FHIR IG analytics| Package | ca.on.oh-eforms |
| Resource Type | QuestionnaireResponse |
| Id | translations-1.json |
| FHIR Version | R4 |
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Note: links and images are rebased to the (stated) source
Patient Safety Screening
Select where applicable
FHIR
FHIRsmith{
"resourceType": "QuestionnaireResponse",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"questionnaire": "http://ontariohealth.ca/fhir/eforms/Questionnaire/translations|1.1.0",
"status": "completed",
"subject": {
"reference": "http://example.org/Patient/pat-53234",
"display": "MOMO ABBAS"
},
"authored": "2026-08-30T21:33:21.444Z",
"author": {
"reference": "http://example.org/Practitioner/smart-Practitioner-71482713",
"type": "Practitioner",
"display": "Susan Clark"
},
"item": [
{
"linkId": "patient_header",
"text": "Patient Information",
"item": [
{
"linkId": "patient_surname",
"text": "Surname:",
"answer": [
{
"valueString": "Smith"
}
]
},
{
"linkId": "patient_firstname",
"text": "First Name:",
"answer": [
{
"valueString": "Jane"
}
]
},
{
"linkId": "patient_date_of_birth",
"text": "DOB:",
"answer": [
{
"valueDate": "1960-01-01"
}
]
},
{
"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": "123 Some Street"
}
]
},
{
"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": "M1M 1M1"
}
]
}
]
},
{
"linkId": "847648250958",
"text": "Select Exam Request",
"item": [
{
"linkId": "medicalImaging_examRequest",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "20390",
"display": "CT Requisition"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "20391",
"display": "MRI Requisition"
}
}
]
},
{
"linkId": "medicalImaging_weightHeightRequirement",
"text": "Weight/height requirement",
"answer": [
{
"valueString": "MRI_HEIGHT_WEIGHT_REQUIRED"
}
]
}
]
},
{
"linkId": "medicalImaging_referral_triageconsiderations",
"text": "Triage Considerations",
"item": [
{
"linkId": "medicalImaging_examRequest_triage",
"text": "Requested Triage Priority",
"answer": [
{
"valueString": "Routine"
}
]
}
]
},
{
"linkId": "medicalImaging_referral_cds",
"text": "Clinical Decision Support",
"item": [
{
"linkId": "medicalImaging_examRequest_cds",
"text": "Display Clinical Decision Support (CDS)",
"answer": [
{
"valueString": "Hide"
}
]
}
]
},
{
"linkId": "medicalImaging_examRequest_CT_group",
"text": "Select CT Exam/Region(s) of Interest:",
"item": [
{
"linkId": "medicalImaging_examRequest_CT_neck",
"text": "Neck",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "20396",
"display": "Neck"
}
}
]
},
{
"linkId": "medicalImaging_examRequest_CT_neck_group",
"item": [
{
"linkId": "medicalImaging_examRequest_CT_neck_specificarea",
"text": "Specific area of interest (optional)",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "20448",
"display": "Neck angiography"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "20414",
"display": "Soft Tissue Neck"
}
}
]
}
]
},
{
"linkId": "medicalImaging_examRequest_CT_spine",
"text": "Spine",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "20397",
"display": "Spine"
}
}
]
},
{
"linkId": "medicalImaging_examRequest_CT_spine_group",
"item": [
{
"linkId": "medicalImaging_examRequest_CT_spine_specificarea",
"text": "Specific area of interest (optional)",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "20415",
"display": "Cervical Spine"
}
}
]
}
]
},
{
"linkId": "medicalImaging_CT_CDS_Osteoarthritis_enabled",
"text": "CT osteoarthritis CDS display condition",
"answer": [
{
"valueBoolean": false
}
]
}
]
},
{
"linkId": "medicalImaging_CT_clinicalindication_CTrefnote",
"text": "CT Request: Clinical History / Indication",
"item": [
{
"linkId": "medicalImaging_CT_clinicalindication_text",
"text": "Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)",
"answer": [
{
"valueString": "Motor vehicle accident"
}
]
}
]
},
{
"linkId": "medicalImaging_examRequest_MRI_group_MRIrefnote",
"text": "Select MRI Exam/Region(s) of Interest:",
"item": [
{
"linkId": "medicalImaging_examRequest_MRI_neck",
"text": "Neck",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "20468",
"display": "Neck"
}
}
]
},
{
"linkId": "medicalImaging_examRequest_MRI_neck_group",
"item": [
{
"linkId": "medicalImaging_examRequest_MRI_neck_specificarea",
"text": "Specific area of interest (optional)",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "20541",
