FHIR IG analytics| Package | ca.on.oh.setp.iar.dev |
| Resource Type | Questionnaire |
| Id | Questionnaire-iar-interrai-contact-assessment-v1.0.0.json |
| FHIR Version | R4 |
No resources found
No resources found
No narrative content found in resource
FHIR
FHIRsmith{
"resourceType": "Questionnaire",
"id": "questionnaire-iar-interrai-contact-assessment-0.1.0",
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-entryMode",
"valueCode": "random"
}
],
"url": "http://ontariohealth.ca/fhir/iar/Questionnaire/oh-interrai-contact-assessment",
"version": "10.0.1_OH",
"title": "interRAI™ Contact Assessment (CA) 10.0.1_OH",
"_title": {
"extension": [
{
"url": "http://ontariohealth.ca/fhir/questionnaire/StructureDefinition/core-short-string",
"valueString": "interRAI Contact Assessment"
}
]
},
"description": "This is the interRAI™ Contact Assessment (CA) Form, version 10.0 – CIHI Canadian Standard. A screening-level assessment used for intake into home and community care. The core content was developed by interRAI, adapted by the Canadian Institute for Health Information (CIHI) and modified by OntarioHealth. The FHIR artifact is maintained and published by Ontario Health.",
"_description": {
"extension": [
{
"url": "http://ontariohealth.ca/fhir/questionnaire/StructureDefinition/core-short-string",
"valueString": "interRAI Contact Assessment 10.0.1_OH"
}
]
},
"status": "draft",
"experimental": true,
"date": "2026-01-01",
"publisher": "Ontario Health",
"approvalDate": "2026-01-01",
"effectivePeriod": {
"start": "2026-10-01"
},
"subjectType": [
"Patient"
],
"code": [
{
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/assessment-form-type",
"code": "INTERRAICA",
"display": "interRAI™ Contact Assessment"
}
],
"item": [
{
"linkId": "A",
"text": "Section A. Demographic Information",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section A. Demographic Information</b>"
}
]
},
"item": [
{
"linkId": "A1",
"text": "1. NAME",
"type": "group",
"item": [
{
"type": "string",
"linkId": "A1a",
"text": "a. Given name"
},
{
"type": "string",
"linkId": "A1b",
"text": "b. Middle initial"
},
{
"type": "string",
"linkId": "A1c",
"text": "c. Family name"
}
]
},
{
"linkId": "A2",
"text": "2. SEX / GENDER IDENTITY",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "A2a",
"text": "a. Sex",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/sex",
"code": "F",
"display": "Female"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/sex",
"code": "M",
"display": "Male"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/sex",
"code": "UN",
"display": "Not assigned male or female"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "A2b",
"text": "b. Gender identity",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/gender-identity",
"code": "M",
"display": "Male"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/gender-identity",
"code": "F",
"display": "Female"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/gender-identity",
"code": "OTH",
"display": "Other gender identity"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/gender-identity",
"code": "UNK",
"display": "Not known"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/gender-identity",
"code": "NA",
"display": "Not applicable"
}
}
]
},
{
"type": "string",
"linkId": "A2c",
"text": "c. Person self-identifies gender as"
}
]
},
{
"type": "date",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
}
],
"linkId": "A3",
"text": "3. BIRTHDATE"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "A4",
"text": "4. MARITAL STATUS",
"answerOption": [
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "1",
"display": "Never married"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "2",
"display": "Married"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "3",
"display": "Partner/significant other"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "4",
"display": "Widowed"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "5",
"display": "Separated"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"code": "6",
"display": "Divorced"
}
}
]
},
{
"linkId": "A5",
"text": "5. NUMERIC IDENTIFIERS",
"type": "group",
"item": [
{
"type": "string",
"linkId": "A5a",
"text": "a. Healthcare Identification Number"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "A5b",
"text": "b. Province or territory issuing Healthcare Identification Number",
"answerOption": [
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"code": "NA",
"display": "not applicable"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"code": "UNK",
"display": "unknown"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "AB",
"display": "Alberta"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "BC",
"display": "British Columbia"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "MB",
"display": "Manitoba"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "NB",
"display": "New Brunswick"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "NL",
"display": "Newfoundland and Labrador"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "NT",
"display": "Northwest Territories"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "NS",
"display": "Nova Scotia"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "NU",
"display": "Nunavut"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "ON",
"display": "Ontario"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "PE",
"display": "Prince Edward Island"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "QC",
"display": "Quebec"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "SK",
"display": "Saskatchewan"
}
},
{
"valueCoding": {
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"code": "YT",
"display": "Yukon"
}
}
]
},
{
"type": "string",
"linkId": "A5c",
"maxLength": 15,
"text": "c. Case record number"
}
]
},
{
"type": "string",
"linkId": "A6",
"maxLength": 6,
"text": "6. POSTAL CODE OF USUAL LIVING ARRANGEMENT"
},
{
"type": "string",
"linkId": "A7",
