FHIR IG analytics| Package | ca.on.oh.setp.iar.dev |
| Resource Type | Questionnaire |
| Id | Questionnaire-iar-interrai-chymh-community-code-v1.0.0-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/Questionnaire/oh-interrai-chymh-community-based-form |
| URL | http://ontariohealth.ca/fhir/Questionnaire/oh-interrai-chymh-community-based-form |
| Version | 1.1 |
| Status | active |
| Title | interRAI™ Child and Youth Mental Health - Community Base (ChYMH-CB) 9.3.0_OH |
| Realm | ca |
| Authority | hl7 |
| Description | This is the interRAI™ Child and Youth Mental Health (ChYMH) Community Based (CB) Form, version 9.3.0 - CIHI Canadian Standard. It represents the core assessment for child and youth mental health in community-based settings. The core content was developed by interRAI, adapted by the Canadian Institute for Health Information (CIHI), and modified by Ontario Health. When applicable, the CHYMH Community Based Form is completed together with the CHYMH Adolescent Supplement as part of a single CHYMH Full assessment. The FHIR artifact is maintained and published by Ontario Health. |
No resources found
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No narrative content found in resource
FHIR
FHIRsmith{
"resourceType": "Questionnaire",
"id": "oh-interrai-chymh-community-based-form",
"language": "en",
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"version": "1.1",
"title": "interRAI™ Child and Youth Mental Health - Community Base (ChYMH-CB) 9.3.0_OH",
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"effectivePeriod": {
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"subjectType": [
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"text": "SECTION A. IDENTIFICATION INFORMATION",
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"text": "NAME",
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"text": "(Jr./Sr.)"
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{
"type": "group",
"linkId": "A2",
"text": "SEX/GENDER IDENTITY",
"prefix": "2.",
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"type": "choice",
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"prefix": "c"
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{
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"prefix": "3.",
"required": true
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{
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"linkId": "A4",
"text": "NUMERIC IDENTIFIERS [EXAMPLE—CANADA]",
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{
"type": "string",
"linkId": "A5",
"maxLength": 11,
"text": "AGENCY IDENTIFIER [EXAMPLE - CANADA]",
"prefix": "5.",
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{
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"text": "CURRENT PAYMENT SOURCES [EXAMPLE—CANADA]",
"prefix": "6.",
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"text": "Provincial or territorial government plan (this province or territory)",
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{
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"linkId": "A6f",
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{
"type": "choice",
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{
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{
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"extension": [
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"linkId": "A8",
"text": "ASSESSMENT REFERENCE DATE",
"prefix": "8."
},
{
"type": "group",
"linkId": "A9",
"text": "EXPRESSED GOALS Enter primary goal in boxes at bottom. Do not include any names(full or partial) or the young person's Health care Identification Number,date of birth,sex or gender.",
"prefix": "9.",
"item": [
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"type": "string",
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"text": "Child’s/youth’s goals",
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{
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{
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"prefix": "b"
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{
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"required": false,
"linkId": "A9b2",
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"prefix": "b"
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]
},
{
"type": "choice",
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"linkId": "A10",
"text": "LEGAL GUARDIANSHIP [EXAMPLE—CANADA]",
"prefix": "10.",
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{
"type": "group",
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"text": "CURRENT DISPUTE OVER CUSTODY OR CHILD/YOUTH ACCESS",
"prefix": "11.",
"item": [
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"required": false,
"linkId": "A11a",
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"extension": [
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"text": "RETURN DATE ( For return assessments only)",
"prefix": "12."
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"prefix": "2."
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{
"type": "group",
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"text": "ABORIGINAL IDENTITY [EXAMPLE—CANADA]",
"prefix": "3.",
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"type": "choice",
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{
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"text": "Inuit",
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},
{
"linkId": "B4",
"text": "PRIMARY LANGUAGE [EXAMPLE—CANADA] eng - English fra - French",
"prefix": "4.",
"type": "choice",
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"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/languages"
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{
"type": "group",
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"text": "INTERPRETER NEEDED",
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"text": "Child/youth",
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{
"type": "choice",
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"text": "Either parent/primary caregiver",
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]
},
{
"type": "choice",
"required": false,
"linkId": "B6",
"text": "BIOLOGICAL MOTHER’S AGE AT TIME OF CHILD’S/YOUTH’S BIRTH",
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{
"type": "choice",
"required": false,
"linkId": "B7",
"text": "MARITAL STATUS OF PARENTS",
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"type": "choice",
"required": false,
"linkId": "B8",
"text": "HISTORY OF FOSTER FAMILY PLACEMENT (Include present placement, if applicable; include any kinship care placements)",
"prefix": "8.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-history-foster-family-placement"
},
{
"type": "group",
"linkId": "B9",
"text": "HISTORY OF CARE INCLUDES SEVERE FAILURE TO PROVIDE FOR BASIC NEEDS—Code for child’s/youth’s age at earliest occurrence",
"prefix": "9.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "B9a",
"text": "Emotional neglect—e.g., left in crib for prolonged periods",
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period2"
},
{
"type": "choice",
"required": false,
"linkId": "B9b",
"text": "Physical needs—e.g., inadequate winter clothing",
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period2"
},
{
"type": "choice",
"required": false,
"linkId": "B9c",
"text": "Safety needs—e.g., child left in car in summer heat",
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period2"
}
]
},
{
"type": "group",
"linkId": "B10",
"text": "MATERNAL SUBSTANCE USE DURING PREGNANCY",
"prefix": "10.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "B10a",
"text": "Alcohol use",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-unknown-uncertain"
},
{
"type": "choice",
"required": false,
"linkId": "B10b",
"text": "Drug use—EXCLUDE PRESCRIBED MEDICATION THAT WAS TAKEN AS DIRECTED",
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-unknown-uncertain"
}
]
},
{
"type": "choice",
"required": false,
"linkId": "B11",
"text": "CHILD RAISED WITH FREQUENT DISRUPTIONS IN CARE —e.g., institutional care, multiple caregivers—EXCLUDE NANNY",
"prefix": "11.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "group",
"linkId": "B12",
"text": "DEVELOPMENTAL HISTORY —Child/youth achieved developmental milestones within appropriate time frame",
"prefix": "12.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "B12a",
"text": "Walking—By 18 months, walked independently",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-unknown"
},
{
"type": "choice",
"required": false,
"linkId": "B12b",
"text": "Talking—By 24 months, combined 2–4 words into short sentences AND had vocabulary of 50–200 words",
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-unknown"
},
{
"type": "choice",
"required": false,
"linkId": "B12c",
"text": "Toilet training—By 4 years, daytime toilet trained",
"prefix": "c",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-unknown"
}
]
},
{
"linkId": "B13",
"text": "CURRENT MEMBERS OF PRIMARY HOUSEHOLD Code only if child's/youth's primary household is a private home. For all other usual living arrangements, code '99'",
"prefix": "13.",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueInteger": 0
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueInteger": 99
}
],
"linkId": "B13a",
"prefix": "a",
"type": "integer",
"required": false,
"text": "Number of adults"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueInteger": 0
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueInteger": 99
}
],
"linkId": "B13b",
"prefix": "b",
"type": "integer",
"required": false,
"text": "Number of minors"
}
]
},
{
"linkId": "B14",
"required": false,
"text": "RESIDENTIAL/LIVING STATUS AT TIME OF ASSESSMENT (EXAMPLE-CANADA)",
"prefix": "14.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-location1"
},
{
"linkId": "B15",
"text": "POSTAL CODE OF USUAL LIVING ARRANGEMENT [EXAMPLE — CANADA]",
"prefix": "15.",
"type": "string",
"required": false
},
{
"linkId": "B16",
"text": "LIVING ARRANGEMENT PRIOR TO ADMISSION If code of “2” is present, Item B21a and B21b must be completed.",
"prefix": "16.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-living-arrangement1"
},
{
"type": "group",
"linkId": "B17",
"text": "RESIDENTIAL/LIVING STATUS OVER LAST 2 YEARS Code for any of the following child/youth lived in",
"prefix": "17.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "B17a",
"text": "Group home",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "B17b",
"text": "Shelter",
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "B18",
"text": "RESIDENTIAL INSTABILITY OVER LAST 2 YEARS — e.g., 3 or more moves, no permanent address, homeless, living in shelter, 'couch surfing'",
"prefix": "18.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "B19",
"text": "TIME SINCE LAST CONTACT WITH COMMUNITY MENTAL HEALTH AGENCY OR PROFESSIONAL IN PAST YEAR — e.g., psychiatrist, social worker",
"prefix": "19.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-since-last-contact"
},
{
"linkId": "B20",
"text": "MENTAL HEALTH RESIDENTIAL/INPATIENT HISTORY",
"prefix": "20.",
"type": "group",
"item": [
{
"linkId": "B20a",
"text": "Time since discharge from last admission",
"prefix": "a",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-since-discharge"
},
{
"linkId": "B20b",
"text": "Number of lifetime admissions — EXCLUDE THIS ADMISSION",
