Supported Hospital Discharge to Social Care

Refer Patient

A referral to Social Care for a Supported Hospital Discharge can take many forms. It could be accompanied by a formal Assessment Notice (as per Care Act 2014), however it is not uncommon for the Social Care Practitioners to get involved early in the discharge process, e.g. to help triage pathway and/or have visibility that one of their service users has been admitted to hospital and may need an early review. By enabling the referral to be sent separately to the Assessment Notice allows Social Care Teams to undertake any Primary care duties, before the patient has formally consented to an assessment.

HTTPS Request

Method:

POST

Request URL:

The request URL will consist of 'https://'+'{Host}'+'{BaseURL}'+'?'+'{QueryString}'

Host Environments:

The Host URLs will determined by the service provider, for example the host URLs for the Nottinghamshire County Council Social Care Data Service are:

Environment	Host
Test	health-interoperability-test.nottscc.gov.uk
Live	health-interoperability.nottscc.gov.uk

Base URL:

/ReferralService/v3/ReferralRequest

Note: the Healthcare Locator Service API can be used to identify the Host and Base URL (excluding the FHIR Resource element).

Query String /Parameters:

None

Example Request Url:

https://health-interoperability-test.nottscc.gov.uk/ReferralService/v3/ReferralRequest

Request Body:

The Request body should be in either json or xml format

The primary base FHIR resource is a CareConnect-SHD-ReferralRequest-1, with references to other resources as per the Entity Relationship Model below: ReferPatientUseCaseDiagram

See Examples for an illustration of the Request body of a typical Referral to Social Care for a Supported Hospital Discharge.

Response

Success

SHALL return a HTTP status code 201 Created on successful execution of the request

SHALL return an HTTP Location response header containing the full resolvable URL to the newly created ReferralRequest.

The URL will contain the ‘server’ assigned logical Id of the new ReferralRequest resource.
The URL format MUST be: https://[host]/[path]/[id].
An example Location response header: https://health-interoperability-test.nottscc.gov.uk/ReferralService/v3/ReferralRequest/11284224.

Note: Implementors MUST be be able to capture and log the ReferralRequest Id in order to send subsequent updates for the referral / reosources that reference it.

Error

An Error SHALL return one of the following HTTP Status Codes and an OperationOutcome with details of the issue:

HTTP Code	Display	Description
`400`	Bad Request	Poor Syntax or breaks a core FHIR constraint
`401`	Unauthorized	User is not authorised to perform the request.
`403`	Forbidden	The request is forbidden, authorization will not help.
`409`	Conflict	User has requested to create a resource that already exists.
`422`	Unprocessable Entity	The syntax is valid, but cannot be processed, e.g. breaks a business rule.
`500`	Internal Error	The server encountered an unexpected condition which prevented it from fulfilling the request.

JSON example of an OperationOutcome for a 409 Conflict Error

{
    "resourceType": "OperationOutcome",
    "issue":  [
        {
            "severity": "error",
            "code": "duplicate",
            "diagnostics": "There is already an active Supported Hospital Discharge referral for patient with NHS number=9111111437",
            "location":  [
                "ReferralRequest/112842246"
            ]
        }
    ]
}

XML example of an OperationOutcome for a 409 Conflict Error

<OperationOutcome xmlns="http://hl7.org/fhir">
    <issue>
        <severity value="error" />
        <code value="duplicate" />
        <diagnostics value="There is already an active Supported Hospital Discharge referral for patient with NHS number=9111111437" />
        <location value="ReferralRequest/112842246" />
    </issue>
</OperationOutcome>

