{
"description": "This assessment 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) with modifications from from OntarioHealth. The FHIR artifact is maintained and published by Ontario Health.",
"_filename": "examples/Questionnaire-iar-contact-asessment-v.2.0.0-oh.json",
"package_name": "ca.on.oh.setp.iar.dev",
"subjectType": [ "Patient" ],
"date": "2026-02-01T21:47:22.96+00:00",
"publisher": "Ontario Health",
"approvalDate": "2026-01-09",
"name": null,
"item": [ {
"item": [ {
"item": [ {
"text": "(Given name)",
"type": "string",
"linkId": "A1a",
"prefix": "a.",
"maxLength": 255
}, {
"text": "(Middle initial)",
"type": "string",
"linkId": "A1b",
"prefix": "b.",
"maxLength": 255
}, {
"text": "(Family name)",
"type": "string",
"linkId": "A1c",
"prefix": "c.",
"maxLength": 255
} ],
"text": "1. NAME",
"type": "group",
"linkId": "A1"
}, {
"item": [ {
"text": "Sex [Country Specific - Canada]",
"type": "choice",
"linkId": "A2a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/sex"
}, {
"text": "Gender identity [Canada - Only]",
"type": "choice",
"linkId": "A2b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/gender-identity"
}, {
"text": "Person self-identifies gender as [Canada - Only] - If the person responded “Other” Gender identity (Ask, “What best identifies your current gender identity?”) if the person does not want to respond to the above question, leave the box blank. This item must not contain any names (full or partial) or the person’s Healthcare Identification Number or date of birth.",
"type": "string",
"linkId": "A2c",
"prefix": "c.",
"maxLength": 25
} ],
"text": "2. SEX / GENDER IDENTITY",
"type": "group",
"linkId": "A2"
}, {
"text": "BIRTHDATE",
"type": "date",
"linkId": "A3",
"prefix": "3.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
} ]
}, {
"text": "MARITAL STATUS",
"type": "choice",
"linkId": "A4",
"prefix": "4.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/marital-status"
}, {
"item": [ {
"text": "Healthcare Identification Number",
"type": "integer",
"linkId": "A5a",
"prefix": "a."
}, {
"text": "Province or territory issuing Healthcare Identification Number",
"type": "choice",
"linkId": "A5b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/issuing-jurisdiction"
}, {
"text": "Case record number",
"type": "integer",
"linkId": "A5c",
"prefix": "c."
} ],
"text": "5. NUMERIC IDENTIFIERS",
"type": "group",
"linkId": "A5"
}, {
"text": "POSTAL CODE OF USUAL LIVING ARRANGEMENT [COUNTRY SPECIFIC - CANADA",
"type": "choice",
"linkId": "A6",
"prefix": "6.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/postal-code"
}, {
"text": "AGENCY IDENTIFIER [COUNTRY SPECIFIC - CANADA]",
"type": "integer",
"linkId": "A7",
"prefix": "7."
}, {
"item": [ {
"text": "First Nations",
"type": "choice",
"linkId": "A8a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/indigenous-identity"
}, {
"text": "Metis",
"type": "choice",
"linkId": "A8b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/indigenous-identity"
}, {
"text": "Inuit",
"type": "choice",
"linkId": "A8c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/indigenous-identity"
} ],
"text": "8. INDIGENOUS IDENTITY [COUNTRY SPECIFIC - CANADA] - Person identifies as First Nations, Métis, or Inuit",
"type": "group",
"linkId": "A8"
}, {
"text": "PRIMARY LANGUAGE [COUNTRY SPECIFIC - CANADA] ",
"type": "choice",
"linkId": "A10",
"prefix": "9.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/languages"
}, {
"text": "INTERPRETER NEEDED",
"type": "choice",
"linkId": "A11",
"prefix": "10.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "REASONS FOR REFERRAL",
"type": "text",
"linkId": "A12",
"prefix": "11."
