{
"description": "This 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) and modified by OntarioHealth. The FHIR artifact is maintained and published by Ontario Health.",
"_filename": "examples/Questionnaire-iar-interrai-contact-assessment-v1.0.0.json",
"package_name": "ca.on.oh.setp.iar.dev",
"subjectType": [ "Patient" ],
"date": "2026-01-01",
"publisher": "Ontario Health",
"approvalDate": "2026-01-01",
"name": null,
"item": [ {
"item": [ {
"item": [ {
"text": "a. Given name",
"type": "string",
"linkId": "A1a"
}, {
"text": "b. Middle initial",
"type": "string",
"linkId": "A1b"
}, {
"text": "c. Family name",
"type": "string",
"linkId": "A1c"
} ],
"text": "1. NAME",
"type": "group",
"linkId": "A1"
}, {
"item": [ {
"text": "a. Sex",
"type": "choice",
"linkId": "A2a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "F",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/sex",
"display": "Female"
}
}, {
"valueCoding": {
"code": "M",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/sex",
"display": "Male"
}
}, {
"valueCoding": {
"code": "UN",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/sex",
"display": "Not assigned male or female"
}
} ]
}, {
"text": "b. Gender identity",
"type": "choice",
"linkId": "A2b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "M",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/gender-identity",
"display": "Male"
}
}, {
"valueCoding": {
"code": "F",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/gender-identity",
"display": "Female"
}
}, {
"valueCoding": {
"code": "OTH",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/gender-identity",
"display": "Other gender identity"
}
}, {
"valueCoding": {
"code": "UNK",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/gender-identity",
"display": "Not known"
}
}, {
"valueCoding": {
"code": "NA",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/gender-identity",
"display": "Not applicable"
}
} ]
}, {
"text": "c. Person self-identifies gender as",
"type": "string",
"linkId": "A2c"
} ],
"text": "2. SEX / GENDER IDENTITY",
"type": "group",
"linkId": "A2"
}, {
"text": "3. BIRTHDATE",
"type": "date",
"linkId": "A3",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
} ]
}, {
"text": "4. MARITAL STATUS",
"type": "choice",
"linkId": "A4",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "1",
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"display": "Never married"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"display": "Married"
}
}, {
"valueCoding": {
"code": "3",
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"display": "Partner/significant other"
}
}, {
"valueCoding": {
"code": "4",
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"display": "Widowed"
}
}, {
"valueCoding": {
"code": "5",
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"display": "Separated"
}
}, {
"valueCoding": {
"code": "6",
"system": "http://terminology.hl7.org/CodeSystem/v3-MaritalStatus",
"display": "Divorced"
}
} ]
}, {
"item": [ {
"text": "a. Healthcare Identification Number",
"type": "string",
"linkId": "A5a"
}, {
"text": "b. Province or territory issuing Healthcare Identification Number",
"type": "choice",
"linkId": "A5b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "NA",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "not applicable"
}
}, {
"valueCoding": {
"code": "UNK",
"system": "http://terminology.hl7.org/CodeSystem/v3-NullFlavor",
"display": "unknown"
}
}, {
"valueCoding": {
"code": "AB",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Alberta"
}
}, {
"valueCoding": {
"code": "BC",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "British Columbia"
}
}, {
"valueCoding": {
"code": "MB",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Manitoba"
}
}, {
"valueCoding": {
"code": "NB",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "New Brunswick"
}
}, {
"valueCoding": {
"code": "NL",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Newfoundland and Labrador"
}
}, {
"valueCoding": {
"code": "NT",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Northwest Territories"
}
}, {
"valueCoding": {
"code": "NS",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Nova Scotia"
}
}, {
"valueCoding": {
"code": "NU",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Nunavut"
}
}, {
"valueCoding": {
"code": "ON",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Ontario"
}
}, {
"valueCoding": {
"code": "PE",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Prince Edward Island"
}
}, {
"valueCoding": {
"code": "QC",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Quebec"
}
}, {
"valueCoding": {
"code": "SK",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Saskatchewan"
}
}, {
"valueCoding": {
"code": "YT",
"system": "http://canadapost.ca/CodeSystem/ProvinceCodes",
"display": "Yukon"
}
} ]
}, {
"text": "c. Case record number",
"type": "string",
"linkId": "A5c",
"maxLength": 15
} ],
"text": "5. NUMERIC IDENTIFIERS",
"type": "group",
"linkId": "A5"
}, {
"text": "6. POSTAL CODE OF USUAL LIVING ARRANGEMENT",
"type": "string",
"linkId": "A6",
"maxLength": 6
}, {
"text": "7. AGENCY IDENTIFIER",
"type": "string",
"linkId": "A7",
"maxLength": 6
}, {
"item": [ {
"text": "a. First Nations",
"type": "choice",
"linkId": "A8a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
}, {
"text": "b. Métis",
"type": "choice",
"linkId": "A8b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
}, {
"text": "c. Inuit",
"type": "choice",
"linkId": "A8c",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
} ],
"text": "8. INDIGENOUS IDENTITY - Person identifies as First Nations, Métis, or Inuit",
"type": "group",
"linkId": "A8"
}, {
"text": "9. PRIMARY LANGUAGE",
"type": "choice",
"linkId": "A9",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "eng",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/languages",