Examples

Request Body

JSON example of a CareConnect-SHD-ReferralRequest-1

{
    "resourceType": "ReferralRequest",
    "meta": {
        "profile":  [
            "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-ReferralRequest-1"
        ]
    },
    "contained":  [
        {
            "resourceType": "Practitioner",
            "id": "patient-gp",
            "meta": {
                "profile":  [
                    "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Practitioner-1"
                ]
            },
            "name":  [
                {
                    "use": "official",
                    "text": "Doctor GP"
                }
            ],
            "address":  [
                {
                    "use": "work",
                    "text": "The Medical Centre, Arnold, Nottingham, NG5 7GH"
                }
            ]
        },
        {
            "resourceType": "Practitioner",
            "id": "lead-clinician",
            "meta": {
                "profile":  [
                    "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Practitioner-1"
                ]
            },
            "name":  [
                {
                    "use": "official",
                    "text": "Lead Clinician"
                }
            ]
        },
        {
            "resourceType": "Location",
            "id": "ward",
            "meta": {
                "profile":  [
                    "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Location-1"
                ]
            },
            "name": "KMH-17",
            "managingOrganization": {
                "reference": "#acute-hospital"
            }
        },
        {
            "resourceType": "Organization",
            "id": "acute-hospital",
            "meta": {
                "profile":  [
                    "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Organization-1"
                ]
            },
            "identifier":  [
                {
                    "system": "https://fhir.nhs.uk/Id/ods-site-code",
                    "value": "RK5BC"
                }
            ],
            "name": "King's Mill Hospital"
        },
        {
            "resourceType": "Patient",
            "id": "patient",
            "meta": {
                "profile":  [
                    "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Patient-1"
                ]
            },
            "extension":  [
                {
                    "url": "https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-NHSCommunication-1",
                    "extension":  [
                        {
                            "url": "language",
                            "valueCodeableConcept": {
                                "coding":  [
                                    {
                                        "system": "https://fhir.hl7.org.uk/STU3/CodeSystem/CareConnect-HumanLanguage-1",
                                        "code": "en",
                                        "display": "English"
                                    }
                                ],
                                "text": "English"
                            }
                        },
                        {
                            "url": "preferred",
                            "valueBoolean": true
                        },
                        {
                            "url": "interpreterRequired",
                            "valueBoolean": false
                        }
                    ]
                }
            ],
            "identifier":  [
                {
                    "extension":  [
                        {
                            "url": "https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-NHSNumberVerificationStatus-1",
                            "valueCodeableConcept": {
                                "coding":  [
                                    {
                                        "system": "https://fhir.hl7.org.uk/STU3/CodeSystem/CareConnect-NHSNumberVerificationStatus-1",
                                        "code": "01",
                                        "display": "Number present and verified"
                                    }
                                ]
                            }
                        }
                    ],
                    "use": "official",
                    "system": "https://fhir.nhs.uk/Id/nhs-number",
                    "value": "9111111704"
                },
                {
                    "use": "secondary",
                    "system": "https://localsystem/indentifier",
                    "value": "D12345678"
                }
            ],
            "name":  [
                {
                    "use": "official",
                    "family": "Oyl",
                    "given":  [
                        "Olive"
                    ]
                }
            ],
            "telecom":  [
                {
                    "system": "phone",
                    "value": "0115 97712345",
                    "use": "home"
                },
                {
                    "system": "phone",
                    "value": "07771 1234567",
                    "use": "mobile"
                },
                {
                    "system": "email",
                    "value": "olive.oyl@gmail.com",
                    "use": "home"
                }
            ],
            "gender": "female",
            "birthDate": "1938-08-05",
            "address":  [
                {
                    "use": "home",
                    "text": "23 Deer Park Drive, Nottingham",
                    "line":  [
                        "23 Deer Park Drive",
                        "Nottingham"
                    ],
                    "postalCode": "NG5 8SA"
                }
            ],
            "maritalStatus": {
                "coding":  [
                    {
                        "system": "http://hl7.org/fhir/v3/NullFlavor",
                        "code": "UNK",
                        "display": "unknown"
                    }
                ],
                "text": "Married"
            },
            "contact":  [
                {
                    "relationship":  [
                        {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CareConnect-PersonRelationshipType-1",
                                    "code": "04",
                                    "display": "Next of kin"
                                }
                            ],
                            "text": "Next of kin"
                        },
                        {
                            "text": "Wife"
                        }
                    ],
                    "name": {
                        "use": "usual",
                        "text": "Next Of Kin"
                    },
                    "telecom":  [
