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Packagebha-ig
Resource TypeQuestionnaire
IdQuestionnaire-BHAAdmissionQuestionnaire.json
FHIR VersionR4
Sourcehttps://build.fhir.org/ig/RatioPBC/bha-ig/Questionnaire-BHAAdmissionQuestionnaire.html
URLhttp://bha.colorado.gov/fhir/bha-ig/Questionnaire/BHAAdmissionQuestionnaire
Version0.1.0-current
Statusactive
Date2025-12-13
NameBHAAdmissionQuestionnaire
TitleBHA Admission Questionnaire
Realmus
DescriptionQuestionnaire used during admission process to collect demographic, social, clinical, and administrative information from patients entering behavioral health services

Resources that use this resource

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Resources that this resource uses

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Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: Questionnaire BHAAdmissionQuestionnaire

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. BHAAdmissionQuestionnaireQuestionnaire used during admission process to collect demographic, social, clinical, and administrative information from patients entering behavioral health servicesQuestionnairehttp://bha.colorado.gov/fhir/bha-ig/Questionnaire/BHAAdmissionQuestionnaire#0.1.0-current
... FIRST_CONTACT_DATEDate of First Contact1..1date
... FIRST_APPOINTMENT_OFFERED_DATEDate of First Appointment Offered1..1date
... MEDICATION_ASSISTED_OPIOID_THERAPYMedication Assisted Opioid Therapy1..1boolean
... REFERRAL_SOURCEReferral Source1..1choiceValue Set: BHA Referral Source
... ARRESTS_PAST_30_DAYSArrests in Past 30 Days1..1integer
... EMPLOYMENT_STATUSEmployment Status1..1choiceValue Set: BHA Employment Status
... MARITAL_STATUSMarital Status1..1choiceValue Set: BHA Marital Status
... LIVING_SITUATIONLiving Situation1..1choiceValue Set: BHA Living Situation
... MONTHLY_INCOMEMonthly Income0..1decimal
... PRIMARY_INCOME_SOURCEPrimary Source of income/support for client (or for client's parent if client >18 years of age)1..1choiceValue Set: BHA Income Source
... PREGNANCY_STATUSPregnancy Status1..1boolean
... WITHIN_1_YEAR_POSTPARTUM_STATUSWithin 1 Year Postpartum Status1..1boolean
... SPECIAL_CONNECTIONS_ENROLLMENTEnrollment in Special Connections1..1boolean
... ACT_ENROLLMENTEnrollment in ACT?1..1boolean
... ASCENT_ENROLLMENTEnrollment in Ascent (FEP)?1..1boolean
... NUMBER_DEPENDENT_CHILDRENNumber of Dependent Children1..1integer
... SELF_HELP_ATTENDANCESelf Help Attendance (Last 30 days at admission)/ Peer Support Attendance1..1integer
... TOTAL_SUBSTANCE_USE_PRIOR_TREATMENTSubstance Use Prior Treatment (Total Lifetime admissions)1..1integer
... PSYCHIATRIC_HOSPITAL_ADMISSIONPsychiatric Hospital Admission (Last 30 days)1..1boolean
... LEGAL_STATUSLegal Status1..1choiceValue Set: BHA Legal Status
... INVOLUNTARY_COMMITMENT_REASONInvoluntary Commitment Reason1..1choiceEnable When:
Value Set: BHA Involuntary Reason
... CRIMINAL_JUSTICE_INVOLVEMENTCriminal Justice Involvement0..1boolean
... EDUCATION_LEVELEducation Level1..1choiceValue Set: BHA Education Level
... SCHOOL_ATTENDANCE_STATUSSchool Attendance Status (in the previous 3 months)1..1choiceValue Set: BHA School Attendance Status
... PSYCHIATRIC_ER_VISIT_6_MONTHSVisit to Psychiatric ER in last 6 months1..1integer
... COMMUNICATION_ACCOMMODATIONSCommunication Accommodations0..1boolean