}, {
"text": "LOCATION OF ASSESSMENT",
"type": "choice",
"linkId": "A13",
"prefix": "12.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/assessment-location"
} ],
"text": "Section A. Demographic Information",
"type": "group",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "Section A. Demographic Information"
} ]
},
"linkId": "A"
}, {
"item": [ {
"text": "ASSESSMENT REFERENCE DATE",
"type": "date",
"linkId": "B1",
"prefix": "1.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
} ]
}, {
"item": [ {
"item": [ {
"text": "Administration of medication (other than IV)",
"type": "choice",
"linkId": "B2aa",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Indwelling catheter",
"type": "choice",
"linkId": "B2ab",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "IV therapy",
"type": "choice",
"linkId": "B2ac",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Wound care",
"type": "choice",
"linkId": "B2ad",
"prefix": "d.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Other (specify)",
"type": "choice",
"linkId": "B2ae1",
"prefix": "e1.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Other (specify) - description",
"type": "string",
"linkId": "B2ae2",
"prefix": "e2.",
"maxLength": 20
}, {
"text": "Condom catheter",
"type": "choice",
"linkId": "B2af",
"prefix": "f.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Drain/tube management",
"type": "choice",
"linkId": "B2ag",
"prefix": "g.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Diabetic teaching",
"type": "choice",
"linkId": "B2ah",
"prefix": "h.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Ostomy management",
"type": "choice",
"linkId": "B2ai",
"prefix": "i.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Sitz bath teaching",
"type": "choice",
"linkId": "B2aj",
"prefix": "j.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Staple/suture removal",
"type": "choice",
"linkId": "B2ak",
"prefix": "k.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Nursing",
"type": "choice",
"linkId": "B2al",
"prefix": "l.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "PT assessment",
"type": "choice",
"linkId": "B2am",
"prefix": "m.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "OT assessment",
"type": "choice",
"linkId": "B2an",
"prefix": "n.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Swallow assessment",
"type": "choice",
"linkId": "B2ao",
"prefix": "o.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/treatment-time-frame-one"
}, {
"text": "Referral to initiate or continue rehabilitation services",
"type": "choice",
"linkId": "B2b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "Referral to initiate or continue palliative services",
"type": "choice",
"linkId": "B2c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
} ],
"text": "Time frame for initiation of ordered treatments in community",
"type": "group",
"linkId": "B2a",
"prefix": "a."
} ],
"text": "2. REFERRAL DETAILS",
"type": "group",
"linkId": "B2"
}, {
"text": "EXPECTED LIVING ARRANGEMENT DURING SERVICE PROVISION",
"type": "choice",
"linkId": "B3",
"prefix": "3.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-living-arrangement"
}, {
"text": "EXPECTED RESIDENTIAL / LIVING STATUS DURING SERVICE PROVISION",
"type": "choice",
"linkId": "B4",
"prefix": "4.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/location"
} ],
"text": "Section B. Intake and Initial History ",
"type": "group",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "Section B. Intake and Initial History "
} ]
},
"linkId": "B"
}, {
"item": [ {
"text": "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",
"type": "choice",
"linkId": "C1",
"prefix": "1.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills"
}, {
"item": [ {
"text": "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",
"type": "choice",
"linkId": "C2a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}, {
"text": "Bath transfer - How person transfers in/out of bath or shower",
"type": "choice",
"linkId": "C2b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}, {
"text": "Personal hygiene - How manages personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing and drying face and hands — EXCLUDE BATHS AND SHOWERS.",
"type": "choice",
"linkId": "C2c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}, {
"text": "Dressing lower body - How dresses and undresses (street clothes, underwear) from the waist down, including prostheses, orthotics, belts, pants, skirts, shoes, fasteners, etc.",
"type": "choice",
"linkId": "C2d",
"prefix": "d.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}, {
"text": "Locomotion - How moves between locations on same floor (walking or wheeling). If in wheelchair, self-sufficiency once in chair.",
"type": "choice",
"linkId": "C2e",
"prefix": "e.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
} ],
"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",
"linkId": "C2"
}, {
"text": "DYSPNEA (Shortness of Breath)",
"type": "choice",
"linkId": "C3",
"prefix": "3.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea"
}, {
"text": "SELF-REPORTED HEALTH Ask: In general, how would you rate your health?",
"type": "choice",
"linkId": "C4",
"prefix": "4.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health"