"maxLength": 6,
"text": "7. AGENCY IDENTIFIER"
},
{
"linkId": "A8",
"text": "8. INDIGENOUS IDENTITY - Person identifies as First Nations, Métis, or Inuit",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
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"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "A8a",
"text": "a. First Nations",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
},
{
"type": "choice",
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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"display": "Drop down"
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]
}
}
],
"linkId": "A8b",
"text": "b. Métis",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
},
{
"type": "choice",
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{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "A8c",
"text": "c. Inuit",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
}
]
},
{
"type": "choice",
"extension": [
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "A9",
"text": "9. PRIMARY LANGUAGE",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/languages",
"code": "eng",
"display": "English"
}
},
{
"valueCoding": {
"code": "fra",
"display": "French"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "A10",
"text": "10. INTERPRETER NEEDED",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
},
{
"type": "string",
"linkId": "A11",
"text": "11. REASONS FOR REFERRAL"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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"display": "Drop down"
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}
}
],
"linkId": "A12",
"text": "12. LOCATION OF ASSESSMENT",
"answerOption": [
{
"valueCoding": {
"code": "1",
"display": "Community"
}
},
{
"valueCoding": {
"code": "2",
"display": "Hospital (excluding emergency department)"
}
},
{
"valueCoding": {
"code": "3",
"display": "Emergency department"
}
},
{
"valueCoding": {
"code": "4",
"display": "Other"
}
}
]
}
]
},
{
"linkId": "B",
"text": "Section B. Intake and Initial History ",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section B. Intake and Initial History </b>"
}
]
},
"item": [
{
"type": "date",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
}
],
"linkId": "B1",
"text": "1. ASSESSMENT REFERENCE DATE"
},
{
"linkId": "B2",
"text": "2. REFERRAL DETAILS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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"code": "drop-down",
"display": "Drop down"
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]
}
}
],
"linkId": "B2a",
"text": "a. Time frame for initiation of ordered treatments in community",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not ordered"
}
},
{
"valueCoding": {
"code": "1",
"display": "Treatment already initiated in community"
}
},
{
"valueCoding": {
"code": "2",
"display": "48 hours or more"
}
},
{
"valueCoding": {
"code": "3",
"display": "24 to less than 48 hours"
}
},
{
"valueCoding": {
"code": "4",
"display": "12 to less than 24 hours"
}
},
{
"valueCoding": {
"code": "5",
"display": "Less than 12 hours"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
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"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "B2a.a",
"text": "a. Administration of medication (other than IV)",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not ordered"
}
},
{
"valueCoding": {
"code": "1",
"display": "Treatment already initiated in community"
}
},
{
"valueCoding": {
"code": "2",
"display": "48 hours or more"
}
},
{
"valueCoding": {
"code": "3",
"display": "24 to less than 48 hours"
}
},
{
"valueCoding": {
"code": "4",
"display": "12 to less than 24 hours"
}
},
{
"valueCoding": {
"code": "5",
"display": "Less than 12 hours"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B2a.b",
"text": "b. Indwelling catheter",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not ordered"
}
},
{
"valueCoding": {
"code": "1",
"display": "Treatment already initiated in community"
}
},
{
"valueCoding": {
"code": "2",
"display": "48 hours or more"
}
},
{
"valueCoding": {
"code": "3",
"display": "24 to less than 48 hours"
}
},
{
"valueCoding": {
"code": "4",
"display": "12 to less than 24 hours"
}
},
{
"valueCoding": {
"code": "5",
"display": "Less than 12 hours"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B2a.c",
"text": "c. IV therapy",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not ordered"
}
},
{
"valueCoding": {
"code": "1",
"display": "Treatment already initiated in community"
}
},
{
"valueCoding": {
"code": "2",
"display": "48 hours or more"
}
},
{
"valueCoding": {
"code": "3",
"display": "24 to less than 48 hours"
}
},
{
"valueCoding": {
"code": "4",
"display": "12 to less than 24 hours"
}
},
{
"valueCoding": {
"code": "5",
"display": "Less than 12 hours"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "B2a.d",
"text": "d. Wound care",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not ordered"
}
},
{
"valueCoding": {
"code": "1",
"display": "Treatment already initiated in community"
}
},
{
"valueCoding": {
"code": "2",
"display": "48 hours or more"
}
},
{
"valueCoding": {
"code": "3",
"display": "24 to less than 48 hours"
}
},
{
"valueCoding": {
"code": "4",
"display": "12 to less than 24 hours"
}
},
{
"valueCoding": {
"code": "5",
"display": "Less than 12 hours"
}
}
]
},
{
"type": "string",
"linkId": "B2a.e",
"text": "e. Other (specify)"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
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"display": "Drop down"
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]
}
}
],
"linkId": "B2b",
"text": "b. Referral to initiate or continue rehabilitation services",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "B2c",
"text": "c. Referral to initiate or continue palliative services",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "B3",
