davinci_dtr_test_kit 0.17.1 → 0.18.0

data/lib/davinci_dtr_test_kit/server/v2.2.0/questionnaire_package_support/adaptive_questionnaire_response_validation_test.rb

@@ -0,0 +1,61 @@
+require_relative '../../../tags'
+require_relative '../../validation_test'
+require_relative '../questionnaire_operation_validation'
+
+module DaVinciDTRTestKit
+  module DTRPayerServerV220
+    class AdaptiveQuestionnaireResponseValidationTest < Inferno::Test
+      include DaVinciDTRTestKit::ValidationTest
+      include QuestionnaireOperationValidation
+
+      ADAPTIVE_QUESTIONNAIRE_SEARCH_PROFILE =
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaire-adapt-search|2.2.0'.freeze
+      ADAPTIVE_QUESTIONNAIRE_EXTENSION_URL = 'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive'.freeze
+
+      id :dtr_v220_payer_adaptive_questionnaire_response_validation
+      title 'Validate adaptive Questionnaires against the DTR AdaptiveQuestionnaire-Search profile'
+      description %(
+        This test validates Questionnaires responses are compliant with the DTR
+        AdaptiveQuestionnaire-Search profile. It will check that the
+        Questionnaires returned from the $questionnaire-package operation are
+        valid against the profile.
+      )
+
+      verifies_requirements 'hl7.fhir.us.davinci-dtr_2.2.0@spec-23'
+
+      run do
+        load_tagged_requests(QUESTIONNAIRE_TAG)
+
+        skip_if requests.blank?, 'No $questionnaire-package requests were made.'
+
+        successful_requests = requests.select { |request| [200, 201].include? request.status }
+
+        skip_if successful_requests.blank?, 'No successful $questionnaire-package requests were made'
+
+        questionnaires = requests.flat_map do |request|
+          resource = FHIR.from_contents(request.response_body)
+          bundles = extract_questionnaire_bundles(resource)
+          next [] if bundles.blank?
+
+          extract_questionnaires_from_bundles(bundles)
+        end
+
+        skip_if questionnaires.blank?, 'No Questionnaires were found.'
+
+        adaptive_questionnaires = questionnaires.select do |questionnaire|
+          questionnaire.extension&.any? do |extension|
+            extension.url == ADAPTIVE_QUESTIONNAIRE_EXTENSION_URL
+          end
+        end
+
+        omit_if adaptive_questionnaires.blank?, 'No adaptive Questionnaires were found.'
+
+        perform_response_validation_test(
+          adaptive_questionnaires,
+          :questionnaire,
+          ADAPTIVE_QUESTIONNAIRE_SEARCH_PROFILE
+        )
+      end
+    end
+  end
+end

data/lib/davinci_dtr_test_kit/server/v2.2.0/questionnaire_package_support/contained_questionnaire_response_references_test.rb

@@ -0,0 +1,42 @@
+# frozen_string_literal: true
+
+require_relative '../questionnaire_response_reference_validation'
+require_relative '../../../cross_suite/v2.2.0/multi_request_message_helper'
+require_relative '../../../tags'
+
+module DaVinciDTRTestKit
+  module DTRPayerServerV220
+    class ContainedQuestionnaireResponseReferencesTest < Inferno::Test
+      include QuestionnaireResponseReferenceValidation
+      include MultiRequestMessageHelper
+
+      id :dtr_v220_payer_contained_questionnaire_response_references
+      title 'Contained QuestionnaireResponse references occur only in answer values'
+      description %(
+        This test verifies that a QuestionnaireResponse returned by `$questionnaire-package`
+        uses contained resource references only as
+        `QuestionnaireResponse.item.answer.valueReference` values.
+      )
+      verifies_requirements 'hl7.fhir.us.davinci-dtr_2.2.0@spec-140',
+                            'hl7.fhir.us.davinci-dtr_2.2.0@spec-141'
+
+      run do
+        load_tagged_requests(QUESTIONNAIRE_TAG)
+        responses_by_request = requests.map { |request| questionnaire_responses_from_request(request) }
+        skip_if responses_by_request.all?(&:empty?), 'No QuestionnaireResponse resources were returned.'
+
+        responses_by_request.each_with_index do |questionnaire_responses, request_index|
+          questionnaire_responses.each do |questionnaire_response|
+            invalid_contained_reference_locations(questionnaire_response).each do |reference|
+              add_request_message('error', reference, request_index)
+            end
+          end
+        end
+
+        message = "#{requests_with_errors_prefix}" \
+                  'Contained resource references are permitted only in item.answer valueReference '
+        assert_no_error_messages("#{message}elements. See Messages for details.")
+      end
+    end
+  end
+end

data/lib/davinci_dtr_test_kit/server/v2.2.0/questionnaire_package_support/dtr_server_no_custom_extension_test.rb

