FHIR IG analytics| Package | ca.on.oh-eforms |
| Resource Type | QuestionnaireResponse |
| Id | 2026-02_Cardiology-SRF-Manual-3.json |
| FHIR Version | R4 |
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FHIR
FHIRsmith{
"resourceType": "QuestionnaireResponse",
"id": "CardiologyOHAuthoredQR-MariaSantos",
"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": "2026-03-12T22:51:31.735Z",
"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": "Santos"
}
]
},
{
"linkId": "patient_firstname",
"text": "First Name:",
"answer": [
{
"valueString": "Maria"
}
]
},
{
"linkId": "patient_date_of_birth",
"text": "DOB:",
"answer": [
{
"valueDate": "1948-05-19"
}
]
},
{
"linkId": "patient_gender",
"text": "Gender:",
"answer": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/administrative-gender",
"code": "female",
"display": "Female"
}
}
]
},
{
"linkId": "patient_hc_pc",
"text": "HN PC:",
"answer": [
{
"valueString": "ON",
"item": [
{
"linkId": "patient_hc_number",
"text": "HN:",
"answer": [
{
"valueString": "7413582609"
}
]
},
{
"linkId": "patient_hc_vc",
"text": "HN VC:",
"answer": [
{
"valueString": "TC"
}
]
}
]
}
]
},
{
"linkId": "patient_address_line1",
"text": "Address (Line 1):",
"answer": [
{
"valueString": "85 King St S",
"item": [
{
"linkId": "patient_address_line2",
"text": "Address (Line 2):",
"answer": [
{
"valueString": "Unit 302"
}
]
},
{
"linkId": "patient_address_city",
"text": "City:",
"answer": [
{
"valueString": "Waterloo"
}
]
},
{
"linkId": "patient_address_province",
"text": "Province:",
"answer": [
{
"valueString": "ON"
}
]
},
{
"linkId": "patient_address_postalcode",
"text": "Postal Code:",
"answer": [
{
"valueString": "N2J 1P2"
}
]
}
]
}
]
},
{
"linkId": "patient_phone_mobile",
"text": "Mobile #:",
"answer": [
{
"valueString": "519-555-0362"
}
]
},
{
"linkId": "patient_phone_home",
"text": "Home #:",
"answer": [
{
"valueString": "519-555-0198"
}
]
},
{
"linkId": "patient_email",
"text": "Email:",
"answer": [
{
"valueString": "maria.santos@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": "home",
"display": "Home"
}
}
]
},
{
"linkId": "additionalinfo_accessibilityconcernsordisability_selectt",
"text": "Accessibility concerns or disability",
"answer": [
{
"valueString": "Accessibility concerns or disability"
}
]
},
{
"linkId": "additionalinfo_accessibilityconcernsordisability",
"text": "Accessibility concerns Options",
"answer": [
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "105503008",
"display": "Wheelchair"
}
},
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "15188001",
"display": "Hearing impaired"
}
}
]
}
]
},
{
"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": "routine",
"display": "Routine"
}
}
]
}
]
},
{
"linkId": "695991571585",
"text": "Service(s) Requested Select all that apply:",
"item": [
{
"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": "832263816528",
"text": "Congestive Heart Failure",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
"code": "20036",
"display": "Congestive Heart Failure"
}
}
]
}
]
},
{
"linkId": "Descriptionofclinicalquestion",
"text": "Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations",
"answer": [
{
"valueString": "77F, progressive exertional dyspnea and bilateral ankle edema x 2 months. BNP elevated at 480. CXR shows mild cardiomegaly. On furosemide 20mg with partial response. Please assess and advise on HF management."
}
]
}
]
},
{
"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": "Suspected CHF (onset Jan 2026)\nHypertension\nType 2 diabetes"
}
]
},
{
"linkId": "cpp_pastmedicalhistory",
"text": "Past Medical History:",
"answer": [
{
"valueString": "Left hip replacement (2020)\nType 2 diabetes (2012)"
}
]
},
{
"linkId": "cpp_currentmedications",
"text": "Current Medications :",
"answer": [
{
"valueString": "Furosemide 20 mg PO daily\nPerindopril 4 mg PO daily\nMetformin 500 mg PO BID\nEmpagliflozin 10 mg PO daily"
}
]
},
{
"linkId": "cpp_familyhistory",
"text": "Family History:",
"answer": [
{
"valueString": "Mother: CHF, deceased age 80"
}
]
},
{
"linkId": "cpp_allergies",
"text": "Allergies:",
"answer": [
{
"valueString": "NKDA"
}
]
}
]
},
{
"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"
}
}
]
}
]
}
]
}