                        {
                            "system": "phone",
                            "value": "0115098765"
                        },
                        {
                            "system": "email",
                            "value": "next.of.kin@gmail.com"
                        }
                    ],
                    "address": {
                        "text": "4 Vale View, Vale View, Newark, Nottinghamshire"
                    }
                },
                {
                    "relationship":  [
                        {
                            "coding":  [
                                {
                                    "system": "https://fhir.hl7.org.uk/CareConnect-PersonRelationshipType-1",
                                    "code": "20",
                                    "display": "Carer"
                                }
                            ],
                            "text": "Carer"
                        },
                        {
                            "text": "Brother"
                        }
                    ],
                    "name": {
                        "use": "usual",
                        "text": "Patient Carer"
                    },
                    "telecom":  [
                        {
                            "system": "phone",
                            "value": "01154444412"
                        },
                        {
                            "system": "email",
                            "value": "patient.carer@gmail.com"
                        }
                    ],
                    "address": {
                        "text": "105 Park Street, Arnold, Nottingham, NG5 1SA"
                    }
                }
            ],
            "generalPractitioner":  [
                {
                    "reference": "#patient-gp"
                }
            ]
        },
        {
            "resourceType": "Encounter",
            "id": "encounter",
            "meta": {
                "profile":  [
                    "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Encounter-1"
                ]
            },
            "extension":  [
                {
                    "url": "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/Extension-SHD-MedicallyFitDetails",
                    "extension":  [
                        {
                            "url": "medicallyFitStatus",
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/SHD-MedicallyFitStatus",
                                "code": "03",
                                "display": "Unknown"
                            }
                        }
                    ]
                }
            ],
            "identifier":  [
                {
                    "system": "https://fhir.nottinghamshire.gov.uk/encounter/identifier",
                    "value": "42c2ecff-9b2f-4bdb-aebd-86c6118b4571"
                }
            ],
            "status": "in-progress",
            "type":  [
                {
                    "coding":  [
                        {
                            "system": "https://fhir.nottinghamshire.gov.uk/encounter/type",
                            "code": "supported-discharge"
                        }
                    ]
                }
            ],
            "participant":  [
                {
                    "individual": {
                        "reference": "#lead-clinician"
                    }
                }
            ],
            "period": {
                "start": "2020-04-27T00:00:00+00:00",
                "end": "2020-05-01T00:00:00+00:00"
            },
            "reason":  [
                {
                    "text": "Admitted with diarrhoea. Treated for diarrhoea"
                }
            ],
            "location":  [
                {
                    "location": {
                        "reference": "#ward"
                    }
                }
            ]
        },
        {
            "resourceType": "Practitioner",
            "id": "referring-clinician",
            "meta": {
                "profile":  [
                    "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Practitioner-1"
                ]
            },
            "name":  [
                {
                    "use": "official",
                    "text": "Referrer Clinician"
                }
            ],
            "telecom":  [
                {
                    "system": "phone",
                    "value": "011500000000",
                    "use": "work"
                },
                {
                    "system": "email",
                    "value": "hospital.liaison@nhs.net",
                    "use": "work"
                }
            ],
            "address":  [
                {
                    "use": "work",
                    "text": "IDAT"
                }
            ],
            "qualification":  [
                {
                    "code": {
                        "text": "Discharge Nurse"
                    }
                }
            ]
        },
        {
            "resourceType": "QuestionnaireResponse",
            "id": "preliminary-needs-questionnaire-response",
            "meta": {
                "profile":  [
                    "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/SHD-QuestionnaireResponse-PreliminaryNeedsAssessment"
                ]
            },
            "questionnaire": {
                "reference": "https://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/SHD-Questionnaire-PreliminaryNeedsAssessment"
            },
            "status": "completed",
            "authored": "2020-04-29T14:31:00.896Z",
            "item":  [
                {
                    "linkId": "1",
                    "text": "Capacity",
                    "item":  [
                        {
                            "linkId": "1.1",
                            "text": "Is the person able to give informed consent to their discharge arrangements?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "unable",
                                        "display": "Unable"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "1.1.1",
                            "text": "If not, give details and a mental capacity assessment is needed",
                            "answer":  [
                                {
                                    "valueString": "If not, give details and a mental capacity assessment is needed"
                                }
                            ]
                        },
                        {
                            "linkId": "1.2",
                            "text": "Deprivation of Liberty Safeguards: Will the person be deprived of their liberty? – i.e. under continuous supervision and control and not free to leave and not able to give informed consent to these arrangements.",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "1.2.1",