@@ -0,0 +1,184 @@
+require_relative '../../../tags'
+
+module DaVinciDTRTestKit
+  module DTRPayerServerV220
+    class DTRNoCustomExtensionTest < Inferno::Test
+      US_CORE_EXTENSION_URLS = [
+        'http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex',
+        'http://hl7.org/fhir/us/core/StructureDefinition/us-core-direct',
+        'http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity',
+        'http://hl7.org/fhir/us/core/StructureDefinition/us-core-race',
+        'http://hl7.org/fhir/us/core/StructureDefinition/uscdi-requirement',
+        'http://hl7.org/fhir/us/core/StructureDefinition/us-core-extension-questionnaire-uri',
+        'http://hl7.org/fhir/us/core/StructureDefinition/us-core-genderIdentity',
+        'http://hl7.org/fhir/us/core/StructureDefinition/us-core-jurisdiction',
+        'http://hl7.org/fhir/us/core/StructureDefinition/us-core-sex',
+        'http://hl7.org/fhir/us/core/StructureDefinition/us-core-tribal-affiliation',
+        'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication-adherence',
+        'http://hl7.org/fhir/StructureDefinition/condition-assertedDate'
+      ].freeze
+
+      HREX_EXTENSION_URLS = [
+        'http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/extension-CoverageDavinciWellknownLocation'
+      ].freeze
+
+      CRD_EXTENSION_URLS = [
+        'http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-coverage-information',
+        'http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-billing-options',
+        'http://hl7.org/fhir/us/davinci-crd/StructureDefinition/ext-request-category',
+        'http://hl7.org/fhir/StructureDefinition/codeOptions',
+        'http://hl7.org/fhir/StructureDefinition/alternate-reference',
+        'http://hl7.org/fhir/5.0/StructureDefinition/extension-CommunicationRequest.payload.content',
+        'http://hl7.org/fhir/5.0/StructureDefinition/extension-Task.requestedPeriod',
+        'http://hl7.org/fhir/5.0/StructureDefinition/extension-Task.requestedPerformer',
+        'http://hl7.org/fhir/5.0/StructureDefinition/extension-Task.performer',
+        'http://hl7.org/fhir/StructureDefinition/request-doNotPerform',
+        'http://hl7.org/fhir/5.0/StructureDefinition/extension-Task.input.value',
+        'http://hl7.org/fhir/5.0/StructureDefinition/extension-Task.output.value',
+        'http://hl7.org/fhir/5.0/StructureDefinition/extension-Task.statusReason'
+      ].freeze
+
+      DTR_EXTENSION_URLS = [
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/activeRole',
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/alternativeExpression',
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/containedReference',
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/information-origin',
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse',
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context',
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/estimated-completion-time',
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/questionnaireAudience',
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-coverage',
+        'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/request-specific'
+      ].freeze
+
+      SDC_EXTENSION_URLS = [
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-answerExpression',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-answerOptionsToggleExpression',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-assemble-expectation',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-assembleContext',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-assembleDefinitionRoot',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-assembledFrom',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-candidateExpression',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-choiceColumn',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-collapsible',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-columnCount',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-contextExpression',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-definitionExtract',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-definitionExtractValue',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-endpoint',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-entryMode',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-extractAllocateId',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-isSubject',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-itemAnswerMedia',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-itemExtractionContext',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-itemMedia',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-itemPopulationContext',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-keyboard',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-lookupQuestionnaire',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-maxQuantity',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-minQuantity',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-observation-extract-category',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-observationExtract',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-observationExtractEntry',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-observationLinkPeriod',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-openLabel',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-optionalDisplay',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-performerType',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-preferredTerminologyServer',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-questionnaireAdaptive',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-shortText',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-sourceQueries',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-sourceStructureMap',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-subQuestionnaire',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-targetStructureMap',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtract',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractBundle',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractContext',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-templateExtractValue',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-unitOpen',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-unitSupplementalSystem',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-width',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaireresponse-isSubject',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-rendering-criticalExtension',
+        'http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-servicerequest-questionnaire'
+      ].freeze
+
+      VALID_EXTENSION_URLS = (US_CORE_EXTENSION_URLS + HREX_EXTENSION_URLS \
+        + DTR_EXTENSION_URLS + SDC_EXTENSION_URLS).freeze
+
+      id :dtr_server_v220_no_custom_extension_test
+      title 'Server processes $questionnaire-package without custom extensions'
+      description %(
+        This test verifies that the DTR server can successfully process a
+        $questionnaire-package request without depending on extensions outside
+        those defined by DTR, HRex, or US Core.
+
+        Successful requests containing additional extensions are permitted.
+        The test passes when at least one successful request is observed that
+        does not depend on such extensions.
+      )
+
+      verifies_requirements 'hl7.fhir.us.davinci-dtr_2.2.0@conf-8'
+
+      run do
+        requests = load_tagged_requests(QUESTIONNAIRE_TAG)
+        skip_if requests.blank?, 'No requests were made in a previous test as expected.'
+
+        successful_requests = requests.select { |request| request.status == 200 }
+        skip_if successful_requests.empty?, 'All service requests were unsuccessful.'
+
+        resources = successful_requests.filter_map { |request| resource_from_request(request) }
+        skip_if resources.empty?, 'No FHIR resources were found in successful $questionnaire-package requests.'
+
+        request_with_no_custom_extensions = resources.any? do |resource|
+          no_custom_extensions?(resource)
+        end
+
+        pass_if request_with_no_custom_extensions
+
+        custom_extensions_string = resources
+          .flat_map { |resource| custom_extensions(resource) }
+          .uniq
+          .map { |extension| "\n- `#{extension}`" }
+          .join
+
+        skip 'No requests were made without custom extensions. The following custom extensions were found: ' \
+             "#{custom_extensions_string}"
+      end
+
+      def resource_from_request(request)
+        FHIR.from_contents(request.request_body)
+      rescue JSON::ParserError
+        nil
+      end
+
+      def no_custom_extensions?(bundle)
+        bundle.each_element do |value, _metadata, path|
+          next unless value.is_a?(FHIR::Extension)
+
+          next if path.to_s.scan('extension').length > 1
+
+          return false unless VALID_EXTENSION_URLS.include?(value.url.to_s)
+        end
+
+        true
+      end
+
+      def custom_extensions(bundle)
+        [].tap do |custom_extensions|
+          bundle.each_element do |value, _metadata, path|
+            next unless value.is_a?(FHIR::Extension)
+
+            next if path.to_s.scan('extension').length > 1
+
+            custom_extensions << value.url.to_s unless VALID_EXTENSION_URLS.include?(value.url.to_s)
+          end
+        end
+      end
+    end
+  end
+end