"text": "3. EXPECTED LIVING ARRANGEMENT DURING SERVICE PROVISION",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/living-arrangement",
"code": "1",
"display": "Alone"
}
},
{
"valueCoding": {
"code": "2",
"display": "With spouse / partner only"
}
},
{
"valueCoding": {
"code": "3",
"display": "With spouse / partner and other(s)"
}
},
{
"valueCoding": {
"code": "4",
"display": "With child (not spouse / partner)"
}
},
{
"valueCoding": {
"code": "5",
"display": "With parent(s) or guardian(s)"
}
},
{
"valueCoding": {
"code": "6",
"display": "With sibling(s)"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/living-arrangement",
"code": "7",
"display": "With other relative(s)"
}
},
{
"valueCoding": {
"code": "8",
"display": "With nonrelative(s)"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "B4",
"text": "4. EXPECTED RESIDENTIAL / LIVING STATUS DURING SERVICE PROVISION",
"answerOption": [
{
"valueCoding": {
"code": "1",
"display": "Private home / apartment / rented room"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"code": "2",
"display": "Board and care"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"code": "3",
"display": "Assisted living or semi-independent living"
}
},
{
"valueCoding": {
"code": "4",
"display": "Mental health residence - e.g. psychiatric group home"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"code": "5",
"display": "Group home for persons with physical disability"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"code": "6",
"display": "Setting for persons with intellectual disability"
}
},
{
"valueCoding": {
"code": "7",
"display": "Psychiatric hospital / unit"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"code": "8",
"display": "Homeless (with or without shelter)"
}
},
{
"valueCoding": {
"code": "9",
"display": "Residential care facility (e.g. long-term care home"
}
},
{
"valueCoding": {
"code": "10",
"display": "Rehabilitation hospital / unit"
}
},
{
"valueCoding": {
"code": "11",
"display": "Hospice facility / palliative care unit"
}
},
{
"valueCoding": {
"code": "12",
"display": "Acute care hospital / unit"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"code": "13",
"display": "Correctional facility"
}
},
{
"valueCoding": {
"code": "14",
"display": "Continuing care hospital / unit"
}
},
{
"valueCoding": {
"code": "15",
"display": "Other"
}
}
]
}
]
},
{
"linkId": "C",
"text": "Section C. Preliminary Screener",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section C. Preliminary Screener</b>"
}
]
},
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C1",
"text": "1. 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",
"answerOption": [
{
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"display": "Independent - Decisions consistent reasonable"
}
},
{
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"display": "Some but not severe impairment"
}
},
{
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"display": "Severely impaired - Never or rarely makes decisions"
}
}
]
},
{
"linkId": "C2",
"text": "2. ACTIVITIES OF DAILY LIVING (ADL) SELF-PERFORMANCE - Most dependent episode over last 24 hours. If ADL did not occur in last 24 hours, code the most recent occurrence.",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C2a",
"text": "a. Bathing - How takes a full-body bath / shower. Includes how each part of body is bathed: arms, upper and lower legs, chest, abdomen, perineal area — EXCLUDE WASHING OF BACK AND HAIR, AS WELL AS TRANSFER IN/OUT OF BATH OR SHOWER",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C2b",
"text": "b. Bath transfer - How person transfers in/out of bath or shower",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C2c",
"text": "c. Personal hygiene - How manages personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing and drying face and hands — EXCLUDE BATHS AND SHOWERS.",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C2d",
"text": "d. Dressing lower body - How dresses and undresses (street clothes, underwear) from the waist down, including prostheses, orthotics, belts, pants, skirts, shoes, fasteners, etc.",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C2e",
"text": "e. Locomotion - How moves between locations on same floor (walking or wheeling). If in wheelchair, self-sufficiency once in chair.",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C3",
"text": "3. DYSPNEA (Shortness of Breath)",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/presence-of-symptom",
"code": "0",
"display": "Absence of symptom"
}
},
{
"valueCoding": {
"code": "1",
"display": "Absent at rest but present when performed moderate activities"
}
},
{
"valueCoding": {
"code": "2",
"display": "Absent at rest but present when performed normal day-to-day activities"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/presence-of-symptom",
"code": "3",
"display": "Present at rest"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C4",
"text": "4. SELF-REPORTED HEALTH (Ask: In general, how would you rate your health?)",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Excellent"
}
},
{
"valueCoding": {
"code": "1",
"display": "Good"
}
},
{
"valueCoding": {
"code": "2",
"display": "Fair"
}
},
{
"valueCoding": {
"code": "3",
"display": "Poor"
}
},
{
"valueCoding": {
"code": "8",
"display": "Person could not (would not) respond"
}
}
]
},
{
"linkId": "C5",
"text": "5. SELF-REPORTED MOOD (Ask: “In the last 3 days, how often have you felt . . .”)",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C5a",
"text": "a. Little interest or pleasure in things you normally enjoy?",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not in last 3 days"
}
},
{
"valueCoding": {
"code": "1",
"display": "Not in last 3 days but often feels that way"
}
},
{
"valueCoding": {
"code": "2",
"display": "In 1-2 of last 3 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C5b",
"text": "b. Anxious, restless, or uneasy?",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not in last 3 days"
}
},