                            "text": "If Yes- give details",
                            "answer":  [
                                {
                                    "valueString": "DOLs"
                                }
                            ]
                        },
                        {
                            "linkId": "1.3",
                            "text": "Are there any cognition or other risks? Any risks being left alone or with others",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "1.3.1",
                            "text": "If Yes- give details",
                            "answer":  [
                                {
                                    "valueString": "Cognition Risks"
                                }
                            ]
                        }
                    ]
                },
                {
                    "linkId": "2",
                    "text": "Current Medical Needs to support discharge arrangements",
                    "item":  [
                        {
                            "linkId": "2.1",
                            "text": "Details of currently prescribed medications",
                            "answer":  [
                                {
                                    "valueString": "Details of currently prescribed medications"
                                }
                            ]
                        },
                        {
                            "linkId": "2.2",
                            "text": "Medical Equipment e.g. oxygen",
                            "answer":  [
                                {
                                    "valueString": "Medical Equipment e.g. oxygen"
                                }
                            ]
                        },
                        {
                            "linkId": "2.3",
                            "text": "Is support with medication required?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "2.3.1",
                            "text": "If Yes- give details, e.g Mediwallet",
                            "answer":  [
                                {
                                    "valueString": "Mediwallet"
                                }
                            ]
                        },
                        {
                            "linkId": "2.4",
                            "text": "Known Allergies",
                            "answer":  [
                                {
                                    "valueString": "Allergies"
                                }
                            ]
                        },
                        {
                            "linkId": "2.5",
                            "text": "Other medical needs which impact discharge arrangements. Past Medical history e.g. COPD, Diabetes",
                            "answer":  [
                                {
                                    "valueString": "Other medical needs which impact discharge arrangements. Past Medical history e.g. COPD, Diabetes"
                                }
                            ]
                        },
                        {
                            "linkId": "2.6",
                            "text": "Details of any tests or awaiting results for after discharge",
                            "answer":  [
                                {
                                    "valueString": "Details of any tests or awaiting results for after discharge"
                                }
                            ]
                        },
                        {
                            "linkId": "2.7",
                            "text": "Has a respect form been completed?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "2.7.1",
                            "text": "If Yes- details of Respect form",
                            "answer":  [
                                {
                                    "valueString": "Do not resuscitate"
                                }
                            ]
                        }
                    ]
                },
                {
                    "linkId": "3",
                    "text": "Living arrangements",
                    "item":  [
                        {
                            "linkId": "3.1",
                            "text": "Does the patient live alone?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "3.2",
                            "text": "Accommodation type and living arrangements. E.g. bungalow, who lives with, etc",
                            "answer":  [
                                {
                                    "valueString": "Flat, floor 6"
                                }
                            ]
                        },
                        {
                            "linkId": "3.3",
                            "text": "Keysafe including number?",
                            "answer":  [
                                {
                                    "valueString": "Yes 123456KS"
                                }
                            ]
                        },
                        {
                            "linkId": "3.4",
                            "text": "Lifeline or similar monitoring equipment?",
                            "answer":  [
                                {
                                    "valueString": "Lifeline Alarm"
                                }
                            ]
                        },
                        {
                            "linkId": "3.5",
                            "text": "Urgent accommodation risks and issues if known – only if this will prevent the discharge going ahead. E.g. EMAS concerns raised, family refusing discharge",
                            "answer":  [
                                {
                                    "valueString": "Urgent accommodation risks and issues if known – only if this will prevent the discharge going ahead. E.g. EMAS concerns raised, family refusing discharge"
                                }
                            ]
                        }
                    ]
                },
                {
                    "linkId": "4",
                    "text": "Input from the person’s discharge care needs",
                    "item":  [
                        {
                            "linkId": "4.1",
                            "text": "Mobility Status - Can the person mobilise?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "with-aid",
                                        "display": "With aid"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.1.1",
                            "text": "If with aid please state the level of assistance required?",
                            "answer":  [
