| Package | fhir.r4.nhsengland.programme |
| Resource Type | Questionnaire |
| Id | NationalProxy-Questionnaire-ProxyAccessRequest-Example |
| FHIR Version | R4 |
| Source | https://simplifier.net/resolve?scope=fhir.r4.nhsengland.programme@0.2.2-pre-release&canonical=https://fhir.nhs.uk/England/Questionnaire/ProxyAccessRequest |
| URL | https://fhir.nhs.uk/England/Questionnaire/ProxyAccessRequest |
| Version | 0.0.1-current |
| Status | draft |
| Date | 2024-07-12 |
| Name | Consent |
| Title | Questionnaire Proxy Access Request |
| Realm | us |
| Authority | hl7 |
| Description | A form to request access to health and care services on behalf of someone else. |
| Purpose | Add someone to your NHS account |
No resources found
No resources found
No narrative content found in resource
FHIR{
"resourceType": "Questionnaire",
"id": "NationalProxy-Questionnaire-ProxyAccessRequest-Example",
"meta": {
"versionId": "52",
"lastUpdated": "2024-08-30T13:36:50.663Z"
},
"url": "https://fhir.nhs.uk/England/Questionnaire/ProxyAccessRequest",
"version": "0.0.1-current",
"name": "Consent",
"title": "Questionnaire Proxy Access Request",
"status": "draft",
"subjectType": [
"RelatedPerson"
],
"date": "2024-07-12",
"publisher": "NHS England",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "https://www.ihe.net/ihe_domains/it_infrastructure/"
}
]
},
{
"telecom": [
{
"system": "email",
"value": "iti@ihe.net"
}
]
},
{
"name": "NHS England",
"telecom": [
{
"system": "email",
"value": "iti@ihe.net"
}
]
}
],
"description": "A form to request access to health and care services on behalf of someone else.",
"useContext": [
{
"code": {
"system": "http://terminology.hl7.org/CodeSystem/usage-context-type",
"code": "task"
},
"valueCodeableConcept": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "887031000000108",
"display": "Consent for information sharing"
}
]
}
}
],
"jurisdiction": [
{
"coding": [
{
"system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
"code": "001"
}
]
}
],
"purpose": "Add someone to your NHS account",
"item": [
{
"linkId": "relatedPerson",
"prefix": "1",
"text": "Proxy details",
"type": "group",
"required": true,
"readOnly": false,
"item": [
{
"linkId": "relatedPerson_identifier",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#identifier",
"prefix": "1.1",
"text": "NHS number",
"type": "string",
"required": true,
"readOnly": false,
"maxLength": 10
},
{
"linkId": "relatedPerson_name",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#name",
"prefix": "1.2",
"text": "Name",
"type": "group",
"required": false,
"item": [
{
"linkId": "relatedPerson_name_first",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#name.given",
"prefix": "1.2.1",
"text": "First name",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "relatedPerson_name_family",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#name.family",
"prefix": "1.2.2",
"text": "Last name",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false
}
]
},
{
"linkId": "relatedPerson_birthDate",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#birthDate",
"prefix": "1.3",
"text": "Date of birth",
"type": "date",
"required": false,
"repeats": false,
"readOnly": 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"
}
]
}
}
],
"linkId": "relatedPerson_basisForAccess",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#relationship",
"code": [
{
"system": "http://snomed.info/sct",
"code": "722011000000106",
"display": "Relationship (qualifier value)"
}
],
"prefix": "1.4",
"text": "Basis for Access",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerOption": [
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"code": "PRN",
"display": "Parent"
}
},
{
"valueCoding": {
"system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-AdditionalPersonRelationshipRole",
"code": "Personal",
"display": "Personal relationship with the patient"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/STU3/CodeSystem/RARecord-ProxyRole-1",
"code": "002",
"display": "Best interest decision made on behalf of the patient (Mental Capacity Act 2005)"
}
}
]
},
{
"extension": [
{
"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": "relatedPerson_relationship",
"definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#relationship",
"code": [
{
"system": "http://snomed.info/sct",
"code": "722011000000106",
"display": "Relationship (qualifier value)"
}
],
"prefix": "1.5",
"text": "Relationship",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerOption": [
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"code": "PRN",
"display": "Parent"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"code": "CHILD",
