{
"description": null,
"_filename": "9cc3ae17-359c-4df6-be26-01e977b705aa.json",
"package_name": "ca.on.health.sadie.preload",
"subjectType": [ "Patient" ],
"date": null,
"meta": {
"profile": [ "http://health.gov.on.ca/sadie/fhir/StructureDefinition/FlexForm" ]
},
"publisher": "ODSP",
"name": "ActivitiesofDailyLivingIndex",
"item": [ {
"item": [ {
"text": "If you encounter an upload error or failure, please try again or fax the attachment to the Disability Adjudication Unit at 416-326-3374. The fax must include the client's first and last name, Member ID and Referral ID on the document or fax cover page.",
"type": "display",
"linkId": "attachment_error_guide_general",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-in-progress"
} ]
}, {
"item": [ {
"text": "Profession",
"type": "string",
"linkId": "0.1.1",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
} ],
"text": "Health Care Professional Details",
"type": "group",
"linkId": "0.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "Important: Member ID and referral ID are provided to ODSP applicants by their caseworkers. The ID's can be found at the top of your applicant's paper Disability Determination Package Forms. If your patient does not have an application started with the ministry, you cannot complete this form.",
"type": "display",
"linkId": "0.2.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.identifier[1].value",
"linkId": "odsp-member-id",
"repeats": false,
"type": "string",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 9
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "Matches*%context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-member-id-referral-id').answer.valueString='fail'*errors.id.invalid"
} ],
"readOnly": false,
"maxLength": 9,
"required": true,
"text": "Member ID (9 digits)"
}, {
"definition": "https://www.hl7.org/fhir/servicerequest-definitions.html#ServiceRequest.identifier[1].value",
"linkId": "odsp-referral-id",
"repeats": false,
"type": "string",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 12
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "Matches*%context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-member-id-referral-id').answer.valueString='fail'*errors.id.invalid"
} ],
"readOnly": false,
"maxLength": 16,
"required": true,
"text": "Referral ID (12 to 16 digits)"
}, {
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.identifier[1].value",
"linkId": "odsp-member-id-referral-id",
"repeats": false,
"type": "string",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "IDValidator*DocumentReference?type=ODSP-Referral-Record&identifier:urn:sadie:request:odsp=%1%&identifier:urn:sadie:patient:odsp=%2%"
}, {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression",
"valueExpression": {
"language": "text/fhirpath",
"expression": "iif(%context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-member-id').answer.valueString.exists() and %context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-referral-id').answer.valueString.exists(), %context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-member-id').answer.valueString + '*' + %context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-referral-id').answer.valueString)",
"description": "Member ID and Referral ID concatenation"
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "^[0-9]{9}\\*{1}[0-9]{12,16}$"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ],
"readOnly": false,
"maxLength": 26,
"required": true,
"text": "Member ID + Referral ID (hidden field for validation purpose)"
}, {
"text": "The referral ID and member ID combination you entered is invalid.
Note: These ID’s can be found at the top of the paper DDP forms. If you do not have access to this information, please contact your patient who can contact their ODSP caseworker to confirm the ID’s. Requests with invalid combination ID’s cannot be submitted.",
"type": "display",
"linkId": "odsp-member-id-referral-id-display-error",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-error"
} ],
"enableWhen": [ {
"operator": "=",
"question": "odsp-member-id-referral-id",
"answerString": "fail"
} ]
}, {
"text": "The referral ID and member ID combination you entered is valid.",
"type": "display",
"linkId": "odsp-member-id-referral-id-display-success",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-success"
} ],
"enableWhen": [ {
"operator": "=",
"question": "odsp-member-id-referral-id",
"answerString": "success"
} ]
}, {
"text": "There was a problem verifying the Member ID and Referral ID. Please enter the values again.",
"type": "display",
"linkId": "odsp-member-id-referral-id-display-system-error",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-error"
} ],
"enableWhen": [ {
"operator": "=",
"question": "odsp-member-id-referral-id",
"answerString": "error"
} ]
}, {
"text": "Please wait while Referral ID and Member ID are validated.",
"type": "display",
"linkId": "odsp-member-id-referral-id-display-in-progress",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-in-progress"
} ],
"enableWhen": [ {
"operator": "=",
"question": "odsp-member-id-referral-id",
"answerString": "in-progress"
} ]
}, {
"type": "string",
"linkId": "details",
"initial": [ {
"valueString": "Activities of Daily Living Index"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ],
"definition": "https://www.hl7.org/fhir/servicerequest-definitions.html#ServiceRequest.orderDetail[0].text"
}, {
"type": "string",
"linkId": "additional-details",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}, {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression",
"valueExpression": {
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-referral-id').answer.valueString",
"description": "ODSP Referral Id"
}
} ],
"definition": "https://www.hl7.org/fhir/servicerequest-definitions.html#ServiceRequest.orderDetail[1].text"
} ],
"text": "Applicant's Social Assistance Identification",
"type": "group",
"linkId": "0.2",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"item": [ {
"text": "Very important: Please ensure that your patient has completed the form, as missing information may impact adjudication timelines.",
"type": "display",
"linkId": "0.3.1-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"text": "With your patient's consent, you may upload their Consent to the Release of Medical and Related Information form.",
"type": "boolean",
"linkId": "0.3.1",
"repeats": false,
"readOnly": false,
"required": true
}, {
"linkId": "0.3.2",
"repeats": false,
"item": [ {
"type": "string",
"linkId": "0.3.2-DocumentType",
"initial": [ {
"valueString": "DDP"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "0.3.2-DocumentSubType",
"initial": [ {
"valueString": "Consent"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "0.3.1",
"answerBoolean": true
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
} ],
"readOnly": false,
"required": false,
"text": "Attach your patient's consent form."