                                {
                                    "valueString": "A frame"
                                }
                            ]
                        },
                        {
                            "linkId": "4.2",
                            "text": "Is the patient able to safely /independently manage stairs?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "no",
                                        "display": "No"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.3",
                            "text": "Are there any steps at the person’s property?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.4",
                            "text": "Is the patient able to transfer off the bed?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "with-equipment",
                                        "display": "With Equipment"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.5",
                            "text": "Is the patient able to transfer off the chair?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "with-equipment",
                                        "display": "With Equipment"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.6",
                            "text": "Is the patient able to transfer off the toilet?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "with-equipment",
                                        "display": "With Equipment"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.7",
                            "text": "If equipment selected on any of the above, has this equipment been ordered to ensure a safe discharge?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "no",
                                        "display": "No"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.8",
                            "text": "How does the person feel they will transfer between areas of their home?  (between bed and chair and toilet or bathroom, any steps at their property, between rooms etc)?",
                            "answer":  [
                                {
                                    "valueString": "How does the person feel they will transfer between areas of their home? (between bed and chair and toilet or bathroom, any steps at their property, between rooms etc)?"
                                }
                            ]
                        },
                        {
                            "linkId": "4.9",
                            "text": "Can the person bear their own weight fully?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "no",
                                        "display": "No"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.9.1",
                            "text": "Details if No or Partially",
                            "answer":  [
                                {
                                    "valueString": "Needs an A Frame"
                                }
                            ]
                        },
                        {
                            "linkId": "4.10",
                            "text": "Can the person prepare drinks or a meal for themselves at home?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "no",
                                        "display": "No"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.10.1",
                            "text": "Please give details of alternative (e.g. meals delivery/ family support)",
                            "answer":  [
                                {
                                    "valueString": "Needs help cooking and feeding"
                                }
                            ]
                        },
                        {
                            "linkId": "4.11",
                            "text": "Does the person have any difficulty swallowing?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.11.1",
                            "text": "If Yes- give details",
                            "answer":  [
                                {
                                    "valueString": "Needs pureed food"
                                }
                            ]
                        },
                        {
                            "linkId": "4.12",
                            "text": "Is the person able to wash and dress themselves on discharge?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "no",
                                        "display": "No"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "4.12.1",
                            "text": "If No- give details",
                            "answer":  [
                                {
                                    "valueString": "Will need help washing"
                                }
                            ]
                        },
                        {
                            "linkId": "4.13",
                            "text": "What does the person want to ideally achieve? e.g. return to independence, support at home etc",
                            "answer":  [
                                {
                                    "valueString": "What does the person want to ideally achieve? e.g. return to independence, support at home etc"
                                }
                            ]
                        }
                    ]
                },
                {
                    "linkId": "5",
                    "text": "Specialist Input needed after discharge",
                    "item":  [
                        {
                            "linkId": "5.1",
                            "text": "Does the person have any wounds or sores that need to be dressed or managed? (awareness for providers on bed sores etc)",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "5.1.1",
                            "text": "If Yes give details",
                            "answer":  [
                                {
                                    "valueString": "Dressing will need changing daily"
                                }
                            ]
                        },
                        {
                            "linkId": "5.2",
                            "text": "Does the person have any Continence needs?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "5.2.1",
                            "text": "If Yes give details",
                            "answer":  [
                                {
                                    "valueString": "Pads required at night"
                                }
                            ]
                        },
                        {
                            "linkId": "5.3",
                            "text": "How will the person support themselves overnight between visits? (e.g. if needs toilet in the night)",
                            "answer":  [
                                {