"prefix": "b",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-number-of-psychiatric-admissions"
},
{
"linkId": "B20c",
"text": "Number of admissions in last 2 years — EXCLUDE THIS ADMISSION",
"prefix": "c",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-number-of-admissions"
},
{
"linkId": "B20d",
"text": "Age in years at first overnight stay",
"prefix": "d",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-age-range"
}
]
},
{
"linkId": "B21",
"text": "ACCESS ARRANGEMENT (INTAKE AND INITIAL HISTORY - ADDITIONAL SUPPLEMENTARY ITEMS) if code of '2' is present in item B16, Item B21a and B21b must be completed",
"prefix": "21.",
"type": "group",
"item": [
{
"linkId": "B21a",
"text": "Relationship to child/youth",
"prefix": "a",
"type": "group",
"item": [
{
"linkId": "B21a1",
"text": "Parent 1",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/iar-chymh-cb-relationship"
},
{
"linkId": "B21a2",
"text": "Parent 2",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/iar-chymh-cb-relationship"
}
]
},
{
"linkId": "B21b",
"text": "Parent Lives with child/youth",
"prefix": "b",
"type": "group",
"item": [
{
"linkId": "B21b1",
"text": "Parent 1",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/iar-chymh-cb-relationship"
},
{
"linkId": "B21b2",
"text": "Parent 2",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/iar-chymh-cb-relationship"
}
]
}
]
}
]
}
]
},
{
"linkId": "C",
"text": "SECTION C. MENTAL STATE INDICATORS",
"type": "group",
"item": [
{
"linkId": "C1",
"text": "Code for indicators observed in the last 3 days, irrespective of the assumed cause [Note: Whenever possible, ask child/youth]",
"prefix": "1.",
"type": "group",
"item": [
{
"linkId": "C1-group1",
"text": "DISTRACTION AND HYPERACTIVITY",
"type": "group",
"item": [
{
"linkId": "C1a",
"text": "Impulsive — e.g., running into traffic; takes risky actions without thinking; difficulty taking turns; interrupts",
"prefix": "a",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1b",
"text": "Easily distracted — e.g., episodes of difficulty paying attention; gets sidetracked",
"prefix": "b",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1c",
"text": "Hyperactivity — Excessive level of activity",
"prefix": "c",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1d",
"text": "Disorganization — e.g., problems organizing personal belongings; difficulty adhering to schedule",
"prefix": "d",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "C1-group2",
"text": "MOOD DISTURBANCE",
"type": "group",
"item": [
{
"linkId": "C1e",
"text": "Sad, pained, or worried facial expressions—e.g., furrowed brow, constant frowning",
"prefix": "e",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1f",
"text": "Crying, tearfulness",
"prefix": "f",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1g",
"text": "Decreased energy — Statements of decrease in energy level (e.g., 'I just don’t feel like doing anything; I am too tired')",
"prefix": "g",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1h",
"text": "Made negative statements—e.g., “Nothing matters; No one likes me; I hate my life; Would rather be dead; What’s the use; Let me die”",
"prefix": "h",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1i",
"text": "Self-deprecation—e.g., “I am stupid; I am bad; I can’t do anything right; I am nothing; I am of no use to anyone”",
"prefix": "i",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1j",
"text": "Expressions of guilt or shame — e.g., 'I’ve done something awful; this is all my fault; I am terrible person'",
"prefix": "j",
"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"
}
]
}
}
],
"type": "choice",
"required": false,
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1k",
"text": "Expressions of hopelessness — e.g., “There’s no hope for the future; nothing’s going to change for the better.”",
"prefix": "k",
"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"
}
]
}
}
],
"type": "choice",
"required": false,
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1l",
"text": "Inflated self-worth — e.g., exaggerated worth or importance, inflated belief about one’s own ability",
"prefix": "l",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1m",
"text": "Irritability — Marked increase in being short-tempered or easily upset",
"prefix": "m",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1n",
"text": "Pressured speech or rapid thoughts — Rapid speech, rapid transition from topic to topic",
"prefix": "n",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1o",
"text": "Labile affect — Affect fluctuates frequently or with or without external explanation",
"prefix": "o",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1p",
"text": "Hypersexuality — Age-inappropriate sexual activity or urges",
"prefix": "p",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1q",
"text": "Flat or blunted affect — Indifference, non-responsiveness, hard to get to smile, etc.",
"prefix": "q",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "C1-group3",
"text": "ANXIETY",
"type": "group",
"item": [
{
"linkId": "C1r",
"text": "Repetitive anxious complaints/concerns (non-health-related) — e.g., persistently seeks attention/reassurance regarding schedules, school, sports, clothing, relationships",
"prefix": "r",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1s",
"text": "Expressions, including nonverbal, of what appear to be unrealistic fears — e.g., fears of being abandoned, being left alone, of strange people, fears of specific objects or situations",
"prefix": "s",
"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"
}
]
}
}
],
"type": "choice",
"required": false,
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1t",
"text": "Obsessive thoughts — Unwanted ideas or thoughts that cannot be eliminated",
"prefix": "t",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1u",
"text": "Compulsive behaviour — e.g., hand washing, repetitive checking of room, counting, hoarding",
"prefix": "u",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1v",
"text": "Intrusive thoughts or flashbacks — Disturbing memories or images that intrude into thoughts, unexpected recall of adverse events",
"prefix": "v",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1w",
"text": "Re-enactments through play of traumatic life events",
"prefix": "w",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1x",
"text": "Episodes of panic — Cascade of symptoms of fear, anxiety, loss of control",
"prefix": "x",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1y",
"text": "Nightmares — e.g., reports frightening dreams, wakens from sleep with expressions of fear (including nonverbal)",
"prefix": "y",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1z",
"text": "Hypervigilance — “Jumpiness” or feeling as though in danger.",
"prefix": "z",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1aa",
"text": "Converses only in specific social situations — e.g., speaks at home but not at school",
"prefix": "aa",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "C1-group4",
"text": "PSYCHOSIS",
"type": "group",
"item": [
{
"linkId": "C1bb",
"text": "Hallucinations — False sensory perception, of any type, with or without insight, without corresponding stimuli (e.g., auditory, visual, tactile, olfactory, gustatory hallucinations, excluding command hallucinations)",
"prefix": "bb",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1cc",
"text": "Command hallucinations — Hallucinations directing the child/youth to do something or to act in a particular manner (e.g., to harm self or others)",
"prefix": "cc",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1dd",
"text": "Delusions — Fixed false beliefs (e.g., grandiose, paranoid, somatic), excluding beliefs specific to child’s/youth’s culture or religion",
"prefix": "dd",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1ee",
"text": "Abnormal thought process — e.g., loosening of associations, blocking, flight of ideas, tangentiality, circumstantiality",
"prefix": "ee",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "C1-group5",
"text": "NEGATIVE SYMPTOMS",
"type": "group",
"item": [
{
"linkId": "C1ff",
"text": "Lack of interest in social interaction",
"prefix": "ff",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1gg",
"text": "Lack of motivation — Absence of sponteneous goal-directed activity",
"prefix": "gg",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1hh",
"text": "Expressions, including nonverbal, of a lack of pleasure in life (anhedonia) — e.g., 'I don’t have fun anymore.'",
"prefix": "hh",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1ii",
"text": "Withdrawal from activities of interest — e.g., long-standing activities, being with family/friends",
"prefix": "ii",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "C1-group6",
"text": "OTHER INDICATORS",
"type": "group",
"item": [
{
"type": "choice",
"required": false,
"linkId": "C1jj",
"text": "Repetitive health complaints—e.g., persistently seeks attention for physical symptoms such as headaches and stomach ache; incessant concern with body functions",
"prefix": "jj",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"required": false,
"linkId": "C1kk",
"text": "Unusual or abnormal physical movements—Unusual facial expressions or mannerisms, peculiar motor behaviour or body posturing (e.g., stereotypes, motor tics, spasticity)",
"prefix": "kk",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1ll",
"text": "Phonic tics — Unusual, abrupt, repetitive, and involuntary sounds (e.g., clearing throat, barking, repeating words or phrases)",
"prefix": "ll",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1mm",
"text": "Hygiene — Unusually poor hygiene, unkempt, dishevelled",
"prefix": "mm",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1nn",
"text": "Denies or minimizes harm done to others — e.g., “They can afford it”; “I didn’t hit the kid that hard”",
"prefix": "nn",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1oo",
"text": "Difficulty falling asleep or staying asleep; waking up too early — restlessness; nonrestful sleep",
"prefix": "oo",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1pp",
"text": "Wakes multiple times at night",
"prefix": "pp",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1qq",
"text": "Falls asleep during the day (exclude naptime)",
"prefix": "qq",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1rr",
"text": "Resists bedtime — e.g., getting into/staying in bed; difficulty going to bed without parent/caregiver intervention; reluctant to sleep on appropriate schedule",
"prefix": "rr",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1ss",
"text": "Episodes of disorganized speech — e.g., speech is nonsensical, irrelevant, or rambling from subject to subject",
"prefix": "ss",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "C1tt",
"text": "Expression of supportive of criminal activity — e.g., “It’s only a crime if you get caught” ",
"prefix": "tt",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
}
]
},
{
"linkId": "C2",
"type": "group",
"text": "SLEEP PROBLEMS RELATED TO HYPOMANIA OR MANIA",
"prefix": "2.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "C2a",
"text": "Child/youth had 24-hour period with less than 2 hours of sleep caused by increased energy level (Code for most recent instance)",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}
]
},
{
"linkId": "C3",