doco Documentation for this format

Source1

{
  "resourceType": "Questionnaire",
  "id": "BHAAdmissionQuestionnaire",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire|3.0.0"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger": 0,
      "_valueInteger": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical": "http://bha.colorado.gov/fhir/bha-ig/ImplementationGuide/bha-ig"
          }
        ]
      }
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode": "trial-use",
      "_valueCode": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical": "http://bha.colorado.gov/fhir/bha-ig/ImplementationGuide/bha-ig"
          }
        ]
      }
    }
  ],
  "url": "http://bha.colorado.gov/fhir/bha-ig/Questionnaire/BHAAdmissionQuestionnaire",
  "version": "0.1.0-current",
  "name": "BHAAdmissionQuestionnaire",
  "title": "BHA Admission Questionnaire",
  "status": "active",
  "subjectType": [
    "Patient"
  ],
  "date": "2025-12-13",
  "publisher": "Colorado Behavioral Health Administration",
  "contact": [
    {
      "name": "Colorado Behavioral Health Administration",
      "telecom": [
        {
          "system": "url",
          "value": "https://bha.colorado.gov"
        },
        {
          "system": "email",
          "value": "FHIRFeedback@state.co.us"
        }
      ]
    }
  ],
  "description": "Questionnaire used during admission process to collect demographic, social, clinical, and administrative information from patients entering behavioral health services",
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
          "code": "840"
        }
      ]
    }
  ],
  "item": [
    {
      "linkId": "FIRST_CONTACT_DATE",
      "text": "Date of First Contact",
      "type": "date",
      "required": true
    },
    {
      "linkId": "FIRST_APPOINTMENT_OFFERED_DATE",
      "text": "Date of First Appointment Offered",
      "type": "date",
      "required": true
    },
    {
      "linkId": "MEDICATION_ASSISTED_OPIOID_THERAPY",
      "text": "Medication Assisted Opioid Therapy",
      "type": "boolean",
      "required": true
    },
    {
      "linkId": "REFERRAL_SOURCE",
      "text": "Referral Source",
      "type": "choice",
      "required": true,
      "answerValueSet": "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-referral-source-vs"
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/StructureDefinition/minValue",
          "valueInteger": 0
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/maxValue",
          "valueInteger": 30
        }
      ],
      "linkId": "ARRESTS_PAST_30_DAYS",
      "text": "Arrests in Past 30 Days",
      "type": "integer",
      "required": true
    },
    {
      "linkId": "EMPLOYMENT_STATUS",
      "text": "Employment Status",
      "type": "choice",
      "required": true,
      "answerValueSet": "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-employment-status-vs"
    },
    {
      "linkId": "MARITAL_STATUS",
      "text": "Marital Status",
      "type": "choice",
      "required": true,
      "answerValueSet": "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-marital-status-vs"
    },
    {
      "linkId": "LIVING_SITUATION",
      "text": "Living Situation",
      "type": "choice",
      "required": true,
      "answerValueSet": "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-living-situation-vs"
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
          "valueCoding": {
            "system": "urn:iso:std:iso:4217",
            "code": "USD"
          }
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/minValue",
          "valueDecimal": 0
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/maxValue",
          "valueDecimal": 9999
        }
      ],
      "linkId": "MONTHLY_INCOME",
      "text": "Monthly Income",
      "type": "decimal",
      "required": false
    },
    {
      "linkId": "PRIMARY_INCOME_SOURCE",
      "text": "Primary Source of income/support for client (or for client's parent if client >18 years of age)",
      "type": "choice",
      "required": true,
      "answerValueSet": "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-income-source-vs"
    },
    {
      "linkId": "PREGNANCY_STATUS",
      "text": "Pregnancy Status",
      "type": "boolean",
      "required": true
    },
    {
      "linkId": "WITHIN_1_YEAR_POSTPARTUM_STATUS",
      "text": "Within 1 Year Postpartum Status",
      "type": "boolean",
      "required": true
    },
    {
      "linkId": "SPECIAL_CONNECTIONS_ENROLLMENT",
      "text": "Enrollment in Special Connections",
      "type": "boolean",