data/lib/davinci_dtr_test_kit/server/v2.2.0/questionnaire_package_support/dtr_server_questionnaire_not_found_test.rb

@@ -0,0 +1,76 @@
+require_relative '../../../tags'
+
+module DaVinciDTRTestKit
+  module DTRPayerServerV220
+    class DTRServerQuestionnaireNotFoundTest < Inferno::Test
+      id :dtr_server_v220_payer_questionnaire_not_found
+      title 'Questionnaire package response includes a warning for an unknown Questionnaire'
+      description %(
+        The DTR Questionnaire Package operation requires the server to return a warning
+        when a requested Questionnaire cannot be found. Inferno adds an unknown Questionnaire
+        to a previously made `$questionnaire-package` request and verifies that the
+        response contains the required warning.
+      )
+
+      verifies_requirements 'hl7.fhir.us.davinci-dtr_2.2.0@oper-9'
+
+      QUESTIONNAIRE_NOT_FOUND_URL = 'https://inferno.health/Questionnaire/does-not-exist'.freeze
+
+      input :url,
+            title: 'Payer FHIR Server Base Url',
+            description: 'Base FHIR URL implementing the DTR server operations.'
+
+      fhir_client do
+        url :url
+        auth_info :backend_services_smart_auth_info
+      end
+
+      run do
+        load_tagged_requests(QUESTIONNAIRE_TAG)
+
+        skip_if requests.blank?,
+                'No $questionnaire-package requests were made in the Request Questionnaires test.'
+
+        questionnaire_package_parameters = FHIR.from_contents(requests.first.request_body)
+
+        assert_resource_type(:parameters, resource: questionnaire_package_parameters)
+
+        questionnaire_package_parameters.parameter << FHIR::Parameters::Parameter.new(
+          name: 'questionnaire',
+          valueCanonical: QUESTIONNAIRE_NOT_FOUND_URL
+        )
+
+        fhir_operation(
+          '/Questionnaire/$questionnaire-package',
+          body: questionnaire_package_parameters,
+          tags: [QUESTIONNAIRE_TAG]
+        )
+
+        assert_valid_json(request.response_body)
+        assert_resource_type(:parameters)
+        assert_valid_resource
+
+        outcome_parameter = resource.parameter.find do |parameter|
+          parameter.name == 'outcome'
+        end
+
+        assert outcome_parameter.present?,
+               'The questionnaire-package response is missing the required `outcome` parameter.'
+
+        outcome = outcome_parameter.resource
+
+        assert outcome.present?,
+               'The `outcome` parameter does not contain an OperationOutcome resource.'
+
+        assert_resource_type(:operation_outcome, resource: outcome)
+
+        has_warning = outcome.issue.any? do |issue|
+          issue.severity == 'warning'
+        end
+
+        assert has_warning,
+               'The OperationOutcome in the `outcome` parameter does not contain a warning issue.'
+      end
+    end
+  end
+end