"text": "PERSISTENT BEHAVIOUR PATTERNS THAT HINDER SOCIALIZATION",
"prefix": "3.",
"type": "group",
"item": [
{
"linkId": "C3a",
"text": "Narrowly restricted range of interest—e.g., constantly talks about trains",
"type": "choice",
"required": false,
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "C3b",
"text": "Excessive preoccupation with an activity or routine",
"type": "choice",
"required": false,
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "C3c",
"text": "Demonstrates lack of social and emotional conventions when socializing—e.g., lack of eye contact",
"type": "choice",
"required": false,
"prefix": "c",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "C3d",
"text": "Extreme shyness—e.g., severe inhibition in familiar social situations",
"type": "choice",
"required": false,
"prefix": "d",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "C4",
"text": "CHANGE IN SEVERITY OR FREQUENCY OF PSYCHIATRIC SYMPTOMS COMPARED TO 30 DAYS AGO, OR SINCE LAST ASSESSMENT IF LESS THAN 30 DAYS AGO",
"type": "choice",
"required": false,
"prefix": "4.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-improvement1"
},
{
"linkId": "C5",
"text": "MENTAL STATE INDICATORS — ONTARIO SUPPLEMENTARY ITEMS Code for indicators observed in the last 3 days, irrespective of the assumed cause (Note: Whenever possible, ask child/youth)",
"type": "group",
"prefix": "5.",
"item": [
{
"linkId": "C5a",
"text": "Demonstrates limited understanding of consequences to behaviour — e.g., that his or her actions will have a negative effect others",
"prefix": "a",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "C5b",
"text": "Demonstrates excessive naïveté — e.g., financially exploited by peers; tricked into transporting drugs for a gang",
"prefix": "b",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
}
]
}
]
},
{
"linkId": "D",
"text": "SECTION D. SUBSTANCE USE OR EXCESSIVE BEHAVIOUR",
"type": "group",
"item": [
{
"type": "choice",
"required": false,
"linkId": "D1",
"text": "SOCIAL ENVIRONMENT ENVOURAGES OR FACILITATES ABUSE OR DRUGS OR ALCOHOL",
"prefix": "1.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "D2",
"text": "USES CAFFEINE OR ENERGY DRINKS Highest number of alcoholic drinks consumed in any single day of the LAST 3 DAYS",
"prefix": "2.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-caffeine-use"
},
{
"type": "choice",
"required": false,
"linkId": "D3",
"text": "SMOKES TOBACCO DAILY",
"prefix": "3.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-smoking"
},
{
"type": "choice",
"required": false,
"linkId": "D4",
"text": "USES OTHER NICOTINE PRODUCT DAILY e.g., electronic cigarette, smokeless tobacco",
"prefix": "4.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-smoking"
},
{
"linkId": "D5",
"text": "PROBLEM VIDEO GAMING AND INTERNET USE IN LAST 90 DAYS - Code for disruption caused by child’s/youth’s unusual pattern of video gaming/Internet use ",
"prefix": "5.",
"type": "group",
"item": [
{
"linkId": "D5a",
"text": "Problem video gaming",
"prefix": "a",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-severity1"
},
{
"linkId": "D5b",
"text": "Problem internet use",
"prefix": "b",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-severity1"
}
]
}
]
},
{
"linkId": "E",
"text": "SECTION E. HARM TO SELF AND OTHERS",
"type": "group",
"item": [
{
"type": "group",
"linkId": "E1",
"text": "SELF-INJURIOUS IDEATION OR ATTEMPT Code for most recent instance",
"prefix": "1.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "E1a",
"text": "Considered performing a self-injurious act",
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"required": false,
"linkId": "E1b",
"text": "Most recent self-injurious attempt",
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}
]
},
{
"linkId": "E2",
"type": "choice",
"required": false,
"text": "INTENT OF ANY SELF-INJURIOUS ATTEMPT WAS TO KILL SELF",
"prefix": "2.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-intent-to-kill-self"
},
{
"linkId": "E3",
"type": "group",
"text": "OTHER INDICATORS OF SELF-INJURIOUS BEHAVIOUR",
"prefix": "3.",
"item": [
{
"linkId": "E3a",
"type": "choice",
"required": false,
"text": "Family, caregiver, friend, or staff expresses concern that the child/youth is at risk for self-injury",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "E3b",
"type": "choice",
"required": false,
"text": "Suicide plan — In LAST 30 DAYS, formulated a scheme to end own life",
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"type": "group",
"linkId": "E4",
"text": "VIOLENCE Code for most recent instance",
"prefix": "4.",
"item": [
{
"linkId": "E4a",
"text": "Violent ideation — e.g., reports of premeditated thoughts, statements, plans to commit violence",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "E4b",
"text": "Intimidation of others or threatened violence — Intentionally makes threatening gestures, verbalizations or stance with no physical contact (e.g., throwing furniture, explicit threats of violence)",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "E4c",
"text": "Violence to others — Acts with purposeful, malicious or vicious intent to cause harm resulting in physical harm to another (e.g., stabbing, choking, beating)",
"type": "choice",
"required": false,
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}
]
},
{
"linkId": "E5",
"text": "EXTREME BEHAVIOUR DISTURBANCE —History of extreme behaviour(s) that suggests serious risk of harm to self (e.g., severe self-mutilation) or others (e.g., torture, homicide)",
"prefix": "5.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-extreme-behaviour-disturbance"
},
{
"type": "group",
"linkId": "E6",
"text": "OTHER INDICATORS OF VIOLENCE Code for most recent instance",
"prefix": "6.",
"item": [
{
"linkId": "E6a",
"text": "Fire setting or misuse of ignition materials or accelerants",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "E6b",
"text": "Cruelty to animals — Deliberate mistreatment of or physical injury to animals — EXCLUDE BEHAVIOURS THAT ARE CONSISTENT WITH CHILD’S/YOUTH’S CULTURAL NORMS",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "E6c",
"text": "Preoccupation with violence — e.g., depictions of violence, verbalizations about violence",
"type": "choice",
"required": false,
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}
]
},
{
"linkId": "E7",
"type": "choice",
"required": false,
"text": "CHILD/YOUTH HAS BEEN KNOWN TO CARRY OR USE WEAPON(S) IN THE LAST YEAR",
"prefix": "7.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "E8",
"type": "group",
"text": "CHILD/YOUTH HAS CAUSED SERIOUS INJURY TO SELF OR ANOTHER IN LAST 90 DAYS (ONTARIO SUPPLEMENTARY ITEMS)- Code for any injury caused by the child/youth that, without appropriate medical care, could result in disfigurement (e.g., large laceration, broken bone, detached retina) or has the potential to be life-threatening (e.g., concussion, major blood loss)",
"prefix": "8.",
"item": [
{
"linkId": "E8a",
"type": "choice",
"required": false,
"text": "To another person",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "E8b",
"type": "choice",
"required": false,
"text": "To self",
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
}
]
},
{
"linkId": "F",
"text": "SECTION F. BEHAVIOUR",
"type": "group",
"item": [
{
"type": "group",
"linkId": "F1",
"text": "BEHAVIOUR SYMPTOMS Code for indicators observed, irrespective of the assumed cause",
"prefix": "1.",
"item": [
{
"linkId": "F1a",
"type": "choice",
"required": false,
"text": "Verbal abuse — e.g., others were threatened, screamed at, cursed at",
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1b",
"type": "choice",
"required": false,
"text": "Physical abuse — e.g., others were hit, shoved, scratched, sexually abused",
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1c",
"type": "choice",
"required": false,
"text": "Socially inappropriate or disruptive behaviour — e.g., screamed out during class, smeared or threw food or feces",
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1d",
"type": "choice",
"required": false,
"text": "Resists care — e.g., taking medications/injections, ADL assistance, eating",
"prefix": "d",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1e",
"type": "choice",
"required": false,
"text": "Destructive behaviour toward property — e.g., throwing or breaking objects, turning over beds or tables, vandalism",
"prefix": "e",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1f",
"type": "choice",
"required": false,
"text": "Outburst of anger — Intense flare-up of anger in reaction to a specific action or event (e.g., tantrums when told “no”)",
"prefix": "f",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1g",
"type": "choice",
"required": false,
"text": "Defiant behaviour — Active, persistent refusal to comply with reasonable requests by others",
"prefix": "g",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1h",
"type": "choice",
"required": false,
"text": "Argumentativeness — Verbally combative, belligerent, quarrelsome, unreasonably and excessively argumentative",
"prefix": "h",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1i",
"type": "choice",
"required": false,
"text": "Extreme risk-taking — e.g., jumping off high rooftop, playing with firearms",
"prefix": "i",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1j",
"type": "choice",
"required": false,
"text": "Repetitive lying — Misrepresentations for personal gain",
"prefix": "j",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1k",
"type": "choice",
"required": false,
"text": "Self-injurious behaviour — e.g., bangs head; pinching, biting, scratching, hitting self, pulling own hair",
"prefix": "k",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1l",
"type": "choice",
"required": false,
"text": "Regressive behaviour — Child/youth has behaviours that revert back to a previous stage in development (e.g., begins sucking thumb again)",
"prefix": "l",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1m",
"type": "choice",
"required": false,
"text": "Excessive or unusual reaction to sensory stimuli — e.g., recoils from touch or does not appear to notice touch; demonstrates aversion to certain fabric textures; does not appear to register pain",
"prefix": "m",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
},
{
"linkId": "F1n",
"type": "choice",
"required": false,
"text": "Inappropriate public sexual behaviour or public disrobing",
"prefix": "n",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period3"
}
]
},
{
"linkId": "F2",
"type": "choice",
"required": false,
"text": "EVIDENCE OF HIGHLY INAPPROPRIATE SEXUAL KNOWLEDGE OR EXCESSIVE PREOCCUPATION WITH SEX IN LAST 90 DAYS",
"prefix": "2.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "F3",
"type": "choice",
"required": false,
"text": "FAMILY, CAREGIVER, FRIEND, OR STAFF EXPRESSES CONCERN ABOUT HIGHLY RISKY OR PROBLEMATIC SEXUAL BEHAVIOUR",
"prefix": "3.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "group",
"linkId": "F4",
"text": "CONDUCT PROBLEMS Code for most recent time of event",
"prefix": "4.",
"item": [
{
"linkId": "F4a",
"text": "Stealing — e.g., theft from family, shoplifting",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "F4b",
"text": "Bullying peers — Pattern of repeated oppression or victimization of others",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "F4c",
"text": "Elopement attempts/threats",
"type": "choice",
"required": false,
