{
"description": "ReSPECT Form - Recommended Summary Plan for Emergency Care and Treatment",
"_filename": "examples/Questionnaire-example.json",
"package_name": "notts.scr.poc",
"subjectType": [ "Patient" ],
"date": "2021-02-25T12:00:00Z",
"publisher": "NottsCC",
"purpose": "ReSPECT Form - Recommended Summary Plan for Emergency Care and Treatment",
"name": "ReSPECT Form",
"item": [ {
"text": "Patient Details and Date Completed will be shared via 'QuestionnaireResponse.subject' and 'QuestionnaireResponse.authored' respectively",
"type": "display",
"linkId": "1"
}, {
"item": [ {
"text": "Summary of relevant information for this plan including diagnoses and relevant personal circumstances:",
"type": "text",
"linkId": "2.1",
"required": false
}, {
"text": "Details of other relevant care planning documents and where to find them (e.g. Advance or Anticipatory Care Plan; Advanced Decision to Refuse Treatment or Advanced Directive; Emergency Plan for Carer):",
"type": "text",
"linkId": "2.2",
"required": false
}, {
"text": "I have a legal welfare proxy in place (e.g. registered welfare attorney, person with parental responsibilities) - if yes provide details in Section 8",
"type": "choice",
"linkId": "2.3",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": false
} ],
"text": "Shared understanding of my health and current condition",
"type": "group",
"linkId": "2",
"required": false
}, {
"item": [ {
"text": "Mark on scale of 0-10, where 0 = 'Living as long as possible matters to me most' and 10 = 'Quality of life and comfort matters to me most':",
"type": "choice",
"linkId": "3.1",
"option": [ {
"valueCoding": {
"code": "0",
"display": "0 - Living as long as possible matters to me most"
}
}, {
"valueCoding": {
"code": "1",
"display": "1"
}
}, {
"valueCoding": {
"code": "2",
"display": "2"
}
}, {
"valueCoding": {
"code": "3",
"display": "3"
}
}, {
"valueCoding": {
"code": "4",
"display": "4"
}
}, {
"valueCoding": {
"code": "5",
"display": "5"
}
}, {
"valueCoding": {
"code": "6",
"display": "6"
}
}, {
"valueCoding": {
"code": "7",
"display": "7"
}
}, {
"valueCoding": {
"code": "8",
"display": "8"
}
}, {
"valueCoding": {
"code": "9",
"display": "9"
}
}, {
"valueCoding": {
"code": "10",
"display": "10 - Quality of life and comfort matters to me most"
}
} ],
"required": false
}, {
"text": "What I most value:",
"type": "text",
"linkId": "3.2",
"required": false
}, {
"text": "What I most fear / wish to avoid:",
"type": "text",
"linkId": "3.3",
"required": false
} ],
"text": "What matters to me in decisions about my treatment and care in an emergency",
"type": "group",
"linkId": "3",
"required": false
}, {
"item": [ {
"text": "Clinical recommendation:",
"type": "choice",
"linkId": "4.1",
"option": [ {
"valueCoding": {
"code": "life",
"display": "Prioritise extending life"
}
}, {
"valueCoding": {
"code": "balance",
"display": "Balance extending life with comfort and valued outcomes"
}
}, {
"valueCoding": {
"code": "comfort",
"display": "Prioritise comfort"
}
} ],
"required": true
}, {
"text": "Now provide clinical guidance on specific realistic interventions that may or may not be wanted or clinically appropriate (including being taken or admitted to hospital +/- receiving life support) and your reasoning for this guidance",
"type": "text",
"linkId": "4.2",
"required": false
}, {
"text": "CPR:",
"type": "choice",
"linkId": "4.3",
"option": [ {
"valueCoding": {
"code": "cpr-recommended",
"display": "CPR attempts recommended (Adult or Child)"
}
}, {
"valueCoding": {
"code": "modified-cpr",
"display": "For modified CPR (CHILD ONLY, AS DETAILED ABOVE)"
}
}, {
"valueCoding": {
"code": "cpr-not-recommended",
"display": "CPR attempts NOT recommended (Adult or Child)"
}
} ],
"required": false
} ],
"text": "Clinical recommendations for emergency care and treatment",
"type": "group",
"linkId": "4",
"required": false
}, {
"item": [ {
"text": "Does the person have capacity to participate in making recommendations on this plan? Document the full capacity assessment in the clinical record.",
"type": "choice",
"linkId": "5.1",
"option": [ {
"valueCoding": {
"code": "yes",
"display": "Yes"
}
}, {
"valueCoding": {
"code": "no",
"display": "No"
}
} ],
"required": true
}, {
"text": "If no, in what way does this person lack capacity? If the person lacks capacity a ReSPECT conversation must take place with the family and/or legal welfare proxy.",
"type": "text",
"linkId": "5.2",
"required": true,
"enableWhen": [ {
"question": "5.1",
"answerCoding": {
"code": "no"
}
} ]
} ],
"text": "Capacity for involvement in making this plan",
"type": "group",
"linkId": "5",
"required": false
}, {
"item": [ {
"text": "The clinician(s) signing this plan is/are confirming that (select A,B or C, OR complete section D below):",
"type": "choice",
"linkId": "6.1",
"option": [ {
"valueCoding": {
"code": "A",
"display": "A: This person has mental capacity to participate in making these recommendations. They have been fully involved in this plan"
}
}, {
"valueCoding": {
"code": "B",
"display": "B: This person does not have the mental capacity, even with support, to participate in making these recommendations. Their past and present views, where ascertainable, have been taken into account. The plan has been made, where applicable, in consultation with their legal proxy, or where no proxy, with family members/friends"
}
}, {
"valueCoding": {
"code": "C",
"display": "C: This person is less than 18 years old (16 in Scotland) and (please select 1 or 2, and also 3 as applicable or explain in section D below)"
}
}, {
"valueCoding": {
"code": "D",
"display": "D: If no other option has been selected, valid reasons must be stated here: (Document full explanation in the clinical record.)"