data/lib/davinci_dtr_test_kit/server/v2.2.0/questionnaire_package_support/dtr_server_questionnaire_package_contents_test.rb

@@ -0,0 +1,89 @@
+require_relative '../../../tags'
+
+module DaVinciDTRTestKit
+  module DTRPayerServerV220
+    class DTRServerQuestionnairePackageContentsTest < Inferno::Test
+      id :dtr_server_v220_payer_questionnaire_package_contents
+      title 'Questionnaire package Bundles include the Questionnaire as the first entry'
+      description %(
+        The DTR Questionnaire Package operation requires each response Bundle to include
+        the requested Questionnaire as its first entry.
+      )
+
+      verifies_requirements 'hl7.fhir.us.davinci-dtr_2.2.0@oper-12'
+
+      run do
+        load_tagged_requests(QUESTIONNAIRE_TAG)
+
+        skip_if requests.blank?,
+                'No $questionnaire-package requests were made in the Request Questionnaires test.'
+
+        valid_questionnaire_package_found = false
+
+        requests.each do |questionnaire_package_exchange|
+          JSON.parse(questionnaire_package_exchange.response_body)
+
+          questionnaire_package_parameters = FHIR.from_contents(
+            questionnaire_package_exchange.response_body
+          )
+
+          next unless questionnaire_package_parameters&.resourceType == 'Parameters'
+
+          package_bundles = questionnaire_package_parameters.parameter.filter_map do |parameter|
+            parameter.resource if parameter.name == 'packagebundle'
+          end
+
+          next if package_bundles.blank?
+
+          valid_questionnaire_package_found = true
+
+          package_bundles.each do |package_bundle|
+            unless package_bundle.resourceType == 'Bundle'
+              add_message(
+                'error',
+                'Unexpected resource type: expected Bundle, but received ' \
+                "#{package_bundle.resourceType}"
+              )
+              next
+            end
+
+            first_entry = package_bundle.entry.first
+
+            unless first_entry.present?
+              add_message(
+                'error',
+                'Each questionnaire-package Bundle must contain at least one entry.'
+              )
+              next
+            end
+
+            unless first_entry.resource.present?
+              add_message(
+                'error',
+                'The first entry in each questionnaire-package Bundle must contain a resource.'
+              )
+              next
+            end
+
+            next if first_entry.resource.resourceType == 'Questionnaire'
+
+            add_message(
+              'error',
+              'Unexpected resource type: expected Questionnaire, but received ' \
+              "#{first_entry.resource.resourceType}"
+            )
+          end
+        rescue JSON::ParserError
+          next
+        end
+
+        skip_if !valid_questionnaire_package_found,
+                'No valid questionnaire-package response Bundles were found.'
+
+        assert_no_error_messages(
+          'Not all questionnaire-package Bundles included the Questionnaire as the first entry.'
+        )
+      end
+    end
+  end
+end

data/lib/davinci_dtr_test_kit/server/v2.2.0/questionnaire_package_support/initial_questionnaire_response_test.rb