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}
]
},
{
"linkId": "F5",
"type": "choice",
"required": false,
"text": "CHILD/YOUTH REPORTS THAT MOST RECENT ELOPEMENT ATTEMPT WAS BASED ON FEAR FOR PERSONAL SAFETY Ask child/youth reason for elopement directly",
"prefix": "5.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-elopement-for-safety"
},
{
"linkId": "F6",
"type": "choice",
"required": false,
"text": "COMPARING BEHAVIOUR AT HOME AND SCHOOL In school, behaviour is",
"prefix": "6.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-behavior-at-home-and-school"
},
{
"type": "group",
"linkId": "F7",
"text": "CHILD/YOUTH HAS BEHAVIOUR PROBLEMS THAT RESPOND TO CAREGIVER INTERVENTION",
"prefix": "7.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "F7a",
"text": "Child/youth can be redirected",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "F7b",
"text": "Child/youth responds to reinforcement — e.g., praise, token",
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
}
]
},
{
"linkId": "G",
"type": "group",
"text": "SECTION G. STRENGTHS AND RESILIENCE",
"item": [
{
"linkId": "G1-group1",
"text": "SECTION G. FUNCTIONAL STATUS (Code as observed over the last 3 days unless noted otherwise)",
"type": "group",
"item": [
{
"type": "group",
"linkId": "G1",
"text": "STRENGTHS",
"prefix": "1.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "G1a",
"text": "Reports having a confidant",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G1b",
"text": "Notable talent — e.g., excels in art, sports, or performance",
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G1c",
"text": "Good school performance in LAST 6 MONTHS",
"prefix": "c",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G1d",
"text": "School engagement — Actively involved in school-based activities (e.g, sports team, club, student council)",
"prefix": "d",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G1e",
"text": "Consisitent positive outlook",
"prefix": "e",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G1f",
"text": "Strong and supportive relationship with family",
"prefix": "f",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G1g",
"text": "Strong and supportive relationship with friends/peers",
"prefix": "g",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G1h",
"text": "Has at least one friend with whom visits/plays/socializes regularly",
"prefix": "h",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G1i",
"text": "Social inclusion by peers — e.g., playmates at recess",
"prefix": "i",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"type": "group",
"linkId": "G2",
"text": "INVOLVEMENT IN STRUCTURED ACTIVITIES IN LAST 90 DAYS",
"prefix": "2.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "G2a",
"text": "Extracurricular lessons/classes — e.g., music, yoga",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G2b",
"text": "Volunteers — e.g., for community services",
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G2c",
"text": "Organized club or team program — e.g., soccer, Scouts",
"prefix": "c",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"type": "group",
"linkId": "G3",
"text": "STRENGHTS AND RESILIENCE - ONTARIO SUPPLEMENTARY ITEMS",
"prefix": "3.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "G3a",
"text": "Reports strong cultural identity — e.g., derives sense of self from cultural background",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "G3b",
"text": "Reports strong spirituality — e.g., has a relationship with his/her faith, meditates or prays",
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "G4",
"text": "EFFECTIVE PROBLEM SOLVING FOR STRESSFUL SITUATIONS - e.g., child/youth identifies and understands sources of stress and enacts strategies to minimize their effect",
"prefix": "4.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
}
]
},
{
"linkId": "H",
"type": "group",
"text": "SECTION H. COGNITION AND EXECUTIVE FUNCTIONING",
"item": [
{
"linkId": "H1",
"text": "COGNITIVE SKILLS FOR DAILY DECISION-MAKING Making decisions regarding tasks of daily life — e.g., when to get up or have meals, which clothes to wear or activities to do",
"prefix": "1.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-daily-decision-making1"
},
{
"linkId": "H2",
"type": "group",
"text": "MEMORY/RECALL ABILITY Code for recall of what was learned or known",
"prefix": "2.",
"item": [
{
"linkId": "H2a",
"type": "choice",
"required": false,
"text": "Short-term memory OK — Seems/appears to recall after 20–30 seconds",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-memory-indicator"
},
{
"linkId": "H2b",
"type": "choice",
"required": false,
"text": "Procedural memory OK — Can perform all or almost all steps in a multistep sequence without cues",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-memory-indicator"
}
]
},
{
"linkId": "H3",
"text": "ADAPTABILITY TO CHANGE IN ROUTINE OR ENVIRONMENT",
"prefix": "3.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-adaptability-to-change"
},
{
"type": "group",
"linkId": "H4",
"text": "EXECUTIVE FUNCTIONING Code for adequacy of child’s/youth’s executive functioning ability compared with typical child/youth of same age.",
"prefix": "4.",
"item": [
{
"type": "choice",
"required": false,
"linkId": "H4a",
"text": "Problem-solving and reasoning ability — How finds solutions to everyday problems, arrives at inferences and conclusions",
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-executive-functioning"
},
{
"type": "choice",
"required": false,
"linkId": "H4b",
"text": "Task initiation — Ability to initiate a task independently",
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-executive-functioning"
},
{
"type": "choice",
"required": false,
"linkId": "H4c",
"text": "Goal setting and self-monitoring — Ability to set goals, monitor own performance, and evaluate own progress",
"prefix": "c",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-executive-functioning"
}
]
}
]
},
{
"linkId": "I",
"text": "SECTION I. INDEPENDENCE IN DAILY ACTIVITIES",
"type": "group",
"item": [
{
"linkId": "I1",
"text": "IADL SELF-PERFORMANCE AND CAPACITY Code for PERFORMANCE in routine activities around the home or in the community during the last 7 DAYS. Code for CAPACITY based on presumed ability to carry out activity as independently as possible. This will require \"speculation\" by the assessor.",
"prefix": "1.",
"type": "group",
"item": [
{
"linkId": "I1a",
"text": "Ordinary housework—How ordinary work around the house is performed (e.g., chores such as doing dishes, making bed, tidying up toys)",
"prefix": "a",
"type": "group",
"item": [
{
"linkId": "I1a_P",
"text": "P - Performance",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I1a_C",
"text": "C - Capacity",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
}
]
},
{
"linkId": "I1b",
"text": "Phone use—How telephone calls are made or received (with assistive devices as needed)",
"prefix": "b",
"type": "group",
"item": [
{
"linkId": "I1b_P",
"text": "P - Performance",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I1b_C",
"text": "C - Capacity",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
}
]
},
{
"linkId": "I1c",
"text": "Use of technology—e.g., how gets on the Internet, uses the computer to play games and do homework",
"prefix": "c",
"type": "group",
"item": [
{
"linkId": "I1c_P",
"text": "P - Performance",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I1c_C",
"text": "C - Capacity",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
}
]
},
{
"linkId": "I1d",
"text": "School tasks—How organizes class materials, including homework and school supplies",
"prefix": "d",
"type": "group",
"item": [
{
"linkId": "I1d_P",
"text": "P - Performance",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I1d_C",
"text": "C - Capacity",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
}
]
},
{
"linkId": "I1e",
"text": "Orientation in familiar indoor environment—e.g., how moves between classes and orient self when at school",
"prefix": "e",
"type": "group",
"item": [
{
"linkId": "I1e_P",
"text": "P - Performance",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I1e_C",
"text": "C - Capacity",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
}
]
},
{
"linkId": "I1f",
"text": "Stairs—How manages full flight of stairs (12–14 stairs)",
"prefix": "f",
"type": "group",
"item": [
{
"linkId": "I1f_P",
"text": "P - Performance",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I1f_C",
"text": "C - Capacity",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
}
]
}
]
},
{
"linkId": "I2",
"text": "ADL SELF-PERFORMANCE Consider all episodes over 7-day period. If all episodes are performed at the same level, score ADL at that level. If any episodes at a level 6, and others less dependent, score ADL as a 5. Otherwise, focus ont he three most dependent episodes [or all episodes if performed fewer than 3 times]. if most dependent episode is 1, score ADL as 1. if not, score ADL as least dependent of those episodes in range 2-5.",
"prefix": "2.",
"type": "group",
"item": [
{
"linkId": "I2a",
"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": "a",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I2b",
"text": "Bathing—How takes a full-body bath/shower. Includes how transfers in and out of tub or shower AND how each part of the body is bathed; arms, upper and lower legs, chest, abdomen and perineal area—EXCLUDE WASHING OF BACK AND HAIR",
"prefix": "b",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I2c",
"text": "Dressing upper body—How dresses and undresses street clothes; underwear above the waist, including prostheses, orthotics, fasteners, pullovers, etc.",
"prefix": "c",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I2d",
"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",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I2e",
"text": "Locomotion—How moves between locations on same floor (walking or wheeling). If in wheelchair, self-sufficiency once in chair",
"prefix": "e",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I2f",
"text": "Toilet use—How uses the toilet room (or commode, bedpan, urinal), cleans self after toilet use or incontinent episodes(s), changes bed pad, manages ostomy or catheter, adjusts clothes—EXCLUDE TRANSFER ON AND OFF TOILET",
"prefix": "f",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
},
{
"linkId": "I2g",
"text": "Eating—How eats and drinks (regardless of skill). Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition)",
"prefix": "g",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
}
]
},
{
"linkId": "I3",
"text": "CHANGE IN ADL STATUS AS COMPARED TO 90 DAYS AGO, OR SINCE LAST ASSESSMENT IF LESS THAN 90 DAYS AGO",
"prefix": "3.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-improvement"
}
]
},
{
"linkId": "J",
"type": "group",
"text": "SECTION J. COMMUNICATION",
"item": [
{
"linkId": "J1",
"type": "choice",
"required": false,
"text": "MAKING SELF UNDERSTOOD (Expression) Expressing information content—both verbal and nonverbal",
"prefix": "1.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-understanding-self"
},
{
"linkId": "J2",
"type": "choice",
"required": false,
"text": "ABILITY TO UNDERSTAND OTHERS (Comprehension) Understanding verbal information content (however able; with hearing appliance normally used)",
"prefix": "2.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-understanding-other"
