FHIR IG analytics| Package | ca.on.oh.setp.iar.dev |
| Resource Type | Questionnaire |
| Id | Questionnaire-iar-contact-asessment-v.2.0.0-oh.json |
| FHIR Version | R4 |
| Source | https://simplifier.net/resolve?scope=ca.on.oh.setp.iar.dev@1.0.0-ballot1-dev&canonical=http://ontariohealth.ca/fhir/iar/Questionnaire/oh-interrai-contact-assessment |
| URL | http://ontariohealth.ca/fhir/iar/Questionnaire/oh-interrai-contact-assessment |
| Version | 10.0.1_OH |
| Status | active |
| Date | 2026-02-01T21:47:22.96+00:00 |
| Title | interRAI™ Contact Assessment (CA) 10.0.1_OH |
| Realm | ca |
| Authority | hl7 |
| Description | This assessment is the interRAI™ Contact Assessment (CA) Form, version 10.0 – CIHI Canadian Standard. A screening-level assessment used for intake into home and community care. The core content was developed by interRAI, adapted by the Canadian Institute for Health Information (CIHI) with modifications from from OntarioHealth. The FHIR artifact is maintained and published by Ontario Health. |
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FHIR
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"linkId": "A7",
"text": "AGENCY IDENTIFIER [COUNTRY SPECIFIC - CANADA]",
"prefix": "7."
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"text": "8. INDIGENOUS IDENTITY [COUNTRY SPECIFIC - CANADA] - Person identifies as First Nations, Métis, or Inuit",
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"text": "Time frame for initiation of ordered treatments in community",
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"linkId": "B2ac",
"text": "IV therapy",
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"linkId": "B2ad",
"text": "Wound care",
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"text": "Condom catheter",
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"linkId": "B2ag",
"text": "Drain/tube management",
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"linkId": "B2ai",
"text": "Ostomy management",
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"linkId": "B2ak",
"text": "Staple/suture removal",
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"linkId": "B2al",
"text": "Nursing",
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"linkId": "B2am",
"text": "PT assessment",
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"text": "OT assessment",
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"linkId": "B2ao",
"text": "Swallow assessment",
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"text": "Referral to initiate or continue rehabilitation services",
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"text": "Referral to initiate or continue palliative services",
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"text": "EXPECTED RESIDENTIAL / LIVING STATUS DURING SERVICE PROVISION",
"prefix": "4.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/location"
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{
"linkId": "C2",
"text": "2. ACTIVITIES OF DAILY LIVING (ADL) SELF-PERFORMANCE - Most dependent episode over last 24 hours. If ADL did not occur in last 24 hours, code the most recent occurrence.",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C2a",
"text": "Bathing - How takes a full-body bath / shower. Includes how each part of body is bathed: arms, upper and lower legs, chest, abdomen, perineal area — EXCLUDE WASHING OF BACK AND HAIR, AS WELL AS TRANSFER IN/OUT OF BATH OR SHOWER",
"prefix": "a.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C2b",
"text": "Bath transfer - How person transfers in/out of bath or shower",
"prefix": "b.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C2c",
"text": "Personal hygiene - How manages personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing and drying face and hands — EXCLUDE BATHS AND SHOWERS.",
"prefix": "c.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C2d",
"text": "Dressing lower body - How dresses and undresses (street clothes, underwear) from the waist down, including prostheses, orthotics, belts, pants, skirts, shoes, fasteners, etc.",
"prefix": "d.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C2e",
"text": "Locomotion - How moves between locations on same floor (walking or wheeling). If in wheelchair, self-sufficiency once in chair.",
"prefix": "e.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C3",
"text": "DYSPNEA (Shortness of Breath)",
"prefix": "3.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C4",
"text": "SELF-REPORTED HEALTH Ask: In general, how would you rate your health?",
"prefix": "4.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health"
},
{
"linkId": "C5",
"text": "5. SELF-REPORTED MOOD [COUNTRY SPECIFIC - CANADA] Ask: “In the last 3 days, how often have you felt . . .”",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C5a",
"text": "Little interest or pleasure in things you normally enjoy?",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C5b",
"text": "Anxious, restless, or uneasy?",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C5c",