"display": "English"
}
}, {
"valueCoding": {
"code": "fra",
"display": "French"
}
} ]
}, {
"text": "10. INTERPRETER NEEDED",
"type": "choice",
"linkId": "A10",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
}, {
"text": "11. REASONS FOR REFERRAL",
"type": "string",
"linkId": "A11"
}, {
"text": "12. LOCATION OF ASSESSMENT",
"type": "choice",
"linkId": "A12",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "1",
"display": "Community"
}
}, {
"valueCoding": {
"code": "2",
"display": "Hospital (excluding emergency department)"
}
}, {
"valueCoding": {
"code": "3",
"display": "Emergency department"
}
}, {
"valueCoding": {
"code": "4",
"display": "Other"
}
} ]
} ],
"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": "1. ASSESSMENT REFERENCE DATE",
"type": "date",
"linkId": "B1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
} ]
}, {
"item": [ {
"text": "a. Time frame for initiation of ordered treatments in community",
"type": "choice",
"linkId": "B2a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not ordered"
}
}, {
"valueCoding": {
"code": "1",
"display": "Treatment already initiated in community"
}
}, {
"valueCoding": {
"code": "2",
"display": "48 hours or more"
}
}, {
"valueCoding": {
"code": "3",
"display": "24 to less than 48 hours"
}
}, {
"valueCoding": {
"code": "4",
"display": "12 to less than 24 hours"
}
}, {
"valueCoding": {
"code": "5",
"display": "Less than 12 hours"
}
} ]
}, {
"text": "a. Administration of medication (other than IV)",
"type": "choice",
"linkId": "B2a.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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not ordered"
}
}, {
"valueCoding": {
"code": "1",
"display": "Treatment already initiated in community"
}
}, {
"valueCoding": {
"code": "2",
"display": "48 hours or more"
}
}, {
"valueCoding": {
"code": "3",
"display": "24 to less than 48 hours"
}
}, {
"valueCoding": {
"code": "4",
"display": "12 to less than 24 hours"
}
}, {
"valueCoding": {
"code": "5",
"display": "Less than 12 hours"
}
} ]
}, {
"text": "b. Indwelling catheter",
"type": "choice",
"linkId": "B2a.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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not ordered"
}
}, {
"valueCoding": {
"code": "1",
"display": "Treatment already initiated in community"
}
}, {
"valueCoding": {
"code": "2",
"display": "48 hours or more"
}
}, {
"valueCoding": {
"code": "3",
"display": "24 to less than 48 hours"
}
}, {
"valueCoding": {
"code": "4",
"display": "12 to less than 24 hours"
}
}, {
"valueCoding": {
"code": "5",
"display": "Less than 12 hours"
}
} ]
}, {
"text": "c. IV therapy",
"type": "choice",
"linkId": "B2a.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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not ordered"
}
}, {
"valueCoding": {
"code": "1",
"display": "Treatment already initiated in community"
}
}, {
"valueCoding": {
"code": "2",
"display": "48 hours or more"
}
}, {
"valueCoding": {
"code": "3",
"display": "24 to less than 48 hours"
}
}, {
"valueCoding": {
"code": "4",
"display": "12 to less than 24 hours"
}
}, {
"valueCoding": {
"code": "5",
"display": "Less than 12 hours"
}
} ]
}, {
"text": "d. Wound care",
"type": "choice",
"linkId": "B2a.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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not ordered"
}
}, {
"valueCoding": {
"code": "1",
"display": "Treatment already initiated in community"
}
}, {
"valueCoding": {
"code": "2",
"display": "48 hours or more"
}
}, {
"valueCoding": {
"code": "3",
"display": "24 to less than 48 hours"
}
}, {
"valueCoding": {
"code": "4",
"display": "12 to less than 24 hours"
}
}, {
"valueCoding": {
"code": "5",
"display": "Less than 12 hours"
}
} ]
}, {
"text": "e. Other (specify)",
"type": "string",
"linkId": "B2a.e"
}, {
"text": "b. Referral to initiate or continue rehabilitation services",
"type": "choice",
"linkId": "B2b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
}, {
"text": "c. Referral to initiate or continue palliative services",
"type": "choice",
"linkId": "B2c",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
} ],
"text": "2. REFERRAL DETAILS",
"type": "group",
"linkId": "B2"
}, {
"text": "3. EXPECTED LIVING ARRANGEMENT DURING SERVICE PROVISION",
"type": "choice",
"linkId": "B3",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/living-arrangement",
"display": "Alone"
}
}, {
"valueCoding": {
"code": "2",
"display": "With spouse / partner only"
}
}, {
"valueCoding": {
"code": "3",
"display": "With spouse / partner and other(s)"
}
}, {
"valueCoding": {
"code": "4",
"display": "With child (not spouse / partner)"
}
}, {
"valueCoding": {
"code": "5",
"display": "With parent(s) or guardian(s)"
}
}, {
"valueCoding": {
"code": "6",
"display": "With sibling(s)"
}
}, {
"valueCoding": {
"code": "7",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/living-arrangement",
"display": "With other relative(s)"
}
}, {
"valueCoding": {
"code": "8",
"display": "With nonrelative(s)"
}
} ]
}, {
"text": "4. EXPECTED RESIDENTIAL / LIVING STATUS DURING SERVICE PROVISION",
"type": "choice",
"linkId": "B4",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "1",
"display": "Private home / apartment / rented room"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"display": "Board and care"
}
}, {
"valueCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"display": "Assisted living or semi-independent living"
}
}, {
"valueCoding": {
"code": "4",
"display": "Mental health residence - e.g. psychiatric group home"
}
}, {
"valueCoding": {
"code": "5",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"display": "Group home for persons with physical disability"
}
}, {
"valueCoding": {
"code": "6",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"display": "Setting for persons with intellectual disability"