}
]
},
{
"linkId": "K",
"type": "group",
"text": "SECTION K. HEARING, VISION, AND MOTOR",
"item": [
{
"linkId": "K1",
"type": "choice",
"required": false,
"text": "HEARING\nAbility to hear (with hearing appliance normally used)",
"prefix": "1.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-hearing"
},
{
"linkId": "K2",
"type": "choice",
"required": false,
"text": "VISION\nAbility to see in adequate light (with glasses or with other visual appliance normally used)",
"prefix": "2.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-vision"
},
{
"linkId": "K3",
"type": "choice",
"required": false,
"text": "DISTANCE VISION\nAbility to see in adequate light (with glasses or with other visual appliance normally used)",
"prefix": "3.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-vision"
},
{
"linkId": "K4",
"type": "choice",
"required": false,
"text": "GROSS MOTOR SKILLS\nAbility to perform skills requiring balance and large muscles of the body in coordinated movement (e.g., jumping, kicking a ball, catching a ball)",
"prefix": "4.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-motor-skill"
},
{
"linkId": "K5",
"type": "choice",
"required": false,
"text": "FINE MOTOR SKILLS\nAbility to perform coordinated movements that involve small muscle (e.g., grasping a pencil, managing buttons, using scissors)",
"prefix": "5.",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-motor-skill"
},
{
"linkId": "K6",
"text": "SENSORY PROCESSING",
"prefix": "6.",
"type": "group",
"item": [
{
"linkId": "K6a",
"text": "Sensory seeking behaviour—e.g., seeks out extremely physically active activities; engages in play that would normally be painful",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"linkId": "K6b",
"text": "Sensory avoiding behaviour—e.g., fearful of activities that involve movement, averse to \"messy\" play",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
}
]
},
{
"linkId": "L",
"text": "SECTION L. HEALTH CONDITIONS",
"type": "group",
"item": [
{
"linkId": "L1",
"text": "PROBLEM FREQUENCY (Code for presence in last 3 days)",
"prefix": "1.",
"type": "group",
"item": [
{
"linkId": "L1a",
"text": "Dizziness",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"linkId": "L1b",
"text": "Increase or decrease in normal appetite",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"linkId": "L1c",
"text": "Vomiting",
"type": "choice",
"required": false,
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"linkId": "L1d",
"text": "Nausea",
"type": "choice",
"required": false,
"prefix": "d",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"linkId": "L1e",
"text": "Constipation",
"type": "choice",
"required": false,
"prefix": "e",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"linkId": "L1f",
"text": "Daytime drowsiness or sedation",
"type": "choice",
"required": false,
"prefix": "f",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"linkId": "L1g",
"text": "Emergent conditions—e.g., itching, fever, rash, bleeding, airway constriction",
"type": "choice",
"required": false,
"prefix": "g",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"linkId": "L1h",
"text": "Headache",
"type": "choice",
"required": false,
"prefix": "h",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"linkId": "L1i",
"text": "Seizures",
"type": "choice",
"required": false,
"prefix": "i",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"linkId": "L1j",
"text": "Dry mouth",
"type": "choice",
"required": false,
"prefix": "j",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
},
{
"linkId": "L1k",
"text": "Hypersalivation or drooling",
"type": "choice",
"required": false,
"prefix": "k",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
}
]
},
{
"linkId": "L2",
"text": "DYSPNEA (shortness of breath)—e.g., asthma",
"prefix": "2.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-symptom"
},
{
"linkId": "L3",
"text": "FATIGUE—Unable to complete normal daily activities—e.g., ADLs, IADLs",
"prefix": "3.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-severity-of-fatigue"
},
{
"linkId": "L4",
"text": "PAIN SYMPTOMS [Note: Always ask the child/youth about pain frequency and intensity. Observe child/youth and ask others who are in contact with the child/youth.]",
"prefix": "4.",
"type": "group",
"item": [
{
"linkId": "L4a",
"text": "Frequency with which child/youth complains or shows evidence of pain (including grimacing, teeth clenching, moaning, withdrawl when touched, or other non-verbal signs suggesting pain)",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-pain"
},
{
"linkId": "L4b",
"text": "Intensity of highest level of pain present",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-severity-of-pain"
}
]
},
{
"linkId": "L5",
"text": "EXTRAPYRAMIDAL SYMPTOMS DURING LAST 3 DAYS",
"prefix": "5.",
"type": "group",
"item": [
{
"linkId": "L5a",
"text": "Akathisia - Subjective feeling of restlessness or need for movement",
"type": "choice",
"required": false,
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "L5b",
"text": "Dyskinesia — e.g., chewing, puckering movement of mouth; abnormal irregular movement of lips; rocking/writhing of trunk",
"type": "choice",
"required": false,
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "L5c",
"text": "Tremor — Involuntary rhythmic movements of the fingers, limbs, head, mouth, tongue",
"type": "choice",
"required": false,
"prefix": "c",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "L5d",
"text": "Bradykinesia — Decrease in spontaneous movements (e.g., reduced body movement, or poverty of facial expression, gestures, speech)",
"type": "choice",
"required": false,
"prefix": "d",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "L5e",
"text": "Rigidity — Resistance to flexion and extension of muscles",
"type": "choice",
"required": false,
"prefix": "e",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "L5f",
"text": "Dystonia — Muscle hypertonicity (e.g., muscle spasms or stiffness, protruding tongue, upward deviation of the eyes)",
"type": "choice",
"required": false,
"prefix": "f",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "L5g",
"text": "Slow shuffling gait — Reduction in speed and stride length, usually with a decrease in pendular arm movement",
"type": "choice",
"required": false,
"prefix": "g",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "L6",
"text": "ELIMINATION PROBLEMS (Code for indicators observed, irrespective of the assumed cause)",
"prefix": "6.",
"type": "group",
"item": [
{
"linkId": "L6a",
"text": "Daytime enuresis—e.g., urinates in pants",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period5"
},
{
"linkId": "L6b",
"text": "Night-time enuresis—e.g., urinates in bed",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period5"
},
{
"linkId": "L6c",
"text": "Encopresis—e.g., defecates in pants",
"type": "choice",
"required": false,
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period5"
}
]
},
{
"linkId": "L7",
"text": "TOTAL HOURS OF EXERCISE OR PHYSICAL ACTIVITY IN LAST 3 DAYS—e.g., walking, dancing, biking, sports",
"prefix": "7.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-amount-of-exercise"
}
]
},
{
"linkId": "M",
"text": "SECTION M. FAMILY AND SOCIAL RELATIONS",
"type": "group",
"item": [
{
"linkId": "M1",
"text": "PARENTING Code for parent/primary caregiver interaction with child/youth. Take into account developmental level of child",
"prefix": "1.",
"type": "group",
"item": [
{
"linkId": "M1a",
"text": "Communicates effectively with child/youth — e.g., parent listens, validates appropriate concerns",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-parenting"
},
{
"linkId": "M1b",
"text": "Assists child/youth with the regulation of emotions — e.g., when overly upset, parent puts things into perspective",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-parenting"
},
{
"linkId": "M1c",
"text": "Uses appropriate disciplinary practices — e.g., calmly addresses misbehaviour, uses developmentally appropriate discipline",
"type": "choice",
"required": false,
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-parenting"
},
{
"linkId": "M1d",
"text": "Demonstrates warmth and support — Responsive to child’s/youth’s needs, shows affection",
"type": "choice",
"required": false,
"prefix": "d",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-parenting"
},
{
"linkId": "M1e",
"text": "Appropriate supervision and monitoring — e.g., parent checks in on 8-year-old regularly to see what he or she is doing; 15-year-old can come and go with regular check-ins; 5-year-old is supervised in bathtub",
"type": "choice",
"required": false,
"prefix": "e",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-parenting"
},
{
"linkId": "M1f",
"text": "Appropriate limit setting or expectations — Clear, reasonable limits are set for child/youth (e.g., 5-year-old not allowed to cook on stove; 11-year-old is not allowed to stay out all night with friends)",
"type": "choice",
"required": false,
"prefix": "f",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-parenting"
}
]
},
{
"linkId": "M2",
"text": "COMFORT-SEEKING BEHAVIOUR Code only for children aged 11 or younger",
"prefix": "2.",
"type": "group",
"item": [
{
"linkId": "M2a",
"text": "Severe reluctance to accept comfort from primary caregiver when distressed",
"type": "choice",
"required": false,
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-no-parent-primary-caregiver"
},
{
"linkId": "M2b",
"text": "When seeking comfort, demonstrates anger and ambivalence toward the caregiver",
"type": "choice",
"required": false,
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-no-parent-primary-caregiver"
},
{
"linkId": "M2c",
"text": "Seeks comfort from any available adult",
"type": "choice",
"required": false,
"prefix": "c",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-no-parent-primary-caregiver"
}
]
},
{
"linkId": "M3",
"text": "FAMILY ACTIVITIES",
"prefix": "3.",
"type": "group",
"item": [
{
"linkId": "M3a",
"text": "Family went on outings for recreation",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period"
},
{
"linkId": "M3b",
"text": "Family participated in sit-down meals together",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period"
}
]
},
{
"linkId": "M4",
"text": "UNPAID SUPPORTS CURRENTLY AVAILABLE TO FAMILY Presence of one or more family members (outside nuclear family) or close friends who are willing and able to provide the following types of support",
"prefix": "4.",
"type": "group",
"item": [
{
"linkId": "M4a",
"text": "Crisis situations",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-availability"
},
{
"linkId": "M4b",
"text": "Financial problems",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-availability"
},
{
"linkId": "M4c",
"text": "Babysitting",
"type": "choice",
"required": false,
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-availability"
},
{
"linkId": "M4d",
"text": "Emotional support",
"type": "choice",
"required": false,
"prefix": "d",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-availability"
},
{
"linkId": "M4e",
"text": "Respite",
"type": "choice",
"required": false,
"prefix": "e",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-availability"
}
]
},
{
"linkId": "M5",
"text": "UNSETTLED RELATIONSHIPS",
"prefix": "5.",
"type": "group",
"item": [
{
"linkId": "M5a",
"text": "Conflict with or repeated criticism of family",
"type": "choice",
"required": false,
