{
"description": "Preliminary Needs Assessment completed by Hospital Staff and shared as part of a Supported Hospital Discharge with third partied (e.g. Social Care, Community Health)",
"_filename": "examples/SHD-Questionnaire-PreliminaryNeedsAssessment.json",
"package_name": "supportedhospitaldischarge.stu3",
"subjectType": [ "Patient" ],
"date": "2020-04-21T17:59:11.362Z",
"publisher": "NottsCC",
"purpose": "Preliminary Needs Assessment completed by Hospital Staff and shared as part of a Supported Hospital Discharge with third partied (e.g. Social Care, Community Health)",
"name": "SHD-Questionnaire-PreliminaryNeedsAssessment",
"item": [ {
"item": [ {
"text": "Is the person able to give informed consent to their discharge arrangements?",
"type": "choice",
"linkId": "1.1",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
}, {
"valueCoding": {
"code": "unable",
"display": "Unable"
}
} ],
"required": true
}, {
"text": "If not, give details and a mental capacity assessment is needed",
"type": "text",
"linkId": "1.1.1",
"required": true,
"enableWhen": [ {
"question": "1.1",
"answerCoding": {
"code": "no"
}
}, {
"question": "1.1",
"answerCoding": {
"code": "unable"
}
} ]
}, {
"text": "Deprivation of Liberty Safeguards: Will the person be deprived of their liberty? – i.e. under continuous supervision and control and not free to leave and not able to give informed consent to these arrangements.",
"type": "choice",
"linkId": "1.2",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If Yes- give details",
"type": "text",
"linkId": "1.2.1",
"required": true,
"enableWhen": [ {
"question": "1.2",
"answerCoding": {
"code": "yes"
}
} ]
}, {
"text": "Are there any cognition or other risks? Any risks being left alone or with others",
"type": "choice",
"linkId": "1.3",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If Yes- give details",
"type": "text",
"linkId": "1.3.1",
"required": true,
"enableWhen": [ {
"question": "1.3",
"answerCoding": {
"code": "yes"
}
} ]
} ],
"text": "Capacity",
"type": "group",
"linkId": "1",
"required": false
}, {
"item": [ {
"text": "Record any amendments or changes to medication not reflected on the GP record",
"type": "text",
"linkId": "2.1",
"required": false
}, {
"text": "Medical Equipment e.g. oxygen",
"type": "text",
"linkId": "2.2",
"required": false
}, {
"text": "Is support with medication required?",
"type": "choice",
"linkId": "2.3",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If Yes- give details, e.g Mediwallet",
"type": "text",
"linkId": "2.3.1",
"required": true,
"enableWhen": [ {
"question": "2.3",
"answerCoding": {
"code": "yes"
}
} ]
}, {
"text": "Known Allergies",
"type": "text",
"linkId": "2.4",
"required": false
}, {
"text": "Other medical needs which impact discharge arrangements. Past Medical history e.g. COPD, Diabetes",
"type": "text",
"linkId": "2.5",
"required": false
}, {
"text": "Details of any tests or awaiting results for after discharge",
"type": "text",
"linkId": "2.6",
"required": false
}, {
"text": "Has a ReSPECT form been completed?",
"type": "choice",
"linkId": "2.7",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If Yes- details of ReSPECT form",
"type": "text",
"linkId": "2.7.1",
"required": true,
"enableWhen": [ {
"question": "2.7",
"answerCoding": {
"code": "yes"
}
} ]
} ],
"text": "Current Medical Needs to support discharge arrangements",
"type": "group",
"linkId": "2",
"required": false
}, {
"item": [ {
"text": "Does the patient live alone?",
"type": "choice",
"linkId": "3.1",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "Accommodation type and living arrangements. E.g. bungalow, who lives with, etc",
"type": "text",
"linkId": "3.2",
"required": false
}, {
"text": "Keysafe including number?",
"type": "text",
"linkId": "3.3",
"required": false
}, {
"text": "Lifeline or similar monitoring equipment?",
"type": "text",
"linkId": "3.4",
"required": false
}, {
"text": "Urgent accommodation risks and issues if known – only if this will prevent the discharge going ahead. E.g. EMAS concerns raised, family refusing discharge",
"type": "text",
"linkId": "3.5",
"required": false
} ],
"text": "Living arrangements",
"type": "group",
"linkId": "3",
"required": false
}, {
"item": [ {
"text": "Mobility Status - Can the person mobilise?",
"type": "choice",
"linkId": "4.1",
"option": [ {
"valueCoding": {
"code": "independently",
"display": "Independently"
}
}, {
"valueCoding": {
"code": "with-aid",
"display": "With aid"
}
} ],
"required": true
}, {
"text": "If with aid please state the level of assistance required?",
"type": "text",
"linkId": "4.1.1",
"required": true,
"enableWhen": [ {
"question": "4.1",
"answerCoding": {
"code": "with-aid"
}
} ]
}, {
"text": "Is the patient able to safely /independently manage stairs?",
"type": "choice",
"linkId": "4.2",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
}, {
"valueCoding": {
"code": "NA",
"display": "Not Applicable"
}
} ],
"required": true
}, {
"text": "Are there any steps at the person’s property?",
"type": "choice",
"linkId": "4.3",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
}, {
"valueCoding": {
"code": "dont-know",
"display": "Don't Know"
}
} ],
"required": true
}, {
"text": "Is the patient able to transfer off the bed?",
"type": "choice",
"linkId": "4.4",
"option": [ {
"valueCoding": {
"code": "independently",