{
"valueCoding": {
"code": "1",
"display": "Not in last 3 days but often feels that way"
}
},
{
"valueCoding": {
"code": "2",
"display": "In 1-2 of last 3 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C5c",
"text": "c. Sad, depressed, or hopeless?",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not in last 3 days"
}
},
{
"valueCoding": {
"code": "1",
"display": "Not in last 3 days but often feels that way"
}
},
{
"valueCoding": {
"code": "2",
"display": "In 1-2 of last 3 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
}
]
}
]
},
{
"linkId": "C6",
"text": "6. INSTABILITY OF CONDITIONS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C6a",
"text": "a. Conditions/diseases make cognitive, ADL, mood, or behaviour patterns unstable",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C6b",
"text": "b. Experiencing an acute episode or a flare-up of a recurrent or chronic problem",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "C7",
"text": "7. HOME CARE OR COMMUNITY SUPPORT SERVICES MAY BE REQUIRED FOR THIS PERSON",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
}
]
},
{
"linkId": "D",
"text": "Section D. Clinical Evaluation",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section D. Clinical Evaluation</b>"
}
]
},
"enableBehavior": "any",
"enableWhen": [
{
"question": "C1",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"code": "1"
}
},
{
"question": "C1",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"code": "2"
}
},
{
"question": "C2a",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2a",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2b",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2b",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2c",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2c",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2d",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2d",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2e",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2e",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C3",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea",
"code": "2"
}
},
{
"question": "C3",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea",
"code": "3"
}
},
{
"question": "C4",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health",
"code": "3"
}
},
{
"question": "C4",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health",
"code": "8"
}
},
{
"question": "C5a",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C5b",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C5c",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C6a",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no",
"code": "1"
}
},
{
"question": "C7",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no",
"code": "1"
}
}
],
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D1",
"text": "1. CHANGE IN DECISION MAKING AS COMPARED TO 90 DAYS AGO (OR SINCE LAST ASSESSMENT IF LESS THAN 90 DAYS AGO)",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"code": "0",
"display": "Improved"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"code": "1",
"display": "No change"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"code": "2",
"display": "Declined"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"code": "8",
"display": "Uncertain"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D2",
"text": "2. ABILITY TO UNDERSTAND OTHERS (Comprehension) - Understanding information content (however able; with hearing or other assistive devices normally used)",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Understands - Clear comprehension"
}
},
{
"valueCoding": {
"code": "1",
"display": "Usually understands - Misses some part/intent of message BUT comprehends most conversation"
}
},
{
"valueCoding": {
"code": "2",
"display": "Often understands - Misses some part/intent of message BUT with repetition or explanation can often comprehend conversation"
}
},
{
"valueCoding": {
"code": "3",
"display": "Sometimes understands - Responds adequately to simple direct communication only"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/understanding-other",
"code": "4",
"display": "Rarely or never understands"
}
}
]
},
{
"linkId": "D3",
"text": "3. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) CAPACITY",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3a",
"text": "a. Meal preparation — How prepares meals (e.g., planning meals, assembling ingredients, cooking, setting out food and utensils)",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3b",
"text": "b. Ordinary housework — How performs ordinary work around the house (e.g., doing dishes, dusting, making bed, tidying up, laundry)",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3c",
"text": "c. .Manage medications — How medications are managed (e.g., remembering to take medications, opening bottles, taking correct drug dosages, giving injections, applying ointments)",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3d",
"text": "d. Stairs — How manages full flight of stairs (e.g., 12–14 stairs)",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3e",
"text": "e. Shopping — How performs in-store shopping for food and household items (e.g., selecting items, paying money) — EXCLUDE TRANSPORTATION OR USE OF GROCERY DELIVERY SERVICES",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D3f",
"text": "f. Transportation — How travels by paid transportation (e.g., navigating bus system, paying taxi fare) or driving self (including getting out of house, into and out of vehicles)",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
},
{
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
},
{
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
}
]
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D4",
"text": "4. CHANGE IN ADL STATUS AS COMPARED TO 90 DAYS AGO (OR SINCE LAST ASSESSMENT IF LESS THAN 90 DAYS AGO)",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"code": "0",