"display": "Neck angiography"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "20488",
"display": "Brachial plexus"
}
}
]
},
{
"linkId": "medicalImaging_examRequest_MRI_neck_specificarea_brachial",
"text": "Brachial Plexus:",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "21323",
"display": "Bilateral"
}
}
]
}
]
},
{
"linkId": "medicalImaging_MRI_CDS_Osteoarthritis_enabled",
"text": "MRI osteoarthritis CDS display condition",
"answer": [
{
"valueBoolean": false
}
]
}
]
},
{
"linkId": "medicalImaging_MRI_clinicalindication_MRIrefnote",
"text": "MRI Request: Clinical History / Indication",
"item": [
{
"linkId": "medicalImaging_MRI_clinicalindication_text",
"text": "Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)",
"answer": [
{
"valueString": "Motor vehicle accident"
}
]
}
]
},
{
"linkId": "medicalImaging_MRIsafety_group_MRIrefnote",
"text": "MRI Safety Screening",
"item": [
{
"linkId": "MRI_safety_none",
"text": "None of the above",
"answer": [
{
"valueString": "None of the above"
}
]
}
]
},
{
"linkId": "medicalImaging_patientsafety_group",
"text": "Patient Safety Screening\n Select where applicable",
"item": [
{
"linkId": "medicalImaging_patientsafety_renal",
"text": "Renal Assessment Questions:",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "21283",
"display": "No known kidney issues"
}
}
]
},
{
"linkId": "medicalImaging_patientsafety_knownhypersensitivity",
"text": "Known hypersensitivity to contrast agents:",
"answer": [
{
"valueString": "Unknown"
}
]
},
{
"linkId": "medicalImaging_patientsafety_breastfeeding",
"text": "Currently breastfeeding",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "21293",
"display": "Currently breastfeeding"
}
}
]
},
{
"linkId": "medicalImaging_weight_height",
"text": "Patient Weight and Height",
"item": [
{
"linkId": "medicalImaging_weight_height_units",
"text": "Units:",
"answer": [
{
"valueString": "Metric (cm/kgs)"
}
]
},
{
"linkId": "medicalImaging_weight_height_required_metric",
"text": "Metric height and weight required",
"item": [
{
"linkId": "medicalImaging_weight_height_required_metric_kg",
"text": "Weight (kgs):",
"answer": [
{
"valueDecimal": 73
}
]
},
{
"linkId": "medicalImaging_weight_height_required_metric_cm",
"text": "Height (cm):",
"answer": [
{
"valueDecimal": 164
}
]
}
]
},
{
"linkId": "medicalImaging_weight_height_date",
"text": "Date of Weight/Height:",
"answer": [
{
"valueDate": "2026-08-30"
}
]
}
]
}
]
},
{
"linkId": "medicalImaging_scheduling_",
"text": "Scheduling",
"item": [
{
"linkId": "medicalImaging_scheduling",
"text": "Request specific appointment date or time interval based on:",
"answer": [
{
"valueString": "Clinical Reasons"
}
]
},
{
"linkId": "medicalImaging_scheduling_clinicalreasons_other",
"text": "Specify Timeframe:",
"answer": [
{
"valueString": "2 weeks"
}
]
},
{
"linkId": "medicalImaging_scheduling_clinicalreasons",
"text": "Clinical Reasons:",
"answer": [
{
"valueString": "Patient navigation (eg., Before a specialist appointment) "
}
]
}
]
},
{
"linkId": "pref_consultant_group",
"item": [
{
"linkId": "preferredconsultlocation_header",
"text": "Preferred Consultant or Location",
"item": [
{
"linkId": "preferredconsultlocation_willingtotravel",
"text": "Patient willing to travel for shorter wait time",
"answer": [
{
"valueString": "Patient willing to travel for shorter wait time"
}
]
}
]
}
]
},
{
"linkId": "602618746069",
"text": "Referrer's Information",
"item": [
{
"linkId": "referrer_address_line1",
"text": "Address (Line 1):",
"answer": [
{
"valueString": "456 Another Street"
}
]
},
{
"linkId": "referrer_address_city",
"text": "City:",
"answer": [
{
"valueString": "Toronto"
}
]
},
{
"linkId": "referrer_address_province",
"text": "Province:",
"answer": [
{
"valueString": "ON"
}
]
},
{
"linkId": "referrer_address_postalcode",
"text": "Postal Code:",
"answer": [
{
"valueString": "M2M 2M2"
}
]
},
{
"linkId": "referrer_signature",
"text": "Signed:",
"answer": [
{
"valueString": "Dr. Bones"
}
]
},
{
"linkId": "referrer_role",
"text": "Role:",
"answer": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
"code": "21276",
"display": "Family Physician"
}
}
]
}
]
},
{
"linkId": "referralService",
"text": "referralService",
"answer": [
{
"valueString": "CT | MRI"
}
]
}
]
}