      "required": true
    },
    {
      "linkId": "ACT_ENROLLMENT",
      "text": "Enrollment in ACT?",
      "type": "boolean",
      "required": true
    },
    {
      "linkId": "ASCENT_ENROLLMENT",
      "text": "Enrollment in Ascent (FEP)?",
      "type": "boolean",
      "required": true
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/StructureDefinition/minValue",
          "valueInteger": 0
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/maxValue",
          "valueInteger": 99
        }
      ],
      "linkId": "NUMBER_DEPENDENT_CHILDREN",
      "text": "Number of Dependent Children",
      "type": "integer",
      "required": true
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/StructureDefinition/minValue",
          "valueInteger": 0
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/maxValue",
          "valueInteger": 30
        }
      ],
      "linkId": "SELF_HELP_ATTENDANCE",
      "text": "Self Help Attendance (Last 30 days at admission)/ Peer Support Attendance",
      "type": "integer",
      "required": true
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/StructureDefinition/minValue",
          "valueInteger": 0
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/maxValue",
          "valueInteger": 30
        }
      ],
      "linkId": "TOTAL_SUBSTANCE_USE_PRIOR_TREATMENT",
      "text": "Substance Use Prior Treatment (Total Lifetime admissions)",
      "type": "integer",
      "required": true
    },
    {
      "linkId": "PSYCHIATRIC_HOSPITAL_ADMISSION",
      "text": "Psychiatric Hospital Admission (Last 30 days)",
      "type": "boolean",
      "required": true
    },
    {
      "linkId": "LEGAL_STATUS",
      "text": "Legal Status",
      "type": "choice",
      "required": true,
      "answerValueSet": "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-legal-status-vs"
    },
    {
      "linkId": "INVOLUNTARY_COMMITMENT_REASON",
      "text": "Involuntary Commitment Reason",
      "type": "choice",
      "enableWhen": [
        {
          "question": "LEGAL_STATUS",
          "operator": "=",
          "answerCoding": {
            "system": "http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status",
            "code": "04",
            "display": "72-hour evaluation and treatment"
          }
        },
        {
          "question": "LEGAL_STATUS",
          "operator": "=",
          "answerCoding": {
            "system": "http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status",
            "code": "05",
            "display": "Short-term certification"
          }
        },
        {
          "question": "LEGAL_STATUS",
          "operator": "=",
          "answerCoding": {
            "system": "http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status",
            "code": "06",
            "display": "Long-term certification"
          }
        },
        {
          "question": "LEGAL_STATUS",
          "operator": "=",
          "answerCoding": {
            "system": "http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status",
            "code": "09",
            "display": "Emergency/Involuntary Alcohol/Drug Commitment"
          }
        }
      ],
      "enableBehavior": "any",
      "required": true,
      "answerValueSet": "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-involuntary-commitment-reason-vs"
    },
    {
      "linkId": "CRIMINAL_JUSTICE_INVOLVEMENT",
      "text": "Criminal Justice Involvement",
      "type": "boolean",
      "required": false
    },
    {
      "linkId": "EDUCATION_LEVEL",
      "text": "Education Level",
      "type": "choice",
      "required": true,
      "answerValueSet": "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-education-level-vs"
    },
    {
      "linkId": "SCHOOL_ATTENDANCE_STATUS",
      "text": "School Attendance Status (in the previous 3 months)",
      "type": "choice",
      "required": true,
      "answerValueSet": "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-school-attendance-status-vs"
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/StructureDefinition/minValue",
          "valueInteger": 0
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/maxValue",
          "valueInteger": 99
        }
      ],
      "linkId": "PSYCHIATRIC_ER_VISIT_6_MONTHS",
      "text": "Visit to Psychiatric ER in last 6 months",
      "type": "integer",
      "required": true
    },
    {
      "linkId": "COMMUNICATION_ACCOMMODATIONS",
      "text": "Communication Accommodations",
      "type": "boolean",
      "required": false
    }
  ]
}