"text": "Sad, depressed, or hopeless?",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}
]
},
{
"linkId": "C6",
"text": "6. INSTABILITY OF CONDITIONS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C6a",
"text": "Conditions/diseases make cognitive, ADL, mood, or behaviour patterns unstable (fluctuating, precarious, or deteriorating)",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C6b",
"text": "Experiencing an acute episode or a flare-up of a recurrent or chronic problem",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C7",
"text": "HOME CARE OR COMMUNITY SUPPORT SERVICES MAY BE REQUIRED FOR THIS PERSON",
"prefix": "7.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "D",
"text": "Section D. Clinical Evaluation",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section D. Clinical Evaluation</b>"
}
]
},
"enableBehavior": "any",
"enableWhen": [
{
"question": "C1",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"code": "1"
}
},
{
"question": "C1",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"code": "2"
}
},
{
"question": "C2a",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2a",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2b",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2b",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2c",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2c",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2d",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2d",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2e",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2e",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C3",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea",
"code": "2"
}
},
{
"question": "C3",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea",
"code": "3"
}
},
{
"question": "C4",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health",
"code": "3"
}
},
{
"question": "C4",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health",
"code": "8"
}
},
{
"question": "C5a",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C5b",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C5c",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C6a",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no",
"code": "1"
}
},
{
"question": "C7",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no",
"code": "1"
}
}
],
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D1",
"text": "CHANGE IN DECISION MAKING AS COMPARED TO 90 DAYS AGO (OR SINCE LAST ASSESSMENT IF LESS THAN 90 DAYS AGO)",
"prefix": "1.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-improvement"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D2",
"text": "ABILITY TO UNDERSTAND OTHERS (Comprehension) - Understanding information content (however able; with hearing or other assistive devices normally used)",
"prefix": "2.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-understanding-other"
},
{
"linkId": "D3",
"text": "3. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) CAPACITY",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3a",
"text": "Meal preparation — How prepares meals (e.g., planning meals, assembling ingredients, cooking, setting out food and utensils)",
"prefix": "a.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3b",
"text": "Ordinary housework — How performs ordinary work around the house (e.g., doing dishes, dusting, making bed, tidying up, laundry)",
"prefix": "b.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3c",
"text": ".Manage medications — How medications are managed (e.g., remembering to take medications, opening bottles, taking correct drug dosages, giving injections, applying ointments)",
"prefix": "c.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3d",
"text": "Stairs — How manages full flight of stairs (e.g., 12–14 stairs)",
"prefix": "d.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3e",
"text": "Shopping — How performs in-store shopping for food and household items (e.g., selecting items, paying money) — EXCLUDE TRANSPORTATION OR USE OF GROCERY DELIVERY SERVICES",
"prefix": "e.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3f",
"text": "Transportation — How travels by paid transportation (e.g., navigating bus system, paying taxi fare) or driving self (including getting out of house, into and out of vehicles)",
"prefix": "f.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D4",
"text": "CHANGE IN ADL STATUS AS COMPARED TO 90 DAYS AGO (OR SINCE LAST ASSESSMENT IF LESS THAN 90 DAYS AGO)",
"prefix": "4.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-improvement"
},
{
"linkId": "D5",
"text": "5. DISEASE DIAGNOSES [COUNTRY SPECIFIC - CANADA]",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5a",
"text": "Alzheimer\"s disease",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5b",
"text": "Dementia other than Alzheimer\"s disease",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5c",
"text": "Stroke",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5d",
"text": "Coronary heart disease",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5e",