@@ -0,0 +1,132 @@
+# frozen_string_literal: true
+
+require_relative '../../../cross_suite/v2.2.0/multi_request_message_helper'
+require_relative '../../../tags'
+require_relative '../questionnaire_operation_validation'
+
+module DaVinciDTRTestKit
+  module DTRPayerServerV220
+    class InitialQuestionnaireResponseTest < Inferno::Test
+      include MultiRequestMessageHelper
+      include QuestionnaireOperationValidation
+
+      CONTEXT_EXTENSION_URL = 'http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context'
+
+      id :dtr_v220_payer_initial_questionnaire_response
+      title 'Questionnaire package contains initial QuestionnaireResponse context'
+      description %(
+        This test verifies that each QuestionnaireResponse returned in a
+        `$questionnaire-package` Bundle is an initial response: it is in-progress.
+
+        This test also verifies `qr-context` when the corresponding
+        `$questionnaire-package` request supplies an `order` parameter. It
+        verifies that a context reference is present in that scenario; it does
+        not determine which input resource each QuestionnaireResponse is
+        associated with or compare reference values.
+
+        The Questionnaire Package Output Parameters profile validation separately
+        verifies that every package Bundle contains exactly one DTR
+        QuestionnaireResponse, including its required `subject` and `qr-coverage`
+        elements.
+      )
+      verifies_requirements 'hl7.fhir.us.davinci-dtr_2.2.0@oper-18'
+
+      run do
+        load_tagged_requests(QUESTIONNAIRE_TAG)
+        questionnaire_responses_found = false
+
+        requests.each_with_index do |request, request_index|
+          package_bundles_from_request(request).each do |package_bundle|
+            questionnaire_response = package_resources(package_bundle, FHIR::QuestionnaireResponse).first
+            next unless questionnaire_response
+
+            questionnaire_responses_found = true
+            validate_initial_questionnaire_response(
+              questionnaire_response,
+              request_index,
+              context_required: request_includes_context_resource?(request)
+            )
+          end
+        end
+
+        skip_if !questionnaire_responses_found,
+                'No QuestionnaireResponse resources were returned; ' \
+                'the response validation test verifies their presence.'
+
+        message = "#{requests_with_errors_prefix}" \
+                  'QuestionnaireResponses in package Bundles must be initial responses ' \
+                  'with context when an order is supplied.'
+        assert_no_error_messages("#{message} See Messages for details.")
+      end
+
+      private
+
+      def validate_initial_questionnaire_response(questionnaire_response, request_index, context_required:)
+        validate_initial_status(questionnaire_response, request_index)
+        validate_context_extensions(questionnaire_response, request_index, context_required:)
+      end
+
+      def validate_initial_status(questionnaire_response, request_index)
+        return if questionnaire_response.status == 'in-progress'
+
+        add_request_message('error', 'QuestionnaireResponse.status must be `in-progress`.', request_index)
+      end
+
+      def validate_context_extensions(questionnaire_response, request_index, context_required:)
+        return unless context_required
+
+        validate_extension(questionnaire_response.extension || [], CONTEXT_EXTENSION_URL, 'qr-context', request_index)
+      end
+
+      def validate_extension(extensions, url, extension_name, request_index)
+        references = extension_references(extensions, url)
+        return unless references.empty?
+
+        add_request_message(
+          'error', "QuestionnaireResponse must include a #{extension_name} extension.", request_index
+        )
+      end
+
+      def extension_references(extensions, url)
+        extensions.filter_map do |extension|
+          extension.valueReference if extension.url == url && extension.valueReference&.reference.present?
+        end
+      end
+
+      def package_bundles_from_request(request)
+        resource = FHIR.from_contents(request.response_body)
+        return [] unless resource.is_a?(FHIR::Parameters)
+
+        extract_questionnaire_bundles(resource)
+      rescue JSON::ParserError
+        []
+      end
+
+      def request_includes_context_resource?(request)
+        parameters = request_parameters(request)
+        parameter_resources(parameters, 'order').present?
+      end
+
+      def request_parameters(request)
+        return unless request.request_body.present?
+
+        resource = FHIR.from_contents(request.request_body)
+        resource if resource.is_a?(FHIR::Parameters)
+      rescue JSON::ParserError
+        nil
+      end
+
+      def parameter_resources(parameters, name)
+        return [] unless parameters
+
+        parameters.parameter.filter_map { |parameter| parameter.resource if parameter.name == name }
+      end
+
+      def package_resources(package_bundle, resource_class)
+        package_bundle.entry.filter_map do |entry|
+          entry.resource if entry.resource.is_a?(resource_class)
+        end
+      end
+    end
+  end
+end