeafnessRiskFactorPrematurity
  • https://fhir.nwgenomics.nhs.uk/CodeSystem/NWGMSA#DeafnessRiskFactorHyperbilirubinemia
  • https://fhir.nwgenomics.nhs.uk/CodeSystem/NWGMSA#DeafnessRiskFactorProlongedNNUStay
  • https://fhir.nwgenomics.nhs.uk/CodeSystem/NWGMSA#DeafnessRiskFactorOtotoxicMedication

Profile: Questionnaire

Patient Details

  • linkId: Patient
  • Definition:: Patient
  • Answers:

Name

Single free-text Name field on this form, unlike the Surname/Forename split most other paper forms use.

  • linkId: NOS/PatientName-designNote
  • Answers:

Date of birth

Gender

Address

Postcode

Hospital Number

NHS no

Referring Clinician

Referring clinician

Address

Email

Ask At Order Entry Questions

  • linkId: AskAtOrderEntry
  • Answers:

Family history/pedigree: other affected individuals, parental consanguinity, ethnicity

Audiogram

  • linkId: Audiogram
  • Answers:

Audiogram findings (serial if relevant)

Severity - right ear

Severity - left ear

Progression

Clinically suspected syndromic diagnosis

Risk factors

MRI performed?

MRI findings

Profile: Questionnaire

LinkIDDescription & Constraintsdoco
.. Patient Definition: Patient
Value Set:
... NOS/PatientName Definition: Patient.name
Value Set:
.... NOS/PatientName-designNote Value Set:
... LN/21112-8 Definition: Patient.birthDate
Value Set:
... LN/46098-0 Definition: Patient.gender
Value Set: AdministrativeGender
... LN/56799-0 Definition: Patient.address.line
Value Set:
... LN/45401-7 Definition: Patient.address.postalCode
Value Set:
... LN/76435-7 Definition: Patient.identifier:MedicalRecordNumber
Value Set:
... LN/89061-6 Definition: Patient.identifier:nhsNumber
Value Set:
.. HealthcareProfessional Definition: PractitionerRole
Value Set:
... LN/18705-4 Definition: PractitionerRole.practitioner.display
Value Set:
... NOS/DepartmentAddress Definition: PractitionerRole.organization.display
Value Set:
... LN/89058-2 Definition: PractitionerRole.telecom.value
Value Set:
.. AskAtOrderEntry Value Set:
... NOS/FamilyHistoryPedigree Definition: ServiceRequest.note
Value Set:
... Audiogram Value Set:
.... NOS/AudiogramFindings Definition: Observation.valueString
Value Set:
.... NOS/AudiogramSeverityRight Definition: Observation.valueQuantity
Value Set:
.... NOS/AudiogramSeverityLeft Definition: Observation.valueQuantity
Value Set:
.... NOS/AudiogramProgression Definition: Observation.valueString
Value Set:
... NOS/SuspectedSyndromicDiagnosis Definition: ServiceRequest.reasonCode
Value Set:
Options: 6 options
... NOS/DeafnessRiskFactors Definition: Observation.valueCodeableConcept
Value Set:
Options: 4 options
... SNM/113091000-mri Definition: Observation.valueBoolean
Value Set:
... NOS/MRIFindings Definition: Observation.valueString
Enable When: Not done yet
Value Set:

doco Documentation for this format

Test this Questionnaire

Try this questionnaire out:

Responses for this Questionnaire

There are currently no QuestionnaireResponse instances for this Questionnaire defined in this IG.