"text": "Chronic obstructive pulmonary disease",
"prefix": "e.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5f",
"text": "Congestive heart failure",
"prefix": "f.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5g",
"text": "Cancer",
"prefix": "g.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5h",
"text": "Diabetes",
"prefix": "h.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"linkId": "D5i",
"text": "Other disease diagnoses",
"type": "group",
"repeats": true,
"item": [
{
"type": "string",
"linkId": "D5ia",
"text": "Diagnosis"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5ib",
"text": "Diagnosis Code",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5ic",
"text": "ICD-10-CA Code",
"answerValueSet": "http://fhir.infoway-inforoute.ca/io/cacore/ValueSet/ICD10CA"
}
]
}
]
},
{
"linkId": "D6",
"text": "6. FALLS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D6a",
"text": "Last 30 days",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-number-of-falls"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D6b",
"text": "31-90 days",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-number-of-falls"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D6c",
"text": "91-180 days",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-number-of-falls"
}
]
},
{
"linkId": "D7",
"text": "7. PROBLEM FREQUENCY",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D7a",
"text": "Dizziness",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D7b",
"text": "Chest pain",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D7c",
"text": "Peripheral edema",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D7d",
"text": "Vomiting",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
}
]
},
{
"linkId": "D8",
"text": "8. PAIN SYMPTOMS [Note: Always ask the person about pain frequency and intensity. Observe person and ask others who are in contact with the person.]",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D8a",
"text": "Frequency with which person complains or shows evidence of pain (including grimacing, teeth clenching, moaning, withdrawal when touched, or other nonverbal signs suggesting pain)",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-pain"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D8b",
"text": "Intensity of highest level of pain present",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-severity-of-pain"
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D9",
"text": "SMOKES TOBACCO DAILY",
"prefix": "9.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/frequency-of-smoking"
},
{
"linkId": "D10",
"text": "10. NUTRITIONAL ISSUES",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D10a",
"text": "In LAST 3 DAYS, noticeable decrease in the amount of food usually eaten or fluids usually consumed",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D10b",
"text": "Weight loss of 5% or more in LAST 30 DAYS or 10% or more in LAST 180 DAYS",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D10c",
"text": "Special diet",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D11",
"text": "PRESENCE OF PRESSURE ULCER / INJURY",
"prefix": "11.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/presence-of-pressure-ulcer"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D12",
"text": "MAJOR SKIN PROBLEMS - e.g., lesions, 2nd- or 3rd-degree burns, healing surgical wounds",
"prefix": "12.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D13",
"text": "TRAUMATIC INJURY - traumatic injury that has a major effect on the care required (e.g., fracture, major physical injury resulting from assault or motor vehicle accident)",
"prefix": "13.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "D14",
"text": "14. TREATMENTS [COUNTRY SPECIFIC - CANADA] - Treatments received or scheduled in LAST 3 DAYS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D14a",
"text": "Indwelling catheter",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-treatment-and-program"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D14b",
"text": "IV therapy",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-treatment-and-program"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D14c",
"text": "Oxygen therapy",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-treatment-and-program"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D14d",
"text": "Ventilator",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-treatment-and-program"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D14e",
"text": "Wound care",
"prefix": "e.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-treatment-and-program"
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D15",
"text": "TIME SINCE LAST HOSPITAL STAY",
"prefix": "15.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-since-last-hospital-stay"
},
{
"type": "integer",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueDecimal": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueDecimal": 90
}
],
"linkId": "D16",
"text": "EMERGENCY DEPARTMENT VISIT",
"prefix": "16."