}
}, {
"valueCoding": {
"code": "7",
"display": "Psychiatric hospital / unit"
}
}, {
"valueCoding": {
"code": "8",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"display": "Homeless (with or without shelter)"
}
}, {
"valueCoding": {
"code": "9",
"display": "Residential care facility (e.g. long-term care home"
}
}, {
"valueCoding": {
"code": "10",
"display": "Rehabilitation hospital / unit"
}
}, {
"valueCoding": {
"code": "11",
"display": "Hospice facility / palliative care unit"
}
}, {
"valueCoding": {
"code": "12",
"display": "Acute care hospital / unit"
}
}, {
"valueCoding": {
"code": "13",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/location-one",
"display": "Correctional facility"
}
}, {
"valueCoding": {
"code": "14",
"display": "Continuing care hospital / unit"
}
}, {
"valueCoding": {
"code": "15",
"display": "Other"
}
} ]
} ],
"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": "1. 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",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"display": "Independent - Decisions consistent reasonable"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"display": "Some but not severe impairment"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/ca-cognitive-skills",
"display": "Severely impaired - Never or rarely makes decisions"
}
} ]
}, {
"item": [ {
"text": "a. 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",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
}, {
"text": "b. Bath transfer - How person transfers in/out of bath or shower",
"type": "choice",
"linkId": "C2b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
}, {
"text": "c. 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",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
}, {
"text": "d. 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",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
}, {
"text": "e. Locomotion - How moves between locations on same floor (walking or wheeling). If in wheelchair, self-sufficiency once in chair.",
"type": "choice",
"linkId": "C2e",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
} ],
"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": "3. DYSPNEA (Shortness of Breath)",
"type": "choice",
"linkId": "C3",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/presence-of-symptom",
"display": "Absence of symptom"
}
}, {
"valueCoding": {
"code": "1",
"display": "Absent at rest but present when performed moderate activities"
}
}, {
"valueCoding": {
"code": "2",
"display": "Absent at rest but present when performed normal day-to-day activities"
}
}, {
"valueCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/presence-of-symptom",
"display": "Present at rest"
}
} ]
}, {
"text": "4. SELF-REPORTED HEALTH (Ask: In general, how would you rate your health?)",
"type": "choice",
"linkId": "C4",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Excellent"
}
}, {
"valueCoding": {
"code": "1",
"display": "Good"
}
}, {
"valueCoding": {
"code": "2",
"display": "Fair"
}
}, {
"valueCoding": {
"code": "3",
"display": "Poor"
}
}, {
"valueCoding": {
"code": "8",
"display": "Person could not (would not) respond"
}
} ]
}, {
"item": [ {
"text": "a. Little interest or pleasure in things you normally enjoy?",
"type": "choice",
"linkId": "C5a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not in last 3 days"
}
}, {
"valueCoding": {
"code": "1",
"display": "Not in last 3 days but often feels that way"
}
}, {
"valueCoding": {
"code": "2",
"display": "In 1-2 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
} ]
}, {
"text": "b. Anxious, restless, or uneasy?",
"type": "choice",
"linkId": "C5b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not in last 3 days"
}
}, {
"valueCoding": {
"code": "1",
"display": "Not in last 3 days but often feels that way"
}
}, {
"valueCoding": {
"code": "2",
"display": "In 1-2 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
} ]
}, {
"text": "c. Sad, depressed, or hopeless?",
"type": "choice",
"linkId": "C5c",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not in last 3 days"
}
}, {
"valueCoding": {
"code": "1",
"display": "Not in last 3 days but often feels that way"
}
}, {
"valueCoding": {
"code": "2",
"display": "In 1-2 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
} ]
} ],
"text": "5. SELF-REPORTED MOOD (Ask: “In the last 3 days, how often have you felt . . .”)",
"type": "group",
"linkId": "C5"
}, {
"item": [ {
"text": "a. Conditions/diseases make cognitive, ADL, mood, or behaviour patterns unstable",
"type": "choice",
"linkId": "C6a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
}, {
"text": "b. Experiencing an acute episode or a flare-up of a recurrent or chronic problem",
"type": "choice",
"linkId": "C6b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
} ],
"text": "6. INSTABILITY OF CONDITIONS",
"type": "group",
"linkId": "C6"
}, {
"text": "7. HOME CARE OR COMMUNITY SUPPORT SERVICES MAY BE REQUIRED FOR THIS PERSON",
"type": "choice",
"linkId": "C7",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
} ],
"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": "1. CHANGE IN DECISION MAKING AS COMPARED TO 90 DAYS AGO (OR SINCE LAST ASSESSMENT IF LESS THAN 90 DAYS AGO)",
"type": "choice",
"linkId": "D1",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"display": "Improved"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"display": "No change"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"display": "Declined"
}
}, {
"valueCoding": {
"code": "8",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"display": "Uncertain"
}
} ]
}, {
"text": "2. ABILITY TO UNDERSTAND OTHERS (Comprehension) - Understanding information content (however able; with hearing or other assistive devices normally used)",
"type": "choice",