"display": "Improved"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"code": "1",
"display": "No change"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"code": "2",
"display": "Declined"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"code": "8",
"display": "Uncertain"
}
}
]
},
{
"linkId": "D5",
"text": "5. DISEASE DIAGNOSES",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5a",
"text": "a. Alzheimer\"s disease",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
},
{
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
},
{
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5b",
"text": "b. Dementia other than Alzheimer\"s disease",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
},
{
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
},
{
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5c",
"text": "c. Stroke",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
},
{
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
},
{
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5d",
"text": "d. Coronary heart disease",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
},
{
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
},
{
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5e",
"text": "e. Chronic obstructive pulmonary disease",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
},
{
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
},
{
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5f",
"text": "f. Congestive heart failure",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
},
{
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
},
{
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5g",
"text": "g. Cancer",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
},
{
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
},
{
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5h",
"text": "h. Diabetes",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
},
{
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
},
{
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
}
]
},
{
"linkId": "D5i",
"text": "Other disease diagnoses",
"type": "group",
"repeats": true,
"item": [
{
"type": "string",
"linkId": "D5ia",
"text": "Diagnosis"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5ib",
"text": "Diagnosis Code",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/sex"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D5ic",
"text": "ICD-10-CA Code",
"answerValueSet": "http://fhir.infoway-inforoute.ca/io/cacore/ValueSet/ICD10CA"
}
]
}
]
},
{
"linkId": "D6",
"text": "6. FALLS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D6a",
"text": "a. Last 30 days",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No fall"
}
},
{
"valueCoding": {
"code": "1",
"display": "1 fall"
}
},
{
"valueCoding": {
"code": "2",
"display": "2 or more falls"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D6b",
"text": "b. 31-90 days",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No fall"
}
},
{
"valueCoding": {
"code": "1",
"display": "1 fall"
}
},
{
"valueCoding": {
"code": "2",
"display": "2 or more falls"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D6c",
"text": "c. 91-180 days",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No fall"
}
},
{
"valueCoding": {
"code": "1",
"display": "1 fall"
}
},
{
"valueCoding": {
"code": "2",
"display": "2 or more falls"
}
}
]
}
]
},
{
"linkId": "D7",
"text": "7. PROBLEM FREQUENCY",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D7a",
"text": "a. Dizziness",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Present but not exhibited in last 3 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "Exhibited on 1 of last 3 days"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "3",
"display": "Exhibited on 2 of last 3 days"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-two",
"code": "4",
"display": "Exhibited daily in last 3 days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D7b",
"text": "b. Chest pain",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Present but not exhibited in last 3 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "Exhibited on 1 of last 3 days"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "3",
"display": "Exhibited on 2 of last 3 days"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-two",
"code": "4",
"display": "Exhibited daily in last 3 days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D7c",
"text": "c. Peripheral edema",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Present but not exhibited in last 3 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "Exhibited on 1 of last 3 days"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "3",
"display": "Exhibited on 2 of last 3 days"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-two",
"code": "4",
"display": "Exhibited daily in last 3 days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D7d",
"text": "d. Vomiting",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "0",
"display": "Not present"
}
},
{
"valueCoding": {
"code": "1",
"display": "Present but not exhibited in last 3 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "Exhibited on 1 of last 3 days"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"code": "3",
"display": "Exhibited on 2 of last 3 days"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-two",
"code": "4",
"display": "Exhibited daily in last 3 days"
}
}
]
}
]
},
{
"linkId": "D8",
"text": "8. PAIN SYMPTOMS [Note: Always ask the person about pain frequency and intensity. Observe person and ask others who are in contact with the person.]",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D8a",
"text": "a. Frequency with which person complains or shows evidence of pain (including grimacing, teeth clenching, moaning, withdrawal when touched, or other nonverbal signs suggesting pain)",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"code": "0",