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D17",
"text": "SURGERY IN LAST 90 DAYS",
"prefix": "17.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/surgery"
},
{
"linkId": "D18",
"text": "18. TWO KEY INFORMAL HELPERS [COUNTRY SPECIFIC - CANADA]",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D18a1",
"text": "Relationship to person - Helper 1",
"prefix": "a.1.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-informal-helper-relationship"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D18a2",
"text": "Relationship to person - Helper 2",
"prefix": "a.2.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-informal-helper-relationship"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D18b1",
"text": "Lives with person - Helper 1",
"prefix": "b.1.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-informal-helper-lives-with-person"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D18b2",
"text": "Lives with person - Helper 2",
"prefix": "b.2.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-informal-helper-lives-with-person"
}
]
},
{
"linkId": "D19",
"text": "19. INFORMAL HELPER STATUS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D19a",
"text": "Primary informal helper expresses feelings of distress, anger, or depression",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D19b",
"text": "Family or close friends report feeling overwhelmed by person\"s illness",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D20",
"text": "DEGREE OF LONELINESS - use self-report when possible (Ask: How often do you feel lonely?)",
"prefix": "20.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/degree-of-loneliness"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D21",
"text": "FINANCES - Because of limited funds, during the last 30 days made trade-offs among purchasing any of the following: adequate food, shelter, clothing, prescribed medications, sufficient home heat or cooling, necessary health care",
"prefix": "21.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "E",
"text": "Section E. Summary",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section E. Summary</b>"
}
]
},
"item": [
{
"linkId": "E1-7",
"type": "group",
"enableBehavior": "any",
"enableWhen": [
{
"question": "C1",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"code": "1"
}
},
{
"question": "C1",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"code": "2"
}
},
{
"question": "C2a",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2a",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2b",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2b",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2c",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2c",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2d",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2d",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2e",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2e",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C3",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea",
"code": "2"
}
},
{
"question": "C3",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea",
"code": "3"
}
},
{
"question": "C4",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health",
"code": "3"
}
},
{
"question": "C4",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health",
"code": "8"
}
},
{
"question": "C5a",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C5b",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C5c",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C6a",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no",
"code": "1"
}
},
{
"question": "C7",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no",
"code": "1"
}
}
],
"item": [
{
"linkId": "E1",
"text": "1. ALGORITHM SCORES - Record the computer-generated scores for each of the following",
"type": "group",
"item": [
{
"type": "integer",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueDecimal": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueDecimal": 6
}
],
"linkId": "E1a",
"text": "Assessment urgency",
"prefix": "a."
},
{
"type": "integer",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueDecimal": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueDecimal": 4
}
],
"linkId": "E1b",
"text": "Service urgency",
"prefix": "b."
},
{
"type": "integer",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueDecimal": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueDecimal": 5
}
],
"linkId": "E1c",
"text": "Rehabilitation",
"prefix": "c."
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E2",
"text": "EXPECTED LENGTH OF SERVICE",
"prefix": "2.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/expected-length-of-service"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E3",
"text": "ASSESSMENT URGENCY - Urgency for comprehensive, face-to-face assessment",
"prefix": "3.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/assessment-urgency"
},
{
"linkId": "E4",
"text": "4. URGENCY OF NEEDED SERVICES",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4a",
"text": "Nursing",
"prefix": "a.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4b",
"text": "Personal support/household management",
"prefix": "b.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4c",
"text": "Physiotherapy",
"prefix": "c.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4d",
"text": "Occupational therapy",
"prefix": "d.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4e",
"text": "Dietitian services",
"prefix": "e.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4f",
"text": "Lab services, equipment, and medical supplies",
"prefix": "f.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4g",
"text": "Social work",
"prefix": "g.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4h",
"text": "Speech-language therapy",
"prefix": "h.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4i1",
"text": "Other (specify)",
"prefix": "i.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E5",
"text": "CLIENT GROUP [COUNTRY SPECIFIC - CANADA]",
"prefix": "5.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/client-group"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E6",
"text": "PRIMARY MODE OF ASSESSMENT",
"prefix": "6.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/assessment-mode"
},
{
"linkId": "E7",
"text": "7. SOURCES OF INFORMATION USED TO COMPLETE THE interRAI CA (Code only ONE PRIMARY source and ALL APPLICABLE SECONDARY sources)",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7a",
"text": "Person",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7b",
"text": "Spouse / partner",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7c",
"text": "Parent/guardian",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7d",
"text": "Child or child-in-law",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7e",
"text": "Other relative",
"prefix": "e.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7f",
"text": "Friend or neighbour",
"prefix": "f.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7g",
"text": "Physician / physician assistant / nurse practitioner",
"prefix": "g.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7h",
"text": "Other home care / other health, or social service provider",
"prefix": "h.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
}
]
}
]
},
{
"linkId": "E8",
"text": "8. SIGNATURE OF PERSON COORDINATING/COMPLETING THE ASSESSMENT",
"type": "group",
"item": [
{
"type": "text",
"linkId": "E8a",
"text": "a. Signature"
},
{
"type": "date",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
}
],
"linkId": "E8b",
"text": "b. Date assessment signed as complete"
}
]
}
]
}
]
}