FHIR IG analytics| Package | ca.on.oh-eforms |
| Resource Type | QuestionnaireResponse |
| Id | 2026-02_Cardiology-SRF-Manual-1.json |
| FHIR Version | R4 |
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FHIR
FHIRsmith{
"resourceType": "QuestionnaireResponse",
"id": "CardiologyOHAuthoredQR-JaneDoe",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"questionnaire": "urn:uuid:d7176d16-5fd4-48a7-b7e6-b488e8df763d|1.0.0",
"status": "completed",
"subject": {
"reference": "Patient/pat-53234",
"display": "MOMO ABBAS"
},
"authored": "2026-03-12T22:37:03.849Z",
"author": {
"reference": "Practitioner/smart-Practitioner-71482713",
"type": "Practitioner",
"display": "Susan Clark"
},
"item": [
{
"linkId": "patient_header",
"text": "Patient Information",
"item": [
{
"linkId": "patient_surname",
"text": "Surname:",
"answer": [
{
"valueString": "Doe"
}
]
},
{
"linkId": "patient_firstname",
"text": "First Name:",
"answer": [
{
"valueString": "Jane"
}
]
},
{
"linkId": "patient_date_of_birth",
"text": "DOB:",
"answer": [
{
"valueDate": "1953-11-22"
}
]
},
{
"linkId": "patient_gender",
"text": "Gender:",
"answer": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/administrative-gender",
"code": "female",
"display": "Female"
}
}
]
},
{
"linkId": "patient_address_line1",
"text": "Address (Line 1):",
"answer": [
{
"valueString": "115 Queen St W",
"item": [
{
"linkId": "patient_address_line2",
"text": "Address (Line 2):",
"answer": [
{
"valueString": "Apt 804"
}
]
},
{
"linkId": "patient_address_city",
"text": "City:",
"answer": [
{
"valueString": "Toronto"
}
]
},
{
"linkId": "patient_address_province",
"text": "Province:",
"answer": [
{
"valueString": "ON"
}
]
},
{
"linkId": "patient_address_postalcode",
"text": "Postal Code:",
"answer": [
{
"valueString": "M5H 2M5"
}
]
}
]
}
]
},
{
"linkId": "patient_phone_mobile",
"text": "Mobile #:",
"answer": [
{
"valueString": "647-555-0291"
}
]
},
{
"linkId": "patient_email",
"text": "Email:",
"answer": [
{
"valueString": "jane.doe@example.com"
}
]
}
]
},
{
"linkId": "additionalinfo_header",
"text": "[Optional] Additional Patient Information",
"item": [
{
"linkId": "additionalinfo_sexassignedatbirth",
"text": "Sex assigned at birth:",
"answer": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA3-6",
"display": "Female"
}
}
]
},
{
"linkId": "additionalinfo_pronouns",
"text": "Pronouns:",
"answer": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA29519-8",
"display": "She/Her"
}
}
]
},
{
"linkId": "additionalinfo_preferredlanguage",
"text": "Preferred language:",
"answer": [
{
"valueCoding": {
"system": "urn:ietf:bcp:47",
"code": "en",
"display": "English"
}
}
]
},
{
"linkId": "additionalinfo_bestmethodofcontact",
"text": "Best method of contact:",
"answer": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/contact-point-use",
"code": "mobile",
"display": "Mobile"
},
"item": [
{
"linkId": "additionalinfo_bestmethodofcontact_voicemails",
"text": "Voicemails acceptable",
"answer": [
{
"valueString": " Voicemails acceptable"
}
]
}
]
}
]
}
]
},
{
"linkId": "102173268919",
"text": "Referral Details",
"item": [
{
"linkId": "cardio_triagecons",
"text": "Triage Considerations",
"item": [
{
"linkId": "referral_requestedpriority",
"text": "Requested Priority:",
"answer": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/request-priority",
"code": "urgent",
"display": "Urgent"
},
"item": [
{
"linkId": "referral_requestedpriority_urgentreason",
"text": "Reason for urgent triage",
"answer": [
{
"valueString": "Recurrent syncope with witnessed pause, fall risk"
}
]
}
]
}
]
}
]
},
{
"linkId": "695991571585",
"text": "Service(s) Requested Select all that apply:",
"item": [
{
"linkId": "223886162384",