"linkId": "D2",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Understands - Clear comprehension"
}
}, {
"valueCoding": {
"code": "1",
"display": "Usually understands - Misses some part/intent of message BUT comprehends most conversation"
}
}, {
"valueCoding": {
"code": "2",
"display": "Often understands - Misses some part/intent of message BUT with repetition or explanation can often comprehend conversation"
}
}, {
"valueCoding": {
"code": "3",
"display": "Sometimes understands - Responds adequately to simple direct communication only"
}
}, {
"valueCoding": {
"code": "4",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/understanding-other",
"display": "Rarely or never understands"
}
} ]
}, {
"item": [ {
"text": "a. Meal preparation — How prepares meals (e.g., planning meals, assembling ingredients, cooking, setting out food and utensils)",
"type": "choice",
"linkId": "D3a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
}, {
"text": "b. Ordinary housework — How performs ordinary work around the house (e.g., doing dishes, dusting, making bed, tidying up, laundry)",
"type": "choice",
"linkId": "D3b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
}, {
"text": "c. .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",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
}, {
"text": "d. Stairs — How manages full flight of stairs (e.g., 12–14 stairs)",
"type": "choice",
"linkId": "D3d",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
}, {
"text": "e. 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",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
}, {
"text": "f. 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",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Independent or set-up help only"
}
}, {
"valueCoding": {
"code": "1",
"display": "Supervision or some physical assistance by others"
}
}, {
"valueCoding": {
"code": "2",
"display": "Total dependence - Full performance by others during entire period"
}
} ]
} ],
"text": "3. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) CAPACITY",
"type": "group",
"linkId": "D3"
}, {
"text": "4. CHANGE IN ADL STATUS AS COMPARED TO 90 DAYS AGO (OR SINCE LAST ASSESSMENT IF LESS THAN 90 DAYS AGO)",
"type": "choice",
"linkId": "D4",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"display": "Improved"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"display": "No change"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"display": "Declined"
}
}, {
"valueCoding": {
"code": "8",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/degree-of-improvement",
"display": "Uncertain"
}
} ]
}, {
"item": [ {
"text": "a. Alzheimer\"s disease",
"type": "choice",
"linkId": "D5a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
}, {
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
}, {
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
} ]
}, {
"text": "b. Dementia other than Alzheimer\"s disease",
"type": "choice",
"linkId": "D5b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
}, {
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
}, {
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
} ]
}, {
"text": "c. Stroke",
"type": "choice",
"linkId": "D5c",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
}, {
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
}, {
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
} ]
}, {
"text": "d. Coronary heart disease",
"type": "choice",
"linkId": "D5d",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
}, {
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
}, {
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
} ]
}, {
"text": "e. Chronic obstructive pulmonary disease",
"type": "choice",
"linkId": "D5e",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
}, {
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
}, {
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
} ]
}, {
"text": "f. Congestive heart failure",
"type": "choice",
"linkId": "D5f",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
}, {
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
}, {
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
} ]
}, {
"text": "g. Cancer",
"type": "choice",
"linkId": "D5g",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
}, {
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
}, {
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
} ]
}, {
"text": "h. Diabetes",
"type": "choice",
"linkId": "D5h",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary diagnosis / diagnoses for current referral"
}
}, {
"valueCoding": {
"code": "2",
"display": "Diagnosis present receiving active treatment"
}
}, {
"valueCoding": {
"code": "3",
"display": "Diagnosis present monitored but no active treatment"
}
} ]
}, {
"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://ontariohealth.ca/fhir/iar/ValueSet/sex"
}, {
"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",
"type": "group",
"linkId": "D5"
}, {
"item": [ {
"text": "a. Last 30 days",
"type": "choice",
"linkId": "D6a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No fall"
}
}, {
"valueCoding": {
"code": "1",
"display": "1 fall"
}
}, {
"valueCoding": {
"code": "2",
"display": "2 or more falls"
}
} ]
}, {
"text": "b. 31-90 days",
"type": "choice",
"linkId": "D6b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No fall"
}
}, {
"valueCoding": {
"code": "1",
"display": "1 fall"
}
}, {
"valueCoding": {
"code": "2",
"display": "2 or more falls"
}
} ]
}, {
"text": "c. 91-180 days",
"type": "choice",
"linkId": "D6c",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No fall"
}
}, {
"valueCoding": {
"code": "1",
"display": "1 fall"
}
}, {
"valueCoding": {
"code": "2",
"display": "2 or more falls"
}
} ]
} ],
"text": "6. FALLS",
"type": "group",
"linkId": "D6"
}, {
"item": [ {
"text": "a. Dizziness",
"type": "choice",