}, {
"item": [ {
"text": "Little interest or pleasure in things you normally enjoy?",
"type": "choice",
"linkId": "C5a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}, {
"text": "Anxious, restless, or uneasy?",
"type": "choice",
"linkId": "C5b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}, {
"text": "Sad, depressed, or hopeless?",
"type": "choice",
"linkId": "C5c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
} ],
"text": "5. SELF-REPORTED MOOD [COUNTRY SPECIFIC - CANADA] Ask: “In the last 3 days, how often have you felt . . .”",
"type": "group",
"linkId": "C5"
}, {
"item": [ {
"text": "Conditions/diseases make cognitive, ADL, mood, or behaviour patterns unstable (fluctuating, precarious, or deteriorating)",
"type": "choice",
"linkId": "C6a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "Experiencing an acute episode or a flare-up of a recurrent or chronic problem",
"type": "choice",
"linkId": "C6b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
} ],
"text": "6. INSTABILITY OF CONDITIONS",
"type": "group",
"linkId": "C6"
}, {
"text": "HOME CARE OR COMMUNITY SUPPORT SERVICES MAY BE REQUIRED FOR THIS PERSON",
"type": "choice",
"linkId": "C7",
"prefix": "7.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
} ],
"text": "Section C. Preliminary Screener",
"type": "group",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "Section C. Preliminary Screener"
} ]
},
"linkId": "C"
}, {
"item": [ {
"text": "CHANGE IN DECISION MAKING AS COMPARED TO 90 DAYS AGO (OR SINCE LAST ASSESSMENT IF LESS THAN 90 DAYS AGO)",
"type": "choice",
"linkId": "D1",
"prefix": "1.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-improvement"
}, {
"text": "ABILITY TO UNDERSTAND OTHERS (Comprehension) - Understanding information content (however able; with hearing or other assistive devices normally used)",
"type": "choice",
"linkId": "D2",
"prefix": "2.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-understanding-other"
}, {
"item": [ {
"text": "Meal preparation — How prepares meals (e.g., planning meals, assembling ingredients, cooking, setting out food and utensils)",
"type": "choice",
"linkId": "D3a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}, {
"text": "Ordinary housework — How performs ordinary work around the house (e.g., doing dishes, dusting, making bed, tidying up, laundry)",
"type": "choice",
"linkId": "D3b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}, {
"text": ".Manage medications — How medications are managed (e.g., remembering to take medications, opening bottles, taking correct drug dosages, giving injections, applying ointments)",
"type": "choice",
"linkId": "D3c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}, {
"text": "Stairs — How manages full flight of stairs (e.g., 12–14 stairs)",
"type": "choice",
"linkId": "D3d",
"prefix": "d.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}, {
"text": "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",
"type": "choice",
"linkId": "D3e",
"prefix": "e.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}, {
"text": "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)",
"type": "choice",
"linkId": "D3f",
"prefix": "f.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
} ],
"text": "3. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) CAPACITY",
"type": "group",
"linkId": "D3"
}, {
"text": "CHANGE IN ADL STATUS AS COMPARED TO 90 DAYS AGO (OR SINCE LAST ASSESSMENT IF LESS THAN 90 DAYS AGO)",
"type": "choice",
"linkId": "D4",
"prefix": "4.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-improvement"
}, {
"item": [ {
"text": "Alzheimer\"s disease",
"type": "choice",
"linkId": "D5a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
}, {
"text": "Dementia other than Alzheimer\"s disease",
"type": "choice",
"linkId": "D5b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
}, {
"text": "Stroke",
"type": "choice",
"linkId": "D5c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
}, {
"text": "Coronary heart disease",
"type": "choice",
"linkId": "D5d",
"prefix": "d.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
}, {
"text": "Chronic obstructive pulmonary disease",
"type": "choice",
"linkId": "D5e",
"prefix": "e.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
}, {
"text": "Congestive heart failure",
"type": "choice",
"linkId": "D5f",
"prefix": "f.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
}, {
"text": "Cancer",
"type": "choice",
"linkId": "D5g",
"prefix": "g.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
}, {
"text": "Diabetes",
"type": "choice",
"linkId": "D5h",
"prefix": "h.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
}, {
"item": [ {
"text": "Diagnosis",
"type": "string",
"linkId": "D5ia"
}, {
"text": "Diagnosis Code",
"type": "choice",
"linkId": "D5ib",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-diagnosis"
}, {
"text": "ICD-10-CA Code",
"type": "choice",
"linkId": "D5ic",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://fhir.infoway-inforoute.ca/io/cacore/ValueSet/ICD10CA"
} ],
"text": "Other disease diagnoses",
"type": "group",
"linkId": "D5i",
"repeats": true
} ],
"text": "5. DISEASE DIAGNOSES [COUNTRY SPECIFIC - CANADA]",
"type": "group",
"linkId": "D5"
}, {