}
} ],
"required": true
}, {
"text": "Please select 1 or 2.",
"type": "choice",
"linkId": "6.2",
"option": [ {
"valueCoding": {
"code": "1",
"display": "1: They have sufficient maturity and understanding to participate in making this plan"
}
}, {
"valueCoding": {
"code": "2",
"display": "2: They do not have sufficient maturity and understanding to participate in this plan. Their views, when known, have been taken into account."
}
} ],
"required": true,
"enableWhen": [ {
"question": "6.1",
"answerCoding": {
"code": "C"
}
} ]
}, {
"text": "3: Those holding parental responsibility have been fully involved in discussing and making this plan.",
"type": "boolean",
"linkId": "6.3",
"required": false,
"enableWhen": [ {
"question": "6.1",
"answerCoding": {
"code": "C"
}
} ]
}, {
"text": "D: Specify reasons",
"type": "text",
"linkId": "6.4",
"required": false,
"enableWhen": [ {
"question": "6.1",
"answerCoding": {
"code": "C"
}
}, {
"question": "6.1",
"answerCoding": {
"code": "D"
}
} ]
} ],
"text": "Involvement in making this plan",
"type": "group",
"linkId": "6",
"required": false
}, {
"item": [ {
"item": [ {
"text": "Grade/speciality",
"type": "string",
"linkId": "7.1.1",
"required": false
}, {
"text": "Clinician name",
"type": "string",
"linkId": "7.1.2",
"required": false
}, {
"text": "GMC/NMC/HCPC no.",
"type": "string",
"linkId": "7.1.3",
"required": false
}, {
"text": "Signature",
"type": "string",
"linkId": "7.1.4",
"required": false
}, {
"text": "Date and time",
"type": "dateTime",
"linkId": "7.1.5",
"required": false
} ],
"text": "Senior responsible clinician",
"type": "group",
"linkId": "7.1",
"required": false
}, {
"item": [ {
"text": "Grade/speciality",
"type": "string",
"linkId": "7.2.1",
"required": false
}, {
"text": "Clinician name",
"type": "string",
"linkId": "7.2.2",
"required": false
}, {
"text": "GMC/NMC/HCPC no.",
"type": "string",
"linkId": "7.2.3",
"required": false
}, {
"text": "Signature",
"type": "string",
"linkId": "7.2.4",
"required": false
}, {
"text": "Date and time",
"type": "dateTime",
"linkId": "7.2.5",
"required": false
} ],
"text": "Other clinicians",
"type": "group",
"linkId": "7.2",
"repeats": true,
"required": false
} ],
"text": "Clinicians' signatures",
"type": "group",
"linkId": "7",
"required": false
}, {
"item": [ {
"item": [ {
"text": "Name",
"type": "string",
"linkId": "8.1.1",
"required": false
}, {
"text": "Involved in planning",
"type": "boolean",
"linkId": "8.1.2",
"required": false
}, {
"text": "Emergency contact no.",
"type": "string",
"linkId": "8.1.3",
"required": false
}, {
"text": "Signature",
"type": "string",
"linkId": "8.1.4",
"required": false
} ],
"text": "Primary emergency contact",
"type": "group",
"linkId": "8.1",
"required": false
}, {
"item": [ {
"text": "Name",
"type": "string",
"linkId": "8.2.1",
"required": false
}, {
"text": "Involved in planning",
"type": "boolean",
"linkId": "8.2.2",
"required": false
}, {
"text": "Emergency contact no.",
"type": "string",
"linkId": "8.2.3",
"required": false
}, {
"text": "Signature",
"type": "string",
"linkId": "8.2.4",
"required": false
} ],
"text": "Other emergency contacts",
"type": "group",
"linkId": "8.2",
"repeats": true,
"required": false
} ],
"text": "Emergency contacts and those involved in discussing this plan",
"type": "group",
"linkId": "8",
"required": false
}, {
"item": [ {
"item": [ {
"text": "Review date",
"type": "date",
"linkId": "9.1.1",
"required": false
}, {
"text": "Grade/speciality",
"type": "string",
"linkId": "9.1.2",
"required": false
}, {
"text": "Clinician name",
"type": "string",
"linkId": "9.1.3",
"required": false
}, {
"text": "GMC/NMC/HCPC no.",
"type": "string",
"linkId": "9.1.4",
"required": false
}, {
"text": "Signature",
"type": "string",
"linkId": "9.1.5",
"required": false
} ],
"text": "Review details",
"type": "group",
"linkId": "9.1",
"repeats": true,
"required": false
} ],
"text": "Form reviewed (e.g. for change of care setting) and remains relevant",
"type": "group",
"linkId": "9",
"required": false
} ],
"type": null,
"experimental": null,
"resourceType": "Questionnaire",
"title": "ReSPECT Form",
"package_version": "0.1.0",
"status": "draft",
"id": "8b90888a-cec3-4d4a-95e2-55b8b51ee5ad",
"kind": null,
"url": "https://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/ReSPECT_Form",
"version": "0.0.1"
}