}, {
"text": "With your patient's consent, you may upload their Self Report form.",
"type": "boolean",
"linkId": "0.3.3",
"repeats": false,
"readOnly": false,
"required": true
}, {
"enableBehavior": "any",
"linkId": "0.3.4",
"repeats": false,
"item": [ {
"type": "string",
"linkId": "0.3.4-DocumentType",
"initial": [ {
"valueString": "DDP"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "0.3.4-DocumentSubType",
"initial": [ {
"valueString": "Self Report"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "0.3.3",
"answerBoolean": true
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
} ],
"readOnly": false,
"required": false,
"text": "Attach your patient's Self Report form."
} ],
"text": "Applicant Forms",
"type": "group",
"linkId": "0.3",
"repeats": false,
"readOnly": false,
"required": false
} ],
"text": "General",
"type": "group",
"linkId": "0",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Header",
"coding": [ {
"code": "header",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Header"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"item": [ {
"text": "Specify the requested patient information:",
"type": "display",
"linkId": "1.1.1.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"text": "First Name",
"type": "string",
"linkId": "patient-first-name",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 25,
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.name.given"
}, {
"text": "Middle Initial",
"type": "string",
"linkId": "1.1.1.2",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 2
}, {
"text": "Last Name",
"type": "string",
"linkId": "patient-last-name",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 25,
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.name.family"
}, {
"text": "Date of Birth",
"type": "date",
"linkId": "patient-date-of-birth",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
} ]
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
}
} ]
} ],
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.birthDate"
} ],
"type": "group",
"linkId": "1.1.1",
"repeats": false
} ],
"text": "Applicant's Information",
"type": "group",
"linkId": "1.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "Unit Number",
"type": "string",
"linkId": "1.2.1",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[A-Za-z0-9]*"
} ],
"maxLength": 10
}, {
"text": "Street Number",
"type": "string",
"linkId": "1.2.2",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
} ],
"maxLength": 10
}, {
"text": "Street Name",
"type": "string",
"linkId": "1.2.3",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 25
}, {
"text": "City/Town",
"type": "string",
"linkId": "1.2.4",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 25
}, {
"text": "Province",
"type": "string",
"linkId": "1.2.5",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 25
}, {
"text": "Postal Code",
"type": "string",
"linkId": "1.2.6",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 6
}, {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[A-Za-z][0-9][A-Za-z] ?[0-9][A-Za-z][0-9]"
} ],
"maxLength": 6
} ],
"text": "Applicant's Current Address",
"type": "group",
"linkId": "1.2",
"repeats": false,
"readOnly": false,
"required": false
} ],
"text": "Applicant",
"type": "group",
"linkId": "1",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Header",
"coding": [ {
"code": "header",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Header"
} ]
}
} ]
}, {
"item": [ {
"text": "If you encounter an upload error or failure, please try again or fax the attachment to the Disability Adjudication Unit at 416-326-3374. The fax must include the client's first and last name, Member ID and Referral ID on the document or fax cover page.",
"type": "display",
"linkId": "attachment_error_guide_form",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-in-progress"
} ]
}, {
"item": [ {
"item": [ {
"text": "This information helps the ministry understand the direct impact of the impairments and restrictions listed in Section 1 on the applicant's current ability to perform and carry out each activity.",
"type": "display",
"linkId": "2.1.1-help",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"text": "This section consists of a list of activities that seeks to understand the impact of the presenting impairments on the applicant's restrictions.",
"type": "display",
"linkId": "2.1.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "Please rate the limitation for each activity",
"type": "choice",
"linkId": "2.1.2.1",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/ODSP-SymptomClassHelp"
}, {
"item": [ {
"text": "1. Bladder control",
"type": "choice",
"linkId": "2.1.2.2.1",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Describe limitation, if needed",
"type": "text",
"linkId": "2.1.2.2.2",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
"valueExpression": {
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.2').item.where(linkId='2.1.2.2.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.2').item.where(linkId='2.1.2.2.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.2').item.where(linkId='2.1.2.2.1').answer.valueCoding.code='3'"
}
} ],
"maxLength": 500
} ],
"type": "group",
"linkId": "2.1.2.2",
"repeats": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
"code": "gtable",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group gtable"
} ]
}
} ]
}, {
"item": [ {
"text": "2. Bowel control",
"type": "choice",
"linkId": "2.1.2.3.1",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Describe limitation, if needed",
"type": "text",
"linkId": "2.1.2.3.2",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
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}
}