"linkId": "D7a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Present but not exhibited in last 3 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "Exhibited on 1 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Exhibited on 2 of last 3 days"
}
}, {
"valueCoding": {
"code": "4",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-two",
"display": "Exhibited daily in last 3 days"
}
} ]
}, {
"text": "b. Chest pain",
"type": "choice",
"linkId": "D7b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Present but not exhibited in last 3 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "Exhibited on 1 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Exhibited on 2 of last 3 days"
}
}, {
"valueCoding": {
"code": "4",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-two",
"display": "Exhibited daily in last 3 days"
}
} ]
}, {
"text": "c. Peripheral edema",
"type": "choice",
"linkId": "D7c",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Present but not exhibited in last 3 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "Exhibited on 1 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Exhibited on 2 of last 3 days"
}
}, {
"valueCoding": {
"code": "4",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-two",
"display": "Exhibited daily in last 3 days"
}
} ]
}, {
"text": "d. Vomiting",
"type": "choice",
"linkId": "D7d",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Not present"
}
}, {
"valueCoding": {
"code": "1",
"display": "Present but not exhibited in last 3 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "Exhibited on 1 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-three",
"display": "Exhibited on 2 of last 3 days"
}
}, {
"valueCoding": {
"code": "4",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-with-time-period-two",
"display": "Exhibited daily in last 3 days"
}
} ]
} ],
"text": "7. PROBLEM FREQUENCY",
"type": "group",
"linkId": "D7"
}, {
"item": [ {
"text": "a. 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",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"display": "No pain"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"display": "Mild"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"display": "Moderate"
}
}, {
"valueCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"display": "Severe"
}
}, {
"valueCoding": {
"code": "4",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"display": "Times when pain is horrible or excruciating"
}
} ]
}, {
"text": "b. Intensity of highest level of pain present",
"type": "choice",
"linkId": "D8b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"display": "No pain"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"display": "Mild"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"display": "Moderate"
}
}, {
"valueCoding": {
"code": "3",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"display": "Severe"
}
}, {
"valueCoding": {
"code": "4",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/severity-of-pain",
"display": "Times when pain is horrible or excruciating"
}
} ]
} ],
"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": "9. SMOKES TOBACCO DAILY",
"type": "choice",
"linkId": "D9",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-of-smoking",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"display": "Not in last 3 days but is usually a daily smoker"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/frequency-of-smoking",
"display": "Yes"
}
} ]
}, {
"item": [ {
"text": "a. In LAST 3 DAYS, noticeable decrease in the amount of food usually eaten or fluids usually consumed",
"type": "choice",
"linkId": "D10a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
}, {
"text": "b. Weight loss of 5% or more in LAST 30 DAYS or 10% or more in LAST 180 DAYS",
"type": "choice",
"linkId": "D10b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
}, {
"text": "c. Special diet",
"type": "choice",
"linkId": "D10c",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
} ],
"text": "10. NUTRITIONAL ISSUES",
"type": "group",
"linkId": "D10"
}, {
"text": "11. PRESENCE OF PRESSURE ULCER / INJURY",
"type": "choice",
"linkId": "D11",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No pressure ulcer"
}
}, {
"valueCoding": {
"code": "1",
"display": "Any area of persistent skin redness"
}
}, {
"valueCoding": {
"code": "2",
"display": "Any break in skin integrity (e.g. partial loss of skin layers breaks in skin exposing muscle or bone)"
}
} ]
}, {
"text": "12. MAJOR SKIN PROBLEMS - e.g., lesions, 2nd- or 3rd-degree burns, healing surgical wounds",
"type": "choice",
"linkId": "D12",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
}, {
"text": "13. 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",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
}, {
"item": [ {
"text": "a. Indwelling catheter",
"type": "choice",
"linkId": "D14a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not ordered AND did not occur"
}
}, {
"valueCoding": {
"code": "1",
"display": "Ordered not implemented"
}
}, {
"valueCoding": {
"code": "2",
"display": "1-2 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
} ]
}, {
"text": "b. IV therapy",
"type": "choice",
"linkId": "D14b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not ordered AND did not occur"
}
}, {
"valueCoding": {
"code": "1",
"display": "Ordered not implemented"
}
}, {
"valueCoding": {
"code": "2",
"display": "1-2 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
} ]
}, {
"text": "c. Oxygen therapy",
"type": "choice",
"linkId": "D14c",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not ordered AND did not occur"
}
}, {
"valueCoding": {
"code": "1",
"display": "Ordered not implemented"
}
}, {
"valueCoding": {
"code": "2",
"display": "1-2 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
} ]
}, {
"text": "d. Ventilator",
"type": "choice",