"display": "No pain"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"code": "1",
"display": "Mild"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"code": "2",
"display": "Moderate"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"code": "3",
"display": "Severe"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"code": "4",
"display": "Times when pain is horrible or excruciating"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D8b",
"text": "b. Intensity of highest level of pain present",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"code": "0",
"display": "No pain"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"code": "1",
"display": "Mild"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"code": "2",
"display": "Moderate"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"code": "3",
"display": "Severe"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"code": "4",
"display": "Times when pain is horrible or excruciating"
}
}
]
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D9",
"text": "9. SMOKES TOBACCO DAILY",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-of-smoking",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"code": "1",
"display": "Not in last 3 days but is usually a daily smoker"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-of-smoking",
"code": "2",
"display": "Yes"
}
}
]
},
{
"linkId": "D10",
"text": "10. NUTRITIONAL ISSUES",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D10a",
"text": "a. In LAST 3 DAYS, noticeable decrease in the amount of food usually eaten or fluids usually consumed",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D10b",
"text": "b. Weight loss of 5% or more in LAST 30 DAYS or 10% or more in LAST 180 DAYS",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D10c",
"text": "c. Special diet",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D11",
"text": "11. PRESENCE OF PRESSURE ULCER / INJURY",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No pressure ulcer"
}
},
{
"valueCoding": {
"code": "1",
"display": "Any area of persistent skin redness"
}
},
{
"valueCoding": {
"code": "2",
"display": "Any break in skin integrity (e.g. partial loss of skin layers breaks in skin exposing muscle or bone)"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D12",
"text": "12. MAJOR SKIN PROBLEMS - e.g., lesions, 2nd- or 3rd-degree burns, healing surgical wounds",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D13",
"text": "13. TRAUMATIC INJURY - traumatic injury that has a major effect on the care required (e.g., fracture, major physical injury resulting from assault or motor vehicle accident)",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
},
{
"linkId": "D14",
"text": "14. TREATMENTS - Treatments received or scheduled in LAST 3 DAYS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D14a",
"text": "a. Indwelling catheter",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not ordered AND did not occur"
}
},
{
"valueCoding": {
"code": "1",
"display": "Ordered not implemented"
}
},
{
"valueCoding": {
"code": "2",
"display": "1-2 of last 3 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D14b",
"text": "b. IV therapy",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not ordered AND did not occur"
}
},
{
"valueCoding": {
"code": "1",
"display": "Ordered not implemented"
}
},
{
"valueCoding": {
"code": "2",
"display": "1-2 of last 3 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D14c",
"text": "c. Oxygen therapy",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not ordered AND did not occur"
}
},
{
"valueCoding": {
"code": "1",
"display": "Ordered not implemented"
}
},
{
"valueCoding": {
"code": "2",
"display": "1-2 of last 3 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D14d",
"text": "d. Ventilator",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not ordered AND did not occur"
}
},
{
"valueCoding": {
"code": "1",
"display": "Ordered not implemented"
}
},
{
"valueCoding": {
"code": "2",
"display": "1-2 of last 3 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D14e",
"text": "e. Wound care",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not ordered AND did not occur"
}
},
{
"valueCoding": {
"code": "1",
"display": "Ordered not implemented"
}
},
{
"valueCoding": {
"code": "2",
"display": "1-2 of last 3 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
}
]
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D15",
"text": "15. TIME SINCE LAST HOSPITAL STAY",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No hospitalization within 90 days"
}
},
{
"valueCoding": {
"code": "1",
"display": "31-90 days ago"
}
},
{
"valueCoding": {
"code": "2",
"display": "15-30 days ago"
}
},
{
"valueCoding": {
"code": "3",
"display": "8-14 days ago"
}
},
{
"valueCoding": {
"code": "4",
"display": "In last 7 days"
}
},
{
"valueCoding": {
"code": "5",
"display": "Now in hospital"
}
}
]
},
{
"type": "string",
"linkId": "D16",
"text": "16. EMERGENCY DEPARTMENT VISIT"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D17",
"text": "17. SURGERY IN LAST 90 DAYS",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"code": "1",
"display": "Yes without general anesthesia"
}
},
{
"valueCoding": {
"code": "2",
"display": "Yes with general anesthesia"
}
}
]
},
{
"linkId": "D18",
"text": "18. TWO KEY INFORMAL HELPERS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D18a.1",
"text": "a.1. Helper 1 - Relationship to person",
"answerOption": [
{
"valueCoding": {
"code": "1",
"display": "Child or child-in-law"
}
},
{
"valueCoding": {
"code": "2",
"display": "Spouse"
}
},
{
"valueCoding": {
"code": "3",
"display": "Partner/significant other"
}
},
{
"valueCoding": {
"code": "4",
"display": "Parent/guardian"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-relationship",
"code": "5",
"display": "Sibling"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-relationship",