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"linkId": "M5b",
"text": "Conflict with or repeated criticism of close friends",
"type": "choice",
"required": false,
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"linkId": "M5c",
"text": "Staff report persistent frustration in dealing with child/youth",
"type": "choice",
"required": false,
"prefix": "c",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"linkId": "M5d",
"text": "Family are persistently hostile or critical of child/youth",
"type": "choice",
"required": false,
"prefix": "d",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"linkId": "M5e",
"text": "Friends are persistently hostile or critical of child/youth",
"type": "choice",
"required": false,
"prefix": "e",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"linkId": "M5f",
"text": "Pervasive conflict with peers (exclude close friends)",
"type": "choice",
"required": false,
"prefix": "f",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"linkId": "M5g",
"text": "Conflict or repeated criticism between parents/primary caregivers",
"type": "choice",
"required": false,
"prefix": "g",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"linkId": "M5h",
"text": "Family members report feeling overwhelmed by child’s/youth’s condition — e.g., severe behaviour problems",
"type": "choice",
"required": false,
"prefix": "h",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
}
]
},
{
"linkId": "M6",
"text": "LENGTH OF TIME WITHOUT PARENTAL SUPERVISION IN TYPICAL 24-HOUR PERIOD IN USUAL RESIDENCE",
"prefix": "6.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-without-parental-supervision"
},
{
"linkId": "M7",
"text": "TWO KEY CAREGIVERS",
"prefix": "7.",
"type": "group",
"item": [
{
"linkId": "M7a",
"text": "Relationship to child/youth",
"type": "group",
"prefix": "a",
"item": [
{
"linkId": "M7a_1",
"text": "Caregiver 1",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-caregiver-relationship"
},
{
"linkId": "M7a_2",
"text": "Caregiver 2",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-caregiver-relationship"
}
]
},
{
"linkId": "M7b",
"text": "Lives with child/young",
"type": "group",
"prefix": "b",
"item": [
{
"linkId": "M7b_1",
"text": "Caregiver 1",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-caregiver-lives-with-child-youth"
},
{
"linkId": "M7b_2",
"text": "Caregiver 2",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-caregiver-lives-with-child-youth"
}
]
}
]
},
{
"linkId": "M8",
"text": "CAREGIVER STATUS",
"prefix": "8.",
"type": "group",
"item": [
{
"linkId": "M8a",
"text": "In school or work full-time",
"type": "group",
"prefix": "a",
"item": [
{
"linkId": "M8a_1",
"text": "Caregiver 1",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-status-of-caregiver"
},
{
"linkId": "M8a_2",
"text": "Caregiver 2",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-status-of-caregiver"
}
]
},
{
"linkId": "M8b",
"text": "In school or work part-time",
"type": "group",
"prefix": "b",
"item": [
{
"linkId": "M8b_1",
"text": "Caregiver 1",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-status-of-caregiver"
},
{
"linkId": "M8b_2",
"text": "Caregiver 2",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-status-of-caregiver"
}
]
}
]
},
{
"linkId": "M9",
"text": "PEER GROUP INCLUDES INDIVIDUALS WITH PERSISTENT ANTISOCIAL BEHAVIOUR",
"prefix": "9.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "M10",
"text": "PARENT(S)/PRIMARY CAREGIVER(S) DEGREE OF INSIGHT INTO CHILD's/YOUTH's MENTAL HEALTH PROBLEM",
"prefix": "10.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-insight"
},
{
"linkId": "M11",
"text": "UNSETTLED RELATIONSHIPS - Parent/primary caregiver is intrusive - e.g. , parent dominates, takes over child-focused activities",
"prefix": "11.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
}
]
},
{
"linkId": "N",
"text": "SECTION N. STRESS AND TRAUMA",
"type": "group",
"item": [
{
"linkId": "N1",
"text": "LIFE EVENTS Code for most recent time of event",
"prefix": "1.",
"type": "group",
"item": [
{
"linkId": "N1a",
"text": "Serious accident or physical impairment",
"prefix": "a",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1b",
"text": "Death or loss of parent or primary caregiver",
"prefix": "b",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1c",
"text": "Death or loss of other close family member",
"prefix": "c",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1d",
"text": "Failed or dropped out of education program",
"prefix": "d",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1e",
"text": "Immigration, including refugee status",
"prefix": "e",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1f",
"text": "Lived in war zone or area of violence conflict (combatant or civilian)",
"type": "choice",
"required": false,
"prefix": "f",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1g",
"text": "Witnesses severe accident, disaster, terrorism, violence, or abuse - EXCLUDE DOMESTIC VIOLENCE OR ABUSE",
"type": "choice",
"required": false,
"prefix": "g",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1h",
"text": "victim of crime - EXCLUDE ASSAULT",
"type": "choice",
"required": false,
"prefix": "h",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1i",
"text": "Victim of sexual abuse or assault",
"type": "choice",
"required": false,
"prefix": "i",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1j",
"text": "Victim of physical assault or abuse",
"type": "choice",
"required": false,
"prefix": "j",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1k",
"text": "victim of emotional abuse",
"type": "choice",
"required": false,
"prefix": "k",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1l",
"text": "Victim of bullying",
"type": "choice",
"required": false,
"prefix": "l",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1m",
"text": "change in legal custodian",
"type": "choice",
"required": false,
"prefix": "m",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1n",
"text": "Abandoned by parent(s)/primary caregiver(s)",
"type": "choice",
"required": false,
"prefix": "n",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1o",
"text": "Witnessed domestic violence",
"type": "choice",
"required": false,
"prefix": "o",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1p",
"text": "Parental addiction or substance abuse",
"type": "choice",
"required": false,
"prefix": "p",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N1q",
"text": "Lives in neighbourhood with pervasive violence or criminal activity",
"prefix": "q",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}
]
},
{
"linkId": "N2",
"text": "DESCRIBES ONE OR MORE OF THESE LIFE EVENTS IN N1 AS INVOKING A SENSE OF HORROR OR INTENSE FEAR",
"prefix": "2.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-or-na-could-not-respond"
},
{
"linkId": "N3",
"text": "MAJOR LIFE STRESSORS FOR PARENT(S)/PRIMARY CAREGIVER(S) IN LAST 90 DAYS",
"prefix": "3.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-major-life-stressor"
},
{
"linkId": "N4",
"text": "FAMILY MEMBER(S) OR OTHER PRIMARY CAREGIVER(S) HAS (HAVE) CURRENT DEVELOPMENTAL OR MENTAL HEALTH ISSUES",
"prefix": "4.",
"type": "group",
"item": [
{
"type": "choice",
"required": false,
"linkId": "N4a",
"prefix": "a",
"text": "Parent(s)/primary caregiver(s)",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"required": false,
"linkId": "N4b",
"prefix": "b",
"text": "Sibling(s)",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "N5",
"text": "CAREGIVER DISTRESS",
"prefix": "5.",
"type": "group",
"item": [
{
"linkId": "N5a",
"text": "Parent/primary caregiver is unable or unwilling to continue in caring activities—e.g., caregiver’s health makes it difficult to continue; lack of desire, completing responsibilities",
"prefix": "a",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-no-parent-primary-caregiver"
},
{
"linkId": "N5b",
"text": "Parent/primary caregiver expresses feelings of distress, anger, or depression",
"prefix": "b",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-no-parent-primary-caregiver"
},
{
"linkId": "N6",
"text": "FINANCES\nBecause of limited funds, during the last 30 days PARENT/PRIMARY CAREGIVER OR YOUTH (if youth is an emancipated minor) made trade-offs among purchasing any of the following: clothing, food, shelter; clothing; prescribed medications; sufficient home heat or cooling; necessary health care, etc.",
"prefix": "6.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "N7",
"text": "CHILD/YOUTH HAS EVER BEEN REMOVED FROM HOME BY CHILD PROTECTION AGENCY OR COURT",
"prefix": "7.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "N8",
"text": "OTHER INDICATORS OF ABUSE OF CHILD/YOUTH\nCode for any current concerns regarding the following indicators of abuse:",
"prefix": "8.",
"type": "group",
"item": [
{
"linkId": "N8a",
"text": "Fearful of a family member or close acquaintance",
"prefix": "a",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "N8b",
"text": "Unexplained bruises or other injuries—e.g., burns",
"prefix": "b",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "N8c",
"text": "Child/youth has concerns for his/her safety",
"prefix": "c",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "N8d",
"text": "Family, caregiver, friend, or staff expresses concern that child/youth is at imminent risk for victimization",
"prefix": "d",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "N9",
"text": "PHYSICALLY RESTRAINED—Limbs restrained, chair prevents rising",
"prefix": "9.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "N10",
"text": "LIFE EVENTS—Difficulty adjusting to sexuality or sexual orientation\nCode for most recent time of event",
"prefix": "10.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"linkId": "N11",
"text": "CHILD/YOUTH HAS BEEN SUBJECTED TO PHYSICAL PUNISHMENT IN LAST 6 MONTHS—e.g., spanking or pinching causing bruising, striking with belt",
"prefix": "11.",
"type": "group",
"item": [
{
"linkId": "N11a",
"text": "By parent(s)/primary caregiver(s)",
"prefix": "a",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "N11b",
"text": "By parent(s)/primary caregiver(s)",
"prefix": "b",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
}
]
}
]
},
{
"linkId": "O",
"text": "SECTION O. MEDICATIONS",
"type": "group",
"item": [
{
"linkId": "O1",
"text": "LIST OF ALL MEDICATIONS",
"prefix": "1.",
"type": "group",
"repeats": true,
"item": [
{
"linkId": "O1a1",
"text": "Name",
"prefix": "a",
"type": "string",
"required": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "^\\d+(\\.\\d+)?(\\/\\d+(\\.\\d+)?)?[%content%]quot;
}
],
"linkId": "O1b1",
"text": "Dose",
"prefix": "b",
"type": "decimal",
"required": false
},
{
"linkId": "O1c1",
"definition": "http://cihi.ca/fhir/irrs/StructureDefinition/irrs-question-list#QuestionList.iM1c1",
"text": "Unit",
"prefix": "c",
"required": false,
"type": "choice",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-unit-of-measure"
},
{
"linkId": "O1d1",
"definition": "http://cihi.ca/fhir/irrs/StructureDefinition/irrs-question-list#QuestionList.iM1d1",
"text": "Route of administration ",
"prefix": "d",
"type": "choice",
"required": false,
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-route-of-administration"
},
{
"linkId": "O1e1",
"definition": "http://cihi.ca/fhir/irrs/StructureDefinition/irrs-question-list#QuestionList.iM1e1",
"text": "Frequency ",
"prefix": "e",
"type": "choice",