"linkId": "D14d",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not ordered AND did not occur"
}
}, {
"valueCoding": {
"code": "1",
"display": "Ordered not implemented"
}
}, {
"valueCoding": {
"code": "2",
"display": "1-2 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
} ]
}, {
"text": "e. Wound care",
"type": "choice",
"linkId": "D14e",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not ordered AND did not occur"
}
}, {
"valueCoding": {
"code": "1",
"display": "Ordered not implemented"
}
}, {
"valueCoding": {
"code": "2",
"display": "1-2 of last 3 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "Daily in last 3 days"
}
} ]
} ],
"text": "14. TREATMENTS - Treatments received or scheduled in LAST 3 DAYS",
"type": "group",
"linkId": "D14"
}, {
"text": "15. TIME SINCE LAST HOSPITAL STAY",
"type": "choice",
"linkId": "D15",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No hospitalization within 90 days"
}
}, {
"valueCoding": {
"code": "1",
"display": "31-90 days ago"
}
}, {
"valueCoding": {
"code": "2",
"display": "15-30 days ago"
}
}, {
"valueCoding": {
"code": "3",
"display": "8-14 days ago"
}
}, {
"valueCoding": {
"code": "4",
"display": "In last 7 days"
}
}, {
"valueCoding": {
"code": "5",
"display": "Now in hospital"
}
} ]
}, {
"text": "16. EMERGENCY DEPARTMENT VISIT",
"type": "string",
"linkId": "D16"
}, {
"text": "17. SURGERY IN LAST 90 DAYS",
"type": "choice",
"linkId": "D17",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"display": "Yes without general anesthesia"
}
}, {
"valueCoding": {
"code": "2",
"display": "Yes with general anesthesia"
}
} ]
}, {
"item": [ {
"text": "a.1. Helper 1 - Relationship to person",
"type": "choice",
"linkId": "D18a.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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "1",
"display": "Child or child-in-law"
}
}, {
"valueCoding": {
"code": "2",
"display": "Spouse"
}
}, {
"valueCoding": {
"code": "3",
"display": "Partner/significant other"
}
}, {
"valueCoding": {
"code": "4",
"display": "Parent/guardian"
}
}, {
"valueCoding": {
"code": "5",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-relationship",
"display": "Sibling"
}
}, {
"valueCoding": {
"code": "6",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-relationship",
"display": "Other relative"
}
}, {
"valueCoding": {
"code": "7",
"display": "Friend"
}
}, {
"valueCoding": {
"code": "8",
"display": "Neighbour"
}
}, {
"valueCoding": {
"code": "9",
"display": "No informal helper"
}
} ]
}, {
"text": "a.2. Helper 2 - Relationship to person",
"type": "choice",
"linkId": "D18a.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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "1",
"display": "Child or child-in-law"
}
}, {
"valueCoding": {
"code": "2",
"display": "Spouse"
}
}, {
"valueCoding": {
"code": "3",
"display": "Partner/significant other"
}
}, {
"valueCoding": {
"code": "4",
"display": "Parent/guardian"
}
}, {
"valueCoding": {
"code": "5",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-relationship",
"display": "Sibling"
}
}, {
"valueCoding": {
"code": "6",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-relationship",
"display": "Other relative"
}
}, {
"valueCoding": {
"code": "7",
"display": "Friend"
}
}, {
"valueCoding": {
"code": "8",
"display": "Neighbour"
}
}, {
"valueCoding": {
"code": "9",
"display": "No informal helper"
}
} ]
}, {
"text": "b.1. Helper 1 - Lives with person",
"type": "choice",
"linkId": "D18b.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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-lives-with-child-youth",
"display": "Yes, 6 months or less"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-lives-with-child-youth",
"display": "Yes, more than 6 months"
}
} ]
}, {
"text": "b.2. Helper 2 - Lives with person",
"type": "choice",
"linkId": "D18b.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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-lives-with-child-youth",
"display": "Yes, 6 months or less"
}
}, {
"valueCoding": {
"code": "2",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/caregiver-lives-with-child-youth",
"display": "Yes, more than 6 months"
}
} ]
} ],
"text": "18. TWO KEY INFORMAL HELPERS",
"type": "group",
"linkId": "D18"
}, {
"item": [ {
"text": "a. Primary informal helper expresses feelings of distress, anger, or depression",
"type": "choice",
"linkId": "D19a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
}, {
"text": "b. Family or close friends report feeling overwhelmed by person\"s illness",
"type": "choice",
"linkId": "D19b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
} ],
"text": "19. INFORMAL HELPER STATUS",
"type": "group",
"linkId": "D19"
}, {
"text": "20. DEGREE OF LONELINESS use self-report when possible (Ask: How often do you feel lonely?)",
"type": "choice",
"linkId": "D20",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not lonely"
}
}, {
"valueCoding": {
"code": "1",
"display": "Only in certain situations or triggered by specific events"
}
}, {
"valueCoding": {
"code": "2",
"display": "Occasionally (less than weekly)"
}
}, {
"valueCoding": {
"code": "3",
"display": "Frequently (weekly but less than daily)"
}
}, {
"valueCoding": {
"code": "4",
"system": "http://snomed.info/sct",
"display": "Daily"
}
} ]
}, {
"text": "21. 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",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "No"
}
}, {
"valueCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/yes-no",
"display": "Yes"
}
} ]
} ],
"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": "a. Assessment urgency (score 1 to 6)",
"type": "integer",
"linkId": "E1a"
}, {
"text": "b. Service urgency (score 1 to 4)",
"type": "integer",
"linkId": "E1b"
}, {
"text": "c. Rehabilitation (score 1 to 5)",
"type": "integer",
"linkId": "E1c"