"display": "Child"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"code": "SPS",
"display": "Partner, wife or husband"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"code": "FAMMEMB",
"display": "Other family member"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"code": "FRND",
"display": "Friend, neighbour or housemate"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleClass",
"code": "CAREGIVER",
"display": "Paid carer or support worker"
}
},
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
"code": "SIGOTHR",
"display": "Other"
}
}
]
},
{
"linkId": "9759901615580",
"prefix": "1.6",
"text": "Relationship - Further information",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 2000
}
]
},
{
"linkId": "parentalApplicationSupplementaryDetails",
"prefix": "2",
"text": "Parental Application Supplementary Details",
"type": "group",
"required": false,
"readOnly": false,
"item": [
{
"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"
}
]
}
}
],
"linkId": "parentalApplicationSupplementaryDetails_evidenceOfResponsibility",
"prefix": "2.1",
"text": "Evidence of parental responsibility",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerOption": [
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
"code": "BRTH",
"display": "Birth certificate"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
"code": "ADPT",
"display": "Adoption certificate"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
"code": "PRNA",
"display": "Court-witnessed parental responsibility agreement"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
"code": "SPRNA",
"display": "Court-witnessed step-parent parental responsibility agreement"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
"code": "PORD",
"display": "Parental order"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
"code": "SGORD",
"display": "Special guardianship order"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
"code": "OTHCOURT",
"display": "Other court order"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
"code": "OTHR",
"display": "Other"
}
}
]
},
{
"linkId": "parentalApplicationSupplementaryDetails_evidenceOfResponsibilityMoreinfo",
"prefix": "2.2",
"text": "Evidence of responsibility - Further Information",
"type": "string",
"enableWhen": [
{
"question": "parentalApplicationSupplementaryDetails_evidenceOfResponsibility",
"operator": "=",
"answerCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
"code": "OTHR",
"display": "Other"
}
}
],
"enableBehavior": "all",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 2000
},
{
"linkId": "parentalApplicationSupplementaryDetails_isCurrentAddressConfirmed",
"prefix": "2.3",
"text": "Is current address confirmed?",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "parentalApplicationSupplementaryDetails_newAddress",
"prefix": "2.4",
"text": "New address",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "parentalApplicationSupplementaryDetails_line1",
"definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.line",
"prefix": "2.4.1",
"text": "Address line 1",
"type": "string",
"required": false,
"readOnly": false
},
{
"linkId": "parentalApplicationSupplementaryDetails_line2",
"definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.line",
"prefix": "2.4.2",
"text": "Address line 2",
"type": "string",
"required": false,
"readOnly": false
},
{
"linkId": "parentalApplicationSupplementaryDetails_line3",
"definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.line",
"prefix": "2.4.3",
"text": "Address line 3",
"type": "string",
"required": false,
"readOnly": false
},
{
"linkId": "parentalApplicationSupplementaryDetails_city",
"definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.city",
"prefix": "2.4.4",
"text": "Town / City",
"type": "string",
"required": false,
"readOnly": false
},
{
"linkId": "parentalApplicationSupplementaryDetails_district",
"definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.district",
"prefix": "2.4.5",
"text": "County",
"type": "string",
"required": false,
"readOnly": false
},
{
"linkId": "parentalApplicationSupplementaryDetails_postalCode",
"definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.postalCode",
"prefix": "2.4.6",
"text": "Postcode",
"type": "string",
"required": false,
"readOnly": false
}
]
},
{
"linkId": "parentalApplicationSupplementaryDetails_liveAtSameAddress",
"prefix": "2.5",
"text": "Do adult and child live at the same address?",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "parentalApplicationSupplementaryDetails_canChildConsent",
"prefix": "2.6",
"text": "Can the child consent?",