"item": [ {
"text": "Last 30 days",
"type": "choice",
"linkId": "D6a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-number-of-falls"
}, {
"text": "31-90 days",
"type": "choice",
"linkId": "D6b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-number-of-falls"
}, {
"text": "91-180 days",
"type": "choice",
"linkId": "D6c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-number-of-falls"
} ],
"text": "6. FALLS",
"type": "group",
"linkId": "D6"
}, {
"item": [ {
"text": "Dizziness",
"type": "choice",
"linkId": "D7a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
}, {
"text": "Chest pain",
"type": "choice",
"linkId": "D7b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
}, {
"text": "Peripheral edema",
"type": "choice",
"linkId": "D7c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
}, {
"text": "Vomiting",
"type": "choice",
"linkId": "D7d",
"prefix": "d.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period2"
} ],
"text": "7. PROBLEM FREQUENCY",
"type": "group",
"linkId": "D7"
}, {
"item": [ {
"text": "Frequency with which person complains or shows evidence of pain (including grimacing, teeth clenching, moaning, withdrawal when touched, or other nonverbal signs suggesting pain)",
"type": "choice",
"linkId": "D8a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-pain"
}, {
"text": "Intensity of highest level of pain present",
"type": "choice",
"linkId": "D8b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-severity-of-pain"
} ],
"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",
"linkId": "D8"
}, {
"text": "SMOKES TOBACCO DAILY",
"type": "choice",
"linkId": "D9",
"prefix": "9.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/frequency-of-smoking"
}, {
"item": [ {
"text": "In LAST 3 DAYS, noticeable decrease in the amount of food usually eaten or fluids usually consumed",
"type": "choice",
"linkId": "D10a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "Weight loss of 5% or more in LAST 30 DAYS or 10% or more in LAST 180 DAYS",
"type": "choice",
"linkId": "D10b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "Special diet",
"type": "choice",
"linkId": "D10c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
} ],
"text": "10. NUTRITIONAL ISSUES",
"type": "group",
"linkId": "D10"
}, {
"text": "PRESENCE OF PRESSURE ULCER / INJURY",
"type": "choice",
"linkId": "D11",
"prefix": "11.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/presence-of-pressure-ulcer"
}, {
"text": "MAJOR SKIN PROBLEMS - e.g., lesions, 2nd- or 3rd-degree burns, healing surgical wounds",
"type": "choice",
"linkId": "D12",
"prefix": "12.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "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)",
"type": "choice",
"linkId": "D13",
"prefix": "13.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"item": [ {
"text": "Indwelling catheter",
"type": "choice",
"linkId": "D14a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-treatment-and-program"
}, {
"text": "IV therapy",
"type": "choice",
"linkId": "D14b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-treatment-and-program"
}, {
"text": "Oxygen therapy",
"type": "choice",
"linkId": "D14c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-treatment-and-program"
}, {
"text": "Ventilator",
"type": "choice",
"linkId": "D14d",
"prefix": "d.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-treatment-and-program"
}, {
"text": "Wound care",
"type": "choice",
"linkId": "D14e",
"prefix": "e.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-treatment-and-program"
} ],
"text": "14. TREATMENTS [COUNTRY SPECIFIC - CANADA] - Treatments received or scheduled in LAST 3 DAYS",
"type": "group",
"linkId": "D14"
}, {
"text": "TIME SINCE LAST HOSPITAL STAY",
"type": "choice",
"linkId": "D15",
"prefix": "15.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-since-last-hospital-stay"
}, {
"text": "EMERGENCY DEPARTMENT VISIT",
"type": "integer",
"linkId": "D16",
"prefix": "16.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueDecimal": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueDecimal": 90
} ]
}, {
"text": "SURGERY IN LAST 90 DAYS",
"type": "choice",
"linkId": "D17",
"prefix": "17.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/surgery"
}, {
"item": [ {
"text": "Relationship to person - Helper 1",
"type": "choice",
"linkId": "D18a1",
"prefix": "a.1.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-informal-helper-relationship"
}, {
"text": "Relationship to person - Helper 2",
"type": "choice",
"linkId": "D18a2",
"prefix": "a.2.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-informal-helper-relationship"
}, {
"text": "Lives with person - Helper 1",
"type": "choice",
"linkId": "D18b1",
"prefix": "b.1.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-informal-helper-lives-with-person"
}, {
"text": "Lives with person - Helper 2",
"type": "choice",
"linkId": "D18b2",
"prefix": "b.2.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-informal-helper-lives-with-person"
} ],
"text": "18. TWO KEY INFORMAL HELPERS [COUNTRY SPECIFIC - CANADA]",
"type": "group",
"linkId": "D18"
}, {
"item": [ {
"text": "Primary informal helper expresses feelings of distress, anger, or depression",
"type": "choice",