} ],
"text": "1. ALGORITHM SCORES - Record the computer-generated scores for each of the following",
"type": "group",
"linkId": "E1"
}, {
"text": "2. EXPECTED LENGTH OF SERVICE",
"type": "choice",
"linkId": "E2",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not lonely"
}
}, {
"valueCoding": {
"code": "1",
"display": "Only in certain situations or triggered by specific events"
}
}, {
"valueCoding": {
"code": "2",
"display": "Occasionally (less than weekly)"
}
}, {
"valueCoding": {
"code": "3",
"display": "Frequently (weekly but less than daily)"
}
}, {
"valueCoding": {
"code": "4",
"system": "http://snomed.info/sct",
"display": "Daily"
}
} ]
}, {
"text": "3. ASSESSMENT URGENCY - Urgency for comprehensive, face-to-face assessment",
"type": "choice",
"linkId": "E3",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "Not required"
}
}, {
"valueCoding": {
"code": "1",
"display": "More than 14 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "8-14 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "Within 7 days"
}
} ]
}, {
"item": [ {
"text": "a. Nursing",
"type": "choice",
"linkId": "E4a",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No services"
}
}, {
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
} ]
}, {
"text": "b. Personal support/household management",
"type": "choice",
"linkId": "E4b",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No services"
}
}, {
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
} ]
}, {
"text": "c. Physiotherapy",
"type": "choice",
"linkId": "E4c",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No services"
}
}, {
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
} ]
}, {
"text": "d. Occupational therapy",
"type": "choice",
"linkId": "E4d",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No services"
}
}, {
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
} ]
}, {
"text": "e. Dietitian services",
"type": "choice",
"linkId": "E4e",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No services"
}
}, {
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
} ]
}, {
"text": "f. Lab services, equipment, and medical supplies",
"type": "choice",
"linkId": "E4f",
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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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No services"
}
}, {
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
} ]
}, {
"text": "g. Social work",
"type": "choice",
"linkId": "E4g",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No services"
}
}, {
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
} ]
}, {
"text": "h. Speech-language therapy",
"type": "choice",
"linkId": "E4h",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"display": "No services"
}
}, {
"valueCoding": {
"code": "1",
"display": "1-14 days"
}
}, {
"valueCoding": {
"code": "2",
"display": "15-60 days"
}
}, {
"valueCoding": {
"code": "3",
"display": "61 or more days"
}
} ]
}, {
"text": "i. Other (specify)",
"type": "string",
"linkId": "E4i"
} ],
"text": "4. URGENCY OF NEEDED SERVICES",
"type": "group",
"linkId": "E4"
}, {
"text": "5. CLIENT GROUP",
"type": "choice",
"linkId": "E5",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "1",
"display": "Acute"
}
}, {
"valueCoding": {
"code": "2",
"display": "End-of-life"
}
}, {
"valueCoding": {
"code": "3",
"display": "Rehabilitation"
}
}, {
"valueCoding": {
"code": "4",
"display": "Long-term supportive care"
}
}, {
"valueCoding": {
"code": "5",
"display": "Maintenance"
}
}, {
"valueCoding": {
"code": "6",
"display": "Assessment only no other home care services"
}
} ]
}, {
"text": "6. PRIMARY MODE OF ASSESSMENT",
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"linkId": "E6",
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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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "1",
"display": "In person"
}
}, {
"valueCoding": {
"code": "2",
"display": "Virtual conference with video"
}
}, {
"valueCoding": {
"code": "3",
"display": "Virtual conference audio only"
}
} ]
}, {
"item": [ {
"text": "a. Person",
"type": "choice",
"linkId": "E7a",
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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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"display": "Not applicable"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary"
}
}, {
"valueCoding": {
"code": "2",
"display": "Secondary"
}
} ]
}, {
"text": "b. Spouse / partner",
"type": "choice",
"linkId": "E7b",
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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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"display": "Not applicable"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary"
}
}, {
"valueCoding": {
"code": "2",
"display": "Secondary"
}
} ]
}, {
"text": "c. Parent/guardian",
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"linkId": "E7c",
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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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"display": "Not applicable"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary"
}
}, {
"valueCoding": {
"code": "2",
"display": "Secondary"
}
} ]
}, {
"text": "d. Child or child-in-law",
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"linkId": "E7d",
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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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"display": "Not applicable"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary"
}
}, {
"valueCoding": {
"code": "2",
"display": "Secondary"
}
} ]
}, {
"text": "e. Other relative",
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"linkId": "E7e",