"code": "6",
"display": "Other relative"
}
},
{
"valueCoding": {
"code": "7",
"display": "Friend"
}
},
{
"valueCoding": {
"code": "8",
"display": "Neighbour"
}
},
{
"valueCoding": {
"code": "9",
"display": "No informal helper"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D18a.2",
"text": "a.2. Helper 2 - Relationship to person",
"answerOption": [
{
"valueCoding": {
"code": "1",
"display": "Child or child-in-law"
}
},
{
"valueCoding": {
"code": "2",
"display": "Spouse"
}
},
{
"valueCoding": {
"code": "3",
"display": "Partner/significant other"
}
},
{
"valueCoding": {
"code": "4",
"display": "Parent/guardian"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-relationship",
"code": "5",
"display": "Sibling"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-relationship",
"code": "6",
"display": "Other relative"
}
},
{
"valueCoding": {
"code": "7",
"display": "Friend"
}
},
{
"valueCoding": {
"code": "8",
"display": "Neighbour"
}
},
{
"valueCoding": {
"code": "9",
"display": "No informal helper"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D18b.1",
"text": "b.1. Helper 1 - Lives with person",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-lives-with-child-youth",
"code": "1",
"display": "Yes, 6 months or less"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-lives-with-child-youth",
"code": "2",
"display": "Yes, more than 6 months"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D18b.2",
"text": "b.2. Helper 2 - Lives with person",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-lives-with-child-youth",
"code": "1",
"display": "Yes, 6 months or less"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-lives-with-child-youth",
"code": "2",
"display": "Yes, more than 6 months"
}
}
]
}
]
},
{
"linkId": "D19",
"text": "19. INFORMAL HELPER STATUS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D19a",
"text": "a. Primary informal helper expresses feelings of distress, anger, or depression",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D19b",
"text": "b. Family or close friends report feeling overwhelmed by person\"s illness",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D20",
"text": "20. DEGREE OF LONELINESS use self-report when possible (Ask: How often do you feel lonely?)",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not lonely"
}
},
{
"valueCoding": {
"code": "1",
"display": "Only in certain situations or triggered by specific events"
}
},
{
"valueCoding": {
"code": "2",
"display": "Occasionally (less than weekly)"
}
},
{
"valueCoding": {
"code": "3",
"display": "Frequently (weekly but less than daily)"
}
},
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "4",
"display": "Daily"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "D21",
"text": "21. FINANCES - Because of limited funds, during the last 30 days made trade-offs among purchasing any of the following: adequate food, shelter, clothing, prescribed medications, sufficient home heat or cooling, necessary health care",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "0",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"code": "1",
"display": "Yes"
}
}
]
}
]
},
{
"linkId": "E",
"text": "Section E. Summary",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section E. Summary</b>"
}
]
},
"item": [
{
"linkId": "E1-7",
"type": "group",
"enableBehavior": "any",
"enableWhen": [
{
"question": "C1",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"code": "1"
}
},
{
"question": "C1",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"code": "2"
}
},
{
"question": "C2a",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2a",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2b",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2b",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2c",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2c",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2d",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2d",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C2e",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "1"
}
},
{
"question": "C2e",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"code": "2"
}
},
{
"question": "C3",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea",
"code": "2"
}
},
{
"question": "C3",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea",
"code": "3"
}
},
{
"question": "C4",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health",
"code": "3"
}
},
{
"question": "C4",
"operator": "=",
"answerCoding": {
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health",
"code": "8"
}
},
{
"question": "C5a",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C5b",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C5c",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1",
"code": "3"
}
},
{
"question": "C6a",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no",
"code": "1"
}
},
{
"question": "C7",
"operator": "=",
"answerCoding": {
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no",
"code": "1"
}
}
],
"item": [
{
"linkId": "E1",
"text": "1. ALGORITHM SCORES - Record the computer-generated scores for each of the following",
"type": "group",
"item": [
{
"type": "integer",
"linkId": "E1a",
"text": "a. Assessment urgency (score 1 to 6)"
},
{
"type": "integer",
"linkId": "E1b",
"text": "b. Service urgency (score 1 to 4)"
},
{
"type": "integer",
"linkId": "E1c",
"text": "c. Rehabilitation (score 1 to 5)"
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E2",
"text": "2. EXPECTED LENGTH OF SERVICE",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not lonely"
}
},
{
"valueCoding": {
"code": "1",
"display": "Only in certain situations or triggered by specific events"
}
},
{
"valueCoding": {
"code": "2",
"display": "Occasionally (less than weekly)"
}
},
{
"valueCoding": {
"code": "3",
"display": "Frequently (weekly but less than daily)"
}
},
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "4",