"type": "boolean",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "parentalApplicationSupplementaryDetails_reasonNoChildConsent",
"prefix": "2.7",
"text": "Reason the child cannot consent?",
"type": "string",
"enableWhen": [
{
"question": "parentalApplicationSupplementaryDetails_canChildConsent",
"operator": "=",
"answerBoolean": false
}
],
"enableBehavior": "all",
"required": false,
"repeats": false,
"readOnly": false
}
]
},
{
"linkId": "patient",
"prefix": "3",
"text": "Patient details",
"type": "group",
"required": true,
"item": [
{
"linkId": "patient_identifier",
"definition": "http://hl7.org/fhir/StructureDefinition/Patient#identifier",
"prefix": "3.1",
"text": "NHS number",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 10
},
{
"linkId": "patient_name",
"definition": "http://hl7.org/fhir/StructureDefinition/Patient#name",
"prefix": "3.2",
"text": "Name",
"type": "group",
"required": false,
"item": [
{
"linkId": "patient_name_first",
"definition": "http://hl7.org/fhir/StructureDefinition/Patient#name.given",
"prefix": "3.2.1",
"text": "First name",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "patient_name_family",
"definition": "http://hl7.org/fhir/StructureDefinition/Patient#name.family",
"prefix": "3.2.2",
"text": "Last name",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false
}
]
},
{
"linkId": "patient_birthDate",
"definition": "http://hl7.org/fhir/StructureDefinition/Patient#birthDate",
"prefix": "3.3",
"text": "Date of birth",
"type": "date",
"required": false,
"repeats": false,
"readOnly": false
}
]
},
{
"linkId": "requestedAccess",
"prefix": "4",
"text": "Requested access",
"type": "group",
"required": true,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "check-box",
"display": "Check-box"
}
]
}
}
],
"linkId": "requestedAccess_accessLevel",
"prefix": "4.1",
"text": "Requested access level",
"type": "choice",
"required": true,
"repeats": true,
"readOnly": false,
"answerOption": [
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
"code": "APPT",
"display": "Appointment Booking"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
"code": "CNTCT",
"display": "Contacting Surgery"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
"code": "RECRD",
"display": "Medical Records Access"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
"code": "TEST",
"display": "Test Results"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
"code": "VACC",
"display": "Vaccination Records"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
"code": "PRESCR",
"display": "Request and manage repeat prescriptions"
}
}
]
},
{
"linkId": "requestedAccess_accessLevelMoreinfo",
"prefix": "4.2",
"text": "Requested access level - further information",
"type": "string",
"enableWhen": [
{
"question": "requestedAccess_accessLevel",
"operator": "=",
"answerCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
"code": "RECRD",
"display": "Medical Records Access"
}
}
],
"enableBehavior": "all",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 2000
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "check-box",
"display": "Check-box"
}
]
}
}
],
"linkId": "requestedAccess_reasonsForAccess",
"prefix": "4.3",
"text": "Reason for access",
"type": "choice",
"required": false,
"repeats": true,
"readOnly": false,
"answerOption": [
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
"code": "COMB",
"display": "Communication Barriers"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
"code": "MHEA",
"display": "Mental Health Condition"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
"code": "PHYS",
"display": "Physical Condition"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
"code": "PRAC",
"display": "Practical Reasons"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
"code": "TECH",
"display": "Technical Barriers"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
"code": "NEUR",
"display": "Neurodiverse"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
"code": "LRN",
"display": "Learning Disability"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
"code": "OTHR",
"display": "Other"
}
},
{
"valueCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
"code": "NotSpecified",
"display": "Prefer not to say"
}
}
]
},
{
"linkId": "requestedAccess_reasonsForAccessMoreinfo",
"prefix": "4.4",
"text": "Reason for access - further information",
"type": "string",
"enableWhen": [
{
"question": "requestedAccess_reasonsForAccess",
"operator": "=",
"answerCoding": {
"system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
"code": "OTHR",
"display": "Other"
}
}
],
"enableBehavior": "all",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 2000
}
]
}
]
}