"required": false,
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency"
},
{
"linkId": "O1f1",
"definition": "http://cihi.ca/fhir/irrs/StructureDefinition/irrs-question-list#QuestionList.iM1f1",
"text": "PRN ",
"prefix": "f",
"type": "choice",
"required": false,
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "O1g1",
"definition": "http://cihi.ca/fhir/irrs/StructureDefinition/irrs-question-list#QuestionList.iM1gc1",
"text": "Computer-entered drug code ",
"prefix": "g",
"type": "choice",
"required": false,
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-medication"
}
]
},
{
"linkId": "O2",
"text": "ADHERENT WITH MEDICATIONS PRESCRIBED BY PHYSICIAN",
"prefix": "2.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-adherence-to-drug"
},
{
"linkId": "O3",
"text": "CHILD/YOUTH STOPPED TAKING PSYCHOTROPIC MEDICATION IN LAST 90 DAYS BECAUSE OF SIDE EFFECTS",
"prefix": "3.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-stopped-psychotropic-medication"
},
{
"linkId": "O4",
"text": "CHILD/YOUTH REFUSED TO TAKE SOME OR ALL OF PRESCRIBED MEDICATION IN LAST 3 DAYS",
"prefix": "4.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-refused-medication"
},
{
"linkId": "O5",
"text": "PARENT/CAREGIVER ASSISTS WITH MEDICATION USE - e.g., provides supervision; administers medications; fills prescriptions",
"prefix": "5.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-assistance-with-medication-use"
},
{
"linkId": "O6",
"text": "ALLERGY TO ANY DRUG",
"prefix": "6.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-drug-allergy"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueInteger": 0
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueInteger": 15
}
],
"linkId": "O7",
"text": "TOTAL NUMBER OF HERBAL/NUTRITIONAL SUPPLEMENTS\nRecord the number of different herbal and nutritional supplements taken regularly or on an occasional basis in the last 3 days. Enter 15 if 15 or higher",
"prefix": "7.",
"type": "integer",
"required": false
}
]
},
{
"linkId": "P",
"text": "SECTION P. PREVENTION, SERVICE UTILIZATION, TREATMENTS",
"type": "group",
"item": [
{
"linkId": "P1",
"text": "PREVENTION",
"prefix": "1.",
"type": "group",
"item": [
{
"linkId": "P1a",
"text": "Dental exam in last YEAR",
"prefix": "a",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "P1b",
"text": "Immunizations up-to-date",
"prefix": "b",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "P2",
"text": "FORMAL CARE Contact with formal care provider",
"prefix": "2.",
"type": "group",
"item": [
{
"linkId": "P2a",
"text": "Psychiatrist",
"prefix": "a",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
},
{
"linkId": "P2b",
"text": "Social worker",
"prefix": "b",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
},
{
"linkId": "P2c",
"text": "Psychologist, psychometrist, psychological associate",
"prefix": "c",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
},
{
"linkId": "P2d",
"text": "Occupational therapist, physiotherapist",
"prefix": "d",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
},
{
"linkId": "P2e",
"text": "Behaviour therapist",
"prefix": "e",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
},
{
"linkId": "P2f",
"text": "Recreation, art, music, play therapist",
"prefix": "f",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
},
{
"linkId": "P2g",
"text": "Registered nurse",
"prefix": "g",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
},
{
"linkId": "P2h",
"text": "Child/youth counsellor",
"prefix": "h",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
},
{
"linkId": "P2i",
"text": "Child protection",
"prefix": "i",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
},
{
"linkId": "P2j",
"text": "Speech-language pathologist",
"prefix": "j",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
},
{
"linkId": "P2k",
"text": "Dietician",
"prefix": "k",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period4"
}
]
},
{
"linkId": "P3",
"text": "FOCUS OF INTERVENTIONS\nCode for types of issues that were a major focus of interventions in LAST 30 DAYS (or since admission if LESS THAN 30 DAYS)",
"prefix": "3.",
"type": "group",
"item": [
{
"linkId": "P3a",
"text": "Life skills training—e.g., communication, money management",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/CodeSystem/irrs-no-intervention"
},
{
"linkId": "P3b",
"text": "Social skills—e.g., interpersonal skills, etiquette",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/CodeSystem/irrs-no-intervention"
},
{
"linkId": "P3c",
"text": "Family functioning—e.g., positive parenting, family cohesion",
"type": "choice",
"required": false,
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/CodeSystem/irrs-no-intervention"
},
{
"linkId": "P3d",
"text": "Anger management",
"type": "choice",
"required": false,
"prefix": "d",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/CodeSystem/irrs-no-intervention"
},
{
"linkId": "P3e",
"text": "Behavioural management",
"type": "choice",
"required": false,
"prefix": "e",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/CodeSystem/irrs-no-intervention"
},
{
"linkId": "P3f",
"text": "Crisis intervention",
"type": "choice",
"required": false,
"prefix": "f",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/CodeSystem/irrs-no-intervention"
},
{
"linkId": "P3g",
"text": "Family preservation—e.g., intensive in-home program",
"type": "choice",
"required": false,
"prefix": "g",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/CodeSystem/irrs-no-intervention"
},
{
"linkId": "P3h",
"text": "Family support—e.g., wraparound, respite",
"type": "choice",
"required": false,
"prefix": "h",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/CodeSystem/irrs-no-intervention"
},
{
"linkId": "P3i",
"text": "Medication management",
"prefix": "i",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/CodeSystem/irrs-no-intervention"
}
]
},
{
"linkId": "P4",
"text": "TREATMENT MODALITIES\nCode for treatment modalities used in LAST 30 DAYS (or since admission if LESS THAN 30 DAYS)",
"prefix": "4.",
"type": "group",
"item": [
{
"linkId": "P4a",
"text": "Individual",
"prefix": "a",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period-of-treatment-modality"
},
{
"linkId": "P4b",
"text": "Group",
"prefix": "b",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period-of-treatment-modality"
},
{
"linkId": "P4c",
"text": "Family or couple",
"prefix": "c",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period-of-treatment-modality"
},
{
"linkId": "P4d",
"text": "Self-help/consumer group",
"type": "choice",
"required": false,
"prefix": "d",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period-of-treatment-modality"
}
]
},
{
"linkId": "P5",
"text": "CASE MANAGEMENT—Receives formal care coordination services",
"prefix": "5.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "P6",
"text": "HOSPITAL USE, EMERGENCY ROOM USE, PHYSICIAN VISIT",
"prefix": "6.",
"type": "group",
"item": [
{
"type": "integer",
"required": false,
"linkId": "P6a",
"text": "Inpatient psychiatric hospital with overnight stay (nonpsychiatric)",
"prefix": "a"
},
{
"type": "integer",
"required": false,
"linkId": "P6b",
"text": "Emergency room visit (not counting overnight stay)",
"prefix": "b"
},
{
"type": "integer",
"required": false,
"linkId": "P6c",
"text": "Physician visit (or authorized assistant or practitioner)",
"prefix": "c"
}
]
},
{
"type": "choice",
"required": false,
"linkId": "P7",
"text": "FAMILY IS APPROPRIATELY ENGAGED IN OR SUPPORTIVE OF TREATMENT PROCESS",
"prefix": "7.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-family-engaged-in-treatment"
},
{
"type": "choice",
"required": false,
"linkId": "P8",
"text": "TRANSITION PLANNING NEEDED—From one setting to another (e.g., educational, vocational, service sector)",
"prefix": "8.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "Q",
"text": "SECTION Q. NUTRITIONAL STATUS",
"type": "group",
"item": [
{
"linkId": "Q1",
"text": "FAMILY, CAREGIVER, FRIEND, OR STAFF EXPRESSES CONCERN ABOUT CHILD/YOUTH’S WEIGHT (Code for nutritional status in LAST 90 DAYS)",
"prefix": "1.",
"type": "group",
"item": [
{
"linkId": "Q1a",
"text": "Weight gain",
"prefix": "a",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "Q1b",
"text": "Weight loss",
"prefix": "b",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "Q1c",
"text": "Failure to gain Weight",
"prefix": "c",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
}
]
},
{
"linkId": "R",
"text": "SECTION R. EDUCATION",
"type": "group",
"item": [
{
"linkId": "R1",
"text": "ENROLLED IN FORMAL EDUCATION PROGRAM If 0 skip to Section S. If 1, skip to item R6",
"prefix": "1.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-formal-education-enrollment"
},
{
"linkId": "R2",
"text": "EDUCATION STATUS [EXAMPLE—CANADA]",
"prefix": "2.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-education-status"
},
{
"linkId": "R3",
"text": "ATTENDANCE IN SCHOOL\nNumber of days absent from school in LAST 90 DAYS",
"prefix": "3.",
"type": "integer",
"required": false
},
{
"linkId": "R4",
"text": "RISK OF DISRUPTED EDUCATION IN LAST 90 DAYS",
"prefix": "4.",
"type": "group",
"item": [
{
"linkId": "R4a",
"text": "Increase in lateness or absenteeism",
"type": "choice",
"required": false,
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"linkId": "R4b",
"text": "Poor productivity or disruptiveness at school",
"type": "choice",
"required": false,
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"linkId": "R4c",
"text": "Expresses intent to quit school",
"type": "choice",
"required": false,
"prefix": "c",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"linkId": "R4d",
"text": "Conflict with school staff—e.g., persistent arguing with teachers; threatening principal",
"type": "choice",
"required": false,
"prefix": "d",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
}
]
},
{
"linkId": "R5",
"text": "STRONG, PERSISTENT DISSATISFACTION WITH SCHOOL",
"prefix": "5.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-dissatisfaction-with-school"
},
{
"linkId": "R6",
"text": "CURRENT DISRUPTED EDUCATION",
"prefix": "6.",
"type": "group",
"item": [
{
"linkId": "R6a",
"text": "Child/youth currently refuses to attend school",
"type": "choice",
"required": false,
"prefix": "a",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "R6b",
"text": "Child/youth currently removed due to disruptive behaviour—e.g., currently suspended or expelled",
"type": "choice",
"required": false,
"prefix": "b",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "R7",
"text": "LAST SCHOOL GRADE COMPLETED SUCCESSFULLY Code 00 if no formal grade level completed",
"prefix": "7.",
"type": "integer",
"required": false
},
{
"linkId": "R8",
"text": "CHILD/YOUTH ASSESSED FOR LEARNING DISORDER IN LAST 3 YEARS",
"prefix": "8.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "R9",
"text": "OVERALL ACADEMIC ABILITY",
"prefix": "9.",
"type": "group",
"item": [
{
"linkId": "R9a",
"text": "Academic PERFORMANCE [P]",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-overall-academic-ability"
},
{
"linkId": "R9b",
"text": "Academic CAPACITY [C]",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-overall-academic-ability1"
}
]
},
{
"linkId": "R10",
"text": "EDUCATION STATUS",
"prefix": "10.",
"type": "group",
"item": [
{
"linkId": "R10a",
"text": "Regular with resource (in-class) support",
"prefix": "a",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "R10b",