"display": "Daily"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E3",
"text": "3. ASSESSMENT URGENCY - Urgency for comprehensive, face-to-face assessment",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "Not required"
}
},
{
"valueCoding": {
"code": "1",
"display": "More than 14 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "8-14 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "Within 7 days"
}
}
]
},
{
"linkId": "E4",
"text": "4. URGENCY OF NEEDED SERVICES",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4a",
"text": "a. Nursing",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No services"
}
},
{
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4b",
"text": "b. Personal support/household management",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No services"
}
},
{
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4c",
"text": "c. Physiotherapy",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No services"
}
},
{
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4d",
"text": "d. Occupational therapy",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No services"
}
},
{
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4e",
"text": "e. Dietitian services",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No services"
}
},
{
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4f",
"text": "f. Lab services, equipment, and medical supplies",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No services"
}
},
{
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4g",
"text": "g. Social work",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No services"
}
},
{
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E4h",
"text": "h. Speech-language therapy",
"answerOption": [
{
"valueCoding": {
"code": "0",
"display": "No services"
}
},
{
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
},
{
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
},
{
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
}
]
},
{
"type": "string",
"linkId": "E4i",
"text": "i. Other (specify)"
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E5",
"text": "5. CLIENT GROUP",
"answerOption": [
{
"valueCoding": {
"code": "1",
"display": "Acute"
}
},
{
"valueCoding": {
"code": "2",
"display": "End-of-life"
}
},
{
"valueCoding": {
"code": "3",
"display": "Rehabilitation"
}
},
{
"valueCoding": {
"code": "4",
"display": "Long-term supportive care"
}
},
{
"valueCoding": {
"code": "5",
"display": "Maintenance"
}
},
{
"valueCoding": {
"code": "6",
"display": "Assessment only no other home care services"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E6",
"text": "6. PRIMARY MODE OF ASSESSMENT",
"answerOption": [
{
"valueCoding": {
"code": "1",
"display": "In person"
}
},
{
"valueCoding": {
"code": "2",
"display": "Virtual conference with video"
}
},
{
"valueCoding": {
"code": "3",
"display": "Virtual conference audio only"
}
}
]
},
{
"linkId": "E7",
"text": "7. SOURCES OF INFORMATION USED TO COMPLETE THE interRAI CA (Code only ONE PRIMARY source and ALL APPLICABLE SECONDARY sources)",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7a",
"text": "a. Person",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"code": "0",
"display": "Not applicable"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary"
}
},
{
"valueCoding": {
"code": "2",
"display": "Secondary"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7b",
"text": "b. Spouse / partner",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"code": "0",
"display": "Not applicable"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary"
}
},
{
"valueCoding": {
"code": "2",
"display": "Secondary"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7c",
"text": "c. Parent/guardian",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"code": "0",
"display": "Not applicable"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary"
}
},
{
"valueCoding": {
"code": "2",
"display": "Secondary"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7d",
"text": "d. Child or child-in-law",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"code": "0",
"display": "Not applicable"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary"
}
},
{
"valueCoding": {
"code": "2",
"display": "Secondary"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7e",
"text": "e. Other relative",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"code": "0",
"display": "Not applicable"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary"
}
},
{
"valueCoding": {
"code": "2",
"display": "Secondary"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7f",
"text": "f. Friend or neighbour",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"code": "0",
"display": "Not applicable"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary"
}
},
{
"valueCoding": {
"code": "2",
"display": "Secondary"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7g",
"text": "g. Physician / physician assistant / nurse practitioner",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"code": "0",
"display": "Not applicable"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary"
}
},
{
"valueCoding": {
"code": "2",
"display": "Secondary"
}
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E7h",
"text": "h. Other home care / other health, or social service provider",
"answerOption": [
{
"valueCoding": {
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"code": "0",
"display": "Not applicable"
}
},
{
"valueCoding": {
"code": "1",
"display": "Primary"
}
},
{
"valueCoding": {
"code": "2",
"display": "Secondary"
}
}
]
}
]
}
]
},
{
"linkId": "E8",
"text": "8. SIGNATURE OF PERSON COORDINATING/COMPLETING THE ASSESSMENT",
"type": "group",
"item": [
{
"type": "text",
"linkId": "E8a",
"text": "a. Signature"
},
{
"type": "date",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
}
],
"linkId": "E8b",
"text": "b. Date assessment signed as complete"
}
]
}
]
}
]
}