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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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"display": "Not applicable"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary"
}
}, {
"valueCoding": {
"code": "2",
"display": "Secondary"
}
} ]
}, {
"text": "f. Friend or neighbour",
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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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"display": "Not applicable"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary"
}
}, {
"valueCoding": {
"code": "2",
"display": "Secondary"
}
} ]
}, {
"text": "g. Physician / physician assistant / nurse practitioner",
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"linkId": "E7g",
"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"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"display": "Not applicable"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary"
}
}, {
"valueCoding": {
"code": "2",
"display": "Secondary"
}
} ]
}, {
"text": "h. Other home care / other health, or social service provider",
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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"
} ]
}
} ],
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"valueCoding": {
"code": "0",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/not-applicable",
"display": "Not applicable"
}
}, {
"valueCoding": {
"code": "1",
"display": "Primary"
}
}, {
"valueCoding": {
"code": "2",
"display": "Secondary"
}
} ]
} ],
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"linkId": "E7"
} ],
"type": "group",
"linkId": "E1-7",
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"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"
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}, {
"operator": "=",
"question": "C2a",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
}
}, {
"operator": "=",
"question": "C2a",
"answerCoding": {
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"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
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}, {
"operator": "=",
"question": "C2b",
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"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
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}, {
"operator": "=",
"question": "C2b",
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"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
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}, {
"operator": "=",
"question": "C2c",
"answerCoding": {
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"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
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}, {
"operator": "=",
"question": "C2c",
"answerCoding": {
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"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
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}, {
"operator": "=",
"question": "C2d",
"answerCoding": {
"code": "1",
"system": "http://ontariohealth.ca/fhir/iar/ValueSet/adl-self-performance"
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}, {
"operator": "=",
"question": "C2d",
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"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",
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"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",
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}
}, {
"operator": "=",
"question": "C4",
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"code": "8",
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}
}, {
"operator": "=",
"question": "C5a",
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"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}
}, {
"operator": "=",
"question": "C5b",
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"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
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}, {
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"question": "C5c",
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"code": "3",
"system": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}
}, {
"operator": "=",
"question": "C6a",
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}
}, {
"operator": "=",
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}
} ],
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}, {
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} ]
} ],
"text": "8. SIGNATURE OF PERSON COORDINATING/COMPLETING THE ASSESSMENT",
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} ],
"text": "Section E. Summary",
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"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
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},
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} ],
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"title": "interRAI™ Contact Assessment (CA) 10.0.1_OH",
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"url": "http://ontariohealth.ca/fhir/questionnaire/StructureDefinition/core-short-string",
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},
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"valueCode": "random"
} ],
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"kind": null,
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"code": [ {
"code": "INTERRAICA",
"system": "http://ontariohealth.ca/fhir/iar/CodeSystem/assessment-form-type",
"display": "interRAI™ Contact Assessment"
} ],
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"url": "http://ontariohealth.ca/fhir/questionnaire/StructureDefinition/core-short-string",
"valueString": "interRAI Contact Assessment"
} ]
},
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"effectivePeriod": {
"start": "2026-10-01"
}
}