"linkId": "D19a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "Family or close friends report feeling overwhelmed by person\"s illness",
"type": "choice",
"linkId": "D19b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
} ],
"text": "19. INFORMAL HELPER STATUS",
"type": "group",
"linkId": "D19"
}, {
"text": "DEGREE OF LONELINESS - use self-report when possible (Ask: How often do you feel lonely?)",
"type": "choice",
"linkId": "D20",
"prefix": "20.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/degree-of-loneliness"
}, {
"text": "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",
"type": "choice",
"linkId": "D21",
"prefix": "21.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
} ],
"text": "Section D. Clinical Evaluation",
"type": "group",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "Section D. Clinical Evaluation"
} ]
},
"linkId": "D",
"enableWhen": [ {
"operator": "=",
"question": "C1",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills"
}
}, {
"operator": "=",
"question": "C1",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills"
}
}, {
"operator": "=",
"question": "C2a",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2a",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2b",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2b",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2c",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2c",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2d",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2d",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2e",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2e",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C3",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea"
}
}, {
"operator": "=",
"question": "C3",
"answerCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea"
}
}, {
"operator": "=",
"question": "C4",
"answerCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health"
}
}, {
"operator": "=",
"question": "C4",
"answerCoding": {
"code": "8",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health"
}
}, {
"operator": "=",
"question": "C5a",
"answerCoding": {
"code": "3",
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}
}, {
"operator": "=",
"question": "C5b",
"answerCoding": {
"code": "3",
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}
}, {
"operator": "=",
"question": "C5c",
"answerCoding": {
"code": "3",
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}
}, {
"operator": "=",
"question": "C6a",
"answerCoding": {
"code": "1",
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
}, {
"operator": "=",
"question": "C7",
"answerCoding": {
"code": "1",
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
} ],
"enableBehavior": "any"
}, {
"item": [ {
"item": [ {
"item": [ {
"text": "Assessment urgency",
"type": "integer",
"linkId": "E1a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueDecimal": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueDecimal": 6
} ]
}, {
"text": "Service urgency",
"type": "integer",
"linkId": "E1b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueDecimal": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueDecimal": 4
} ]
}, {
"text": "Rehabilitation",
"type": "integer",
"linkId": "E1c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueDecimal": 1
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueDecimal": 5
} ]
} ],
"text": "1. ALGORITHM SCORES - Record the computer-generated scores for each of the following",
"type": "group",
"linkId": "E1"
}, {
"text": "EXPECTED LENGTH OF SERVICE",
"type": "choice",
"linkId": "E2",
"prefix": "2.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/expected-length-of-service"
}, {
"text": "ASSESSMENT URGENCY - Urgency for comprehensive, face-to-face assessment",
"type": "choice",
"linkId": "E3",
"prefix": "3.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/assessment-urgency"
}, {
"item": [ {
"text": "Nursing",
"type": "choice",
"linkId": "E4a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
}, {
"text": "Personal support/household management",
"type": "choice",
"linkId": "E4b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
}, {
"text": "Physiotherapy",
"type": "choice",
"linkId": "E4c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
}, {
"text": "Occupational therapy",
"type": "choice",
"linkId": "E4d",
"prefix": "d.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
}, {
"text": "Dietitian services",
"type": "choice",
"linkId": "E4e",
"prefix": "e.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
}, {
"text": "Lab services, equipment, and medical supplies",
"type": "choice",
"linkId": "E4f",
"prefix": "f.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
}, {
"text": "Social work",
"type": "choice",
"linkId": "E4g",
"prefix": "g.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
}, {
"text": "Speech-language therapy",
"type": "choice",
"linkId": "E4h",
"prefix": "h.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
}, {
"text": "Other (specify)",
"type": "choice",
"linkId": "E4i1",
"prefix": "i.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/urgency-of-needed-services"
} ],
"text": "4. URGENCY OF NEEDED SERVICES",
"type": "group",
"linkId": "E4"