"text": "Cardiac Testing",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
"code": "20001",
"display": "Cardiac Testing"
}
}
]
},
{
"linkId": "660331267409",
"text": "Exam(s) Requested",
"item": [
{
"linkId": "279226023495",
"text": "Holter Monitoring",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
"code": "20007",
"display": "Holter Monitoring"
}
}
]
},
{
"linkId": "440449731882",
"text": "sub holter monitoring",
"item": [
{
"linkId": "423992261841",
"text": "48 Hours",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
"code": "20018",
"display": "48 Hours"
}
}
]
}
]
}
]
},
{
"linkId": "785727177547",
"text": "Cardiology Consultation",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
"code": "20002",
"display": "Cardiology Consultation"
}
}
]
}
]
},
{
"linkId": "186952778859",
"text": "Concern(s) / Indication(s) Triggering Referral Select all that apply:",
"item": [
{
"linkId": "197975129599",
"text": "Syncope",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
"code": "20045",
"display": "Syncope"
}
}
]
}
]
},
{
"linkId": "Descriptionofclinicalquestion",
"text": "Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations",
"answer": [
{
"valueString": "72F, two syncopal episodes in past 3 weeks. Witness reports 3-5 sec unresponsiveness, no seizure activity. In-office ECG shows sinus bradycardia 48 bpm. On metoprolol for HTN. Please assess for arrhythmic cause and need for pacemaker evaluation."
}
]
}
]
},
{
"linkId": "cpp_header",
"text": "Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP",
"item": [
{
"linkId": "cpp_currentprob",
"text": "Current Problem List:",
"answer": [
{
"valueString": "Hypertension\nRecurrent syncope (onset Feb 2026)\nOsteoarthritis, bilateral knees"
}
]
},
{
"linkId": "cpp_pastmedicalhistory",
"text": "Past Medical History:",
"answer": [
{
"valueString": "Cholecystectomy (2008)\nNo prior cardiac history"
}
]
},
{
"linkId": "cpp_currentmedications",
"text": "Current Medications :",
"answer": [
{
"valueString": "Metoprolol 50 mg PO BID\nHydrochlorothiazide 12.5 mg PO daily\nAcetaminophen 500 mg PO PRN"
}
]
},
{
"linkId": "cpp_familyhistory",
"text": "Family History:",
"answer": [
{
"valueString": "Non-contributory"
}
]
},
{
"linkId": "cpp_allergies",
"text": "Allergies:",
"answer": [
{
"valueString": "Penicillin (hives)"
}
]
}
]
},
{
"linkId": "referrer_header",
"text": "Referrer's Information",
"item": [
{
"linkId": "referrer_sitename",
"text": "Site Name:",
"answer": [
{
"valueString": "Amplify Primary Care"
}
]
},
{
"linkId": "referrer_address_line1",
"text": "Address (Line 1):",
"answer": [
{
"valueString": "10248 Yonge St",
"item": [
{
"linkId": "referrer_address_line2",
"text": "Address (Line 2):",
"answer": [
{
"valueString": "Suite 515"
}
]
},
{
"linkId": "referrer_address_city",
"text": "City:",
"answer": [
{
"valueString": "Richmond Hill"
}
]
},
{
"linkId": "referrer_address_province",
"text": "Province:",
"answer": [
{
"valueString": "ON"
}
]
},
{
"linkId": "referrer_address_postalcode",
"text": "Postal Code:",
"answer": [
{
"valueString": "L4C 5K9"
}
]
}
]
}
]
},
{
"linkId": "referrer_phone",
"text": "Phone #:",
"answer": [
{
"valueString": "\t416-555-5555"
}
]
},
{
"linkId": "referrer_fax",
"text": "Fax #:",
"answer": [
{
"valueString": "\t416-555-5555"
}
]
},
{
"linkId": "referrer_billing",
"text": "Billing Number:",
"answer": [
{
"valueInteger": 55554
}
]
},
{
"linkId": "referrer_professionalid",
"text": "Professional ID:",
"answer": [
{
"valueInteger": 55555
}
]
},
{
"linkId": "referrer_signature",
"text": "Signed:",
"answer": [
{
"valueString": "Dr. Sean Sender"
}
]
},
{
"linkId": "referrer_role",
"text": "Role:",
"answer": [
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "62247001",
"display": "Family Physician"
}
}
]
}
]
}
]
}