"text": "Regular with withdrawal (out of class) support",
"prefix": "b",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "R10c",
"text": "Special education with partial integration",
"prefix": "c",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "R10d",
"text": "Special education without integration",
"prefix": "d",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
}
]
},
{
"linkId": "S",
"text": "SECTION S. ENVIRONMENT ASSESSMENT",
"type": "group",
"item": [
{
"linkId": "S1",
"text": "HOME ENVIRONMENT",
"prefix": "1.",
"type": "group",
"item": [
{
"linkId": "S1a",
"text": "Disrepair of the home—e.g., hazardous clutter, inadequate or no lighting; holes in floor; leaking pipes",
"prefix": "a",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-condition-of-home-environment"
},
{
"linkId": "S1b",
"text": "Squalid condition—e.g., extremely dirty, infestation by bugs",
"prefix": "b",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-condition-of-home-environment"
},
{
"linkId": "S1c",
"text": "Inadequate heating or cooling—e.g., too hot in summer, too cold in winter",
"prefix": "c",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-condition-of-home-environment"
},
{
"linkId": "S1d",
"text": "Lack of personal safety—e.g., fear of violence; safety problem in going to mailbox or visiting neighbours; heavy traffic in street",
"prefix": "d",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-condition-of-home-environment"
},
{
"linkId": "S1e",
"text": "Limited access to home or rooms in home—e.g., difficulty entering or leaving home; unable to climb stairs",
"prefix": "e",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-condition-of-home-environment"
}
]
}
]
},
{
"linkId": "T",
"text": "SECTION T. DIAGNOSTIC AND OTHER HEALTH INFORMATION",
"type": "group",
"item": [
{
"linkId": "T1",
"text": "RESULTS FROM PRIOR TEST OF INTELLECTUAL FUNCTIONING",
"prefix": "1.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-intellectual-functioning"
},
{
"linkId": "T2",
"text": "PROVISIONAL DIAGNOSTIC CATEGORY (EXAMPLE—CANADA)",
"prefix": "2.",
"type": "group",
"item": [
{
"linkId": "T2a",
"text": "Autism spectrum disorder",
"prefix": "a",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2b",
"text": "Substance-related and addictive disorders",
"prefix": "b",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2c",
"text": "Schizophrenia and other psychotic disorders",
"prefix": "c",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2d",
"text": "Bipolar and related disorders",
"prefix": "d",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2e",
"text": "Depressive disorders",
"prefix": "e",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2f",
"text": "Anxiety disorders—e.g., social, separation, and generalized anxiety",
"type": "choice",
"required": false,
"prefix": "f",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2g",
"text": "Obsessive-compulsive and related disorders",
"type": "choice",
"required": false,
"prefix": "g",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2h",
"text": "Sleep and wake disorders",
"type": "choice",
"required": false,
"prefix": "h",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2i",
"text": "Reactive attachment disorder",
"type": "choice",
"required": false,
"prefix": "i",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2j",
"text": "Adjustment disorders",
"type": "choice",
"required": false,
"prefix": "j",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2k",
"text": "Attention deficit hyperactivity disorder",
"type": "choice",
"required": false,
"prefix": "k",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2l",
"text": "Learning disorders",
"type": "choice",
"required": false,
"prefix": "l",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2m",
"text": "Communication disorders",
"type": "choice",
"required": false,
"prefix": "m",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2n",
"text": "Intellectual disabilities",
"type": "choice",
"required": false,
"prefix": "n",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2o",
"text": "Oppositional, impulse-control, and conduct disorders",
"type": "choice",
"required": false,
"prefix": "o",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2p",
"text": "Feeding and eating disorders",
"type": "choice",
"required": false,
"prefix": "p",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
},
{
"linkId": "T2q",
"text": "Motor disorders—e.g. developmental coordination disorder, tic disorder",
"type": "choice",
"required": false,
"prefix": "q",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-ranking-of-diagnosis"
}
]
},
{
"linkId": "T3",
"text": "MEDICAL DIAGNOSES",
"prefix": "3.",
"type": "group",
"item": [
{
"linkId": "T3a",
"text": "Asthma",
"type": "choice",
"required": false,
"prefix": "a",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"linkId": "T3b",
"text": "Diabetes mellitus",
"type": "choice",
"required": false,
"prefix": "b",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"linkId": "T3c",
"text": "Epilepsy or seizure disorders",
"type": "choice",
"required": false,
"prefix": "c",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"linkId": "T3d",
"text": "Fetal alcohol effects/syndrome",
"type": "choice",
"required": false,
"prefix": "d",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"linkId": "T3e",
"text": "Migraine",
"type": "choice",
"required": false,
"prefix": "e",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"linkId": "T3f",
"text": "Traumatic brain injury",
"type": "choice",
"required": false,
"prefix": "f",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"linkId": "T3g",
"text": "Severe (anaphylactic) allergy—EXCLUDE MEDICATION ALLERGIES",
"type": "choice",
"required": false,
"prefix": "g",
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"linkId": "T3h",
"text": "Other Medical diagnoses",
"type": "group",
"repeats": true,
"item": [
{
"linkId": "T3ha",
"text": "Disease Name",
"type": "string",
"required": false
},
{
"linkId": "T3hb",
"definition": "http://cihi.ca/fhir/irrs/StructureDefinition/irrs-question-list#QuestionList.iI2aa",
"text": "Disease Code",
"type": "choice",
"required": false,
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
},
{
"linkId": "T3hc",
"definition": "http://cihi.ca/fhir/irrs/StructureDefinition/irrs-question-list#QuestionList.iI2abb",
"text": "Disease Diagnoses ICD-10-CA",
"type": "choice",
"required": false,
"answerValueSet": "http://cihi.ca/fhir/ValueSet/icd-10-ca"
}
]
}
]
},
{
"linkId": "T4",
"text": "HISTORY OF CONCUSSIONS",
"prefix": "4.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-history-of-concussion"
},
{
"linkId": "T5",
"text": "TIME NEEDED TO RECOVER FROM ANY CONCUSSION",
"prefix": "5.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-concussion-recovery-time"
}
]
},
{
"linkId": "U",
"text": "SECTION U. SERVICE TERMINATION",
"type": "group",
"item": [
{
"linkId": "U1",
"text": "HOW LONG CHILD/YOUTH IS EXPECTED TO RECEIVE SERVICES FROM THIS AGENCY (count from assessment reference date, including that day)",
"prefix": "1.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-length-expected-to-receive-services"
},
{
"linkId": "U2",
"text": "COMPLETION OF ADOLESCENT SUPPLEMENT—UNDER 12 YEARS\nFor children under 12 years, indicate whether the Adolescent Supplement is completed with the assessment",
"prefix": "2.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "U3",
"text": "RESOURCES KNOWN TO BE AVAILABLE UPON DISCHARGE",
"prefix": "3.",
"type": "group",
"item": [
{
"linkId": "U3a",
"text": "Formal mental health treatment—e.g., psychiatrist, social worker",
"prefix": "a",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-refused-not-needed"
},
{
"linkId": "U3b",
"text": "Formal case coordination services—EXCLUDE SCHOOL",
"prefix": "b",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-refused-not-needed"
},
{
"linkId": "U3c",
"text": "School resources—e.g., behaviour support plan",
"prefix": "c",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-refused-not-needed"
}
]
}
]
},
{
"linkId": "V",
"text": "SECTION V. DISCHARGE",
"type": "group",
"item": [
{
"linkId": "V1",
"text": "LAST DAY OF INVOLVEMENT WITH PROGRAM OR AGENCY",
"prefix": "1.",
"type": "date",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
}
]
},
{
"linkId": "V2",
"text": "DISCHARGED TO [EXAMPLE—CANADA]",
"prefix": "2.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-service-delivery-location-role-type"
},
{
"linkId": "V3",
"text": "LIVING ARRANGEMENT AT DISCHARGE",
"prefix": "3.",
"type": "choice",
"required": false,
"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"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-living-arrangement1"
},
{
"linkId": "V4",
"text": "DEGREE TO WHICH CLINICIAN FEELS THE FAMILY’S GOALS OF CARE WERE MET\nBased on clinical judgment of the child/youth’s case, please indicate the degree to which the family’s goals of care were met",
"prefix": "4.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-clinician-feels-family-goals-met"
},
{
"linkId": "V5a",
"text": "Reduction in severity of needs or symptoms",
"prefix": "5a.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "V5b",
"text": "Improvement in functioning/enhanced strengths",
"prefix": "5b.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "V5c",
"text": "Majority (more than 50%) of treatment goals successfully attained",
"prefix": "5c.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "V5d",
"text": "Child/youth or caregiver concur outcome is positive",
"prefix": "5d.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "W",
"text": "SECTION W. ASSESSMENT INFORMATION",
"type": "group",
"item": [
{
"linkId": "W1",
"text": "SIGNATURE OF PERSON COORDINATING/COMPLETING THE ASSESSMENT",
"prefix": "1.",
"type": "string",
"required": false
},
{
"linkId": "W2",
"text": "DATE ASSESSMENT SIGNED AS COMPLETE",
"prefix": "2.",
"type": "date",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
}
]
},
{
"linkId": "W3",
"text": "SOURCES OF INFORMATION USED TO COMPLETE ASSESSMENT",
"prefix": "3.",
"type": "group",
"item": [
{
"linkId": "W3a",
"text": "Client",
"prefix": "a",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"linkId": "W3b",
"text": "Parent/primary caregiver",
"prefix": "b",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"linkId": "W3c",
"text": "Other relative",
"prefix": "c",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"linkId": "W3d",
"text": "Physician",
"prefix": "d",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"linkId": "W3e",
"text": "Staff at school",
"prefix": "e",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"linkId": "W3f",
"text": "Other (specify)",
"prefix": "f",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
}
]
},
{
"linkId": "W4",
"text": "TYPE OF COMMUNICATION USED TO COMPLETE ASSESSMENT",
"prefix": "4.",
"type": "group",
"item": [
{
"linkId": "W4a",
"text": "Telephone",
"prefix": "a.",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "W4b",
"text": "In person",
"prefix": "b",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "W4c",
"text": "Fax/written/e-mail",
"prefix": "c",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "W4d",
"text": "Videoconferencing",
"prefix": "d",
"type": "choice",
"required": false,
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
]
}
}
],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
}
]
}
]
}