"display": "Independently"
}
}, {
"valueCoding": {
"code": "with-equipment",
"display": "With Equipment"
}
} ],
"required": true
}, {
"text": "Is the patient able to transfer off the chair?",
"type": "choice",
"linkId": "4.5",
"option": [ {
"valueCoding": {
"code": "independently",
"display": "Independently"
}
}, {
"valueCoding": {
"code": "with-equipment",
"display": "With Equipment"
}
} ],
"required": true
}, {
"text": "Is the patient able to transfer off the toilet?",
"type": "choice",
"linkId": "4.6",
"option": [ {
"valueCoding": {
"code": "independently",
"display": "Independently"
}
}, {
"valueCoding": {
"code": "with-equipment",
"display": "With Equipment"
}
} ],
"required": true
}, {
"text": "If equipment selected on any of the above, has this equipment been ordered to ensure a safe discharge?",
"type": "choice",
"linkId": "4.7",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true,
"enableWhen": [ {
"question": "4.4",
"answerCoding": {
"code": "with-equipment"
}
}, {
"question": "4.5",
"answerCoding": {
"code": "with-equipment"
}
}, {
"question": "4.6",
"answerCoding": {
"code": "with-equipment"
}
} ]
}, {
"text": "How does the person feel they will transfer between areas of their home? (between bed and chair and toilet or bathroom, any steps at their property, between rooms etc)?",
"type": "text",
"linkId": "4.8",
"required": false
}, {
"text": "Can the person bear their own weight fully?",
"type": "choice",
"linkId": "4.9",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
}, {
"valueCoding": {
"code": "partially",
"display": "Partially"
}
} ],
"required": true
}, {
"text": "Details if No or Partially",
"type": "text",
"linkId": "4.9.1",
"required": true,
"enableWhen": [ {
"question": "4.9",
"answerCoding": {
"code": "no"
}
}, {
"question": "4.9",
"answerCoding": {
"code": "partially"
}
} ]
}, {
"text": "Can the person prepare drinks or a meal for themselves at home?",
"type": "choice",
"linkId": "4.10",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "Please give details of alternative (e.g. meals delivery/ family support)",
"type": "text",
"linkId": "4.10.1",
"required": true,
"enableWhen": [ {
"question": "4.10",
"answerCoding": {
"code": "no"
}
} ]
}, {
"text": "Does the person have any difficulty swallowing?",
"type": "choice",
"linkId": "4.11",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If Yes- give details",
"type": "text",
"linkId": "4.11.1",
"required": true,
"enableWhen": [ {
"question": "4.11",
"answerCoding": {
"code": "yes"
}
} ]
}, {
"text": "Is the person able to wash and dress themselves on discharge?",
"type": "choice",
"linkId": "4.12",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If No- give details",
"type": "text",
"linkId": "4.12.1",
"required": true,
"enableWhen": [ {
"question": "4.12",
"answerCoding": {
"code": "no"
}
} ]
}, {
"text": "What does the person want to ideally achieve? e.g. return to independence, support at home etc",
"type": "text",
"linkId": "4.13",
"required": false
} ],
"text": "Input from the person’s discharge care needs",
"type": "group",
"linkId": "4",
"required": false
}, {
"item": [ {
"text": "Does the person have any wounds or sores that need to be dressed or managed? (awareness for providers on bed sores etc)",
"type": "choice",
"linkId": "5.1",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If Yes give details",
"type": "text",
"linkId": "5.1.1",
"required": true,
"enableWhen": [ {
"question": "5.1",
"answerCoding": {
"code": "yes"
}
} ]
}, {
"text": "Does the person have any Continence needs?",
"type": "choice",
"linkId": "5.2",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If Yes give details",
"type": "text",
"linkId": "5.2.1",
"required": true,
"enableWhen": [ {
"question": "5.2",
"answerCoding": {
"code": "yes"
}
} ]
}, {
"text": "How will the person support themselves overnight between visits? (e.g. if needs toilet in the night)",
"type": "text",
"linkId": "5.3",
"required": false
}, {
"text": "Can the person fully communicate their needs?",
"type": "choice",
"linkId": "5.4",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If No please give communication needs. e.g. translator, carer support",
"type": "text",
"linkId": "5.4.1",
"required": true,
"enableWhen": [ {
"question": "5.4",
"answerCoding": {
"code": "no"
}
} ]
}, {
"text": "Has transport been arranged for this person?",
"type": "choice",
"linkId": "5.5",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If Yes date and time booked for",
"type": "dateTime",
"linkId": "5.5.1",
"required": true,
"enableWhen": [ {
"question": "5.5",
"answerCoding": {
"code": "yes"
}
} ]
} ],
"text": "Specialist Input needed after discharge",
"type": "group",
"linkId": "5",
"required": false
}, {
"item": [ {
"text": "Please use this section to provide any other additional information that is relevant to the discharge",
"type": "text",
"linkId": "6.1",
"required": false
} ],
"text": "Additional Information",
"type": "group",
"linkId": "6",
"required": false
} ],
"type": null,
"experimental": null,
"resourceType": "Questionnaire",
"title": "SHD-Questionnaire-PreliminaryNeedsAssessment",
"package_version": "0.1.3",
"status": "draft",
"id": "33a93cb3-beb4-4a98-a355-266832bfb8cb",
"kind": null,
"url": "https://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/SHD-Questionnaire-PreliminaryNeedsAssessment",
"version": "0.0.1"
}