}, {
"text": "CLIENT GROUP [COUNTRY SPECIFIC - CANADA]",
"type": "choice",
"linkId": "E5",
"prefix": "5.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/client-group"
}, {
"text": "PRIMARY MODE OF ASSESSMENT",
"type": "choice",
"linkId": "E6",
"prefix": "6.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/assessment-mode"
}, {
"item": [ {
"text": "Person",
"type": "choice",
"linkId": "E7a",
"prefix": "a.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
}, {
"text": "Spouse / partner",
"type": "choice",
"linkId": "E7b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
}, {
"text": "Parent/guardian",
"type": "choice",
"linkId": "E7c",
"prefix": "c.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
}, {
"text": "Child or child-in-law",
"type": "choice",
"linkId": "E7d",
"prefix": "d.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
}, {
"text": "Other relative",
"type": "choice",
"linkId": "E7e",
"prefix": "e.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
}, {
"text": "Friend or neighbour",
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"linkId": "E7f",
"prefix": "f.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
}, {
"text": "Physician / physician assistant / nurse practitioner",
"type": "choice",
"linkId": "E7g",
"prefix": "g.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
}, {
"text": "Other home care / other health, or social service provider",
"type": "choice",
"linkId": "E7h",
"prefix": "h.",
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
} ],
"text": "7. SOURCES OF INFORMATION USED TO COMPLETE THE interRAI CA (Code only ONE PRIMARY source and ALL APPLICABLE SECONDARY sources)",
"type": "group",
"linkId": "E7"
} ],
"type": "group",
"linkId": "E1-7",
"enableWhen": [ {
"operator": "=",
"question": "C1",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills"
}
}, {
"operator": "=",
"question": "C1",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills"
}
}, {
"operator": "=",
"question": "C2a",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2a",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2b",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2b",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2c",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2c",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2d",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2d",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2e",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2e",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C3",
"answerCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea"
}
}, {
"operator": "=",
"question": "C3",
"answerCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/dyspnea"
}
}, {
"operator": "=",
"question": "C4",
"answerCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health"
}
}, {
"operator": "=",
"question": "C4",
"answerCoding": {
"code": "8",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/self-reported-health"
}
}, {
"operator": "=",
"question": "C5a",
"answerCoding": {
"code": "3",
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}
}, {
"operator": "=",
"question": "C5b",
"answerCoding": {
"code": "3",
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}
}, {
"operator": "=",
"question": "C5c",
"answerCoding": {
"code": "3",
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}
}, {
"operator": "=",
"question": "C6a",
"answerCoding": {
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}
}, {
"operator": "=",
"question": "C7",
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"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
} ],
"enableBehavior": "any"
}, {
"item": [ {
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"type": "text",
"linkId": "E8a"
}, {
"text": "b. Date assessment signed as complete",
"type": "date",
"linkId": "E8b",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
} ]
} ],
"text": "8. SIGNATURE OF PERSON COORDINATING/COMPLETING THE ASSESSMENT",
"type": "group",
"linkId": "E8"
} ],
"text": "Section E. Summary",
"type": "group",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "Section E. Summary"
} ]
},
"linkId": "E"
} ],
"type": null,
"experimental": "false",
"resourceType": "Questionnaire",
"title": "interRAI™ Contact Assessment (CA) 10.0.1_OH",
"_description": {
"extension": [ {
"url": "http://ontariohealth.ca/fhir/questionnaire/StructureDefinition/core-short-string",
"valueString": "interRAI™ Contact Assessment (CA) Form, version 10.0 – CIHI Canadian Standard"
} ]
},
"package_version": "1.0.0-ballot1-dev",
"extension": [ {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-entryMode",
"valueCode": "random"
} ],
"status": "active",
"id": "c5268586-5fb5-4155-9f83-d314200d1574",
"kind": null,
"url": "http://ontariohealth.ca/fhir/iar/Questionnaire/oh-interrai-contact-assessment",
"code": [ {
"code": "interRAICA",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/assessment-form-type",
"display": "interRAI Contact Assessment"
} ],
"_title": {
"extension": [ {
"url": "http://ontariohealth.ca/fhir/questionnaire/StructureDefinition/core-short-string",
"valueString": "interRAICA 10.0.1_OH"
} ]
},
"version": "10.0.1_OH",
"effectivePeriod": {
"start": "2026-10-01"
}
}