                                    "valueString": "How will the person support themselves overnight between visits? (e.g. if needs toilet in the night)"
                                }
                            ]
                        },
                        {
                            "linkId": "5.4",
                            "text": "Can the person fully communicate their needs?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "no",
                                        "display": "No"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "5.4.1",
                            "text": "If No please give communication needs. e.g. translator, carer support",
                            "answer":  [
                                {
                                    "valueString": "Translator for French"
                                }
                            ]
                        },
                        {
                            "linkId": "5.5",
                            "text": "Are you planning to organise hospital transport for this person?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "5.5.1",
                            "text": "If Yes date and time booked for",
                            "answer":  [
                                {
                                    "valueDateTime": "2020-05-01T12:10:00.000Z"
                                }
                            ]
                        }
                    ]
                },
                {
                    "linkId": "6",
                    "text": "Additional Information",
                    "item":  [
                        {
                            "linkId": "6.1",
                            "text": "Please use this section to provide any other additional information that is relevant to the discharge",
                            "answer":  [
                                {
                                    "valueString": "Please use this section to provide any other additional information that is relevant to the discharge"
                                }
                            ]
                        }
                    ]
                }
            ]
        },
        {
            "resourceType": "QuestionnaireResponse",
            "id": "covid-19-questionnaire-response",
            "meta": {
                "profile":  [
                    "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/SHD-QuestionnaireResponse-COVID19"
                ]
            },
            "questionnaire": {
                "reference": "https://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/SHD-Questionnaire-COVID19"
            },
            "status": "completed",
            "authored": "2020-04-29T14:48:01.228Z",
            "item":  [
                {
                    "linkId": "1",
                    "text": "Covid 19 Emergency Humanitarian response",
                    "item":  [
                        {
                            "linkId": "1.1",
                            "text": "What is the person’s Covid 19 Test result?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "awaiting-result",
                                        "display": "Awaiting Result"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "1.2",
                            "text": "Will the person be self-isolating on discharge?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "1.2.1",
                            "text": "If Yes – Why and for how long? (E.g shielding or in a vulnerable category)",
                            "answer":  [
                                {
                                    "valueString": "In vulnerable category"
                                }
                            ]
                        },
                        {
                            "linkId": "1.3",
                            "text": "Does the person need food delivery or shopping support?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "1.3.1",
                            "text": "If Yes- give details",
                            "answer":  [
                                {
                                    "valueString": "Will need weekly shopping - no freezer in home"
                                }
                            ]
                        },
                        {
                            "linkId": "1.4",
                            "text": "Does the person need medication delivery support?",
                            "answer":  [
                                {
                                    "valueCoding": {
                                        "code": "yes",
                                        "display": "Yes"
                                    }
                                }
                            ]
                        },
                        {
                            "linkId": "1.4.1",
                            "text": "If Yes- give details",
                            "answer":  [
                                {
                                    "valueString": "Weekly meds delivery"
                                }
                            ]
                        }
                    ]
                }
            ]
        },
        {
            "resourceType": "QuestionnaireResponse",
            "id": "chc-checklist-questionnaire-response",
            "meta": {
                "profile":  [
                    "https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/SHD-QuestionnaireResponse-CHCChecklist"
                ]
            },
            "questionnaire": {
                "reference": "https://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/SHD-Questionnaire-CHCChecklist"
            },
            "status": "completed",
            "authored": "2020-02-19T08:30:00+00:00",
            "item":  [
                {
                    "linkId": "1.1",
                    "text": "Name of the assessor(s) who completed the CHC Checklist",
                    "answer":  [
                        {
                            "valueString": "CHC Nurse"
                        }
                    ]
                },
                {
                    "linkId": "1.2",
                    "text": "Contact details of assessors (name, role, organisation, telephone number, email address)",
                    "answer":  [
                        {
                            "valueString": "Nurse contact details"
                        }
                    ]
                },
                {
                    "linkId": "1.3",
                    "text": "Was the individual involved in the completion of the Checklist?",
                    "answer":  [
                        {
                            "valueBoolean": true
                        }
                    ]
                },
                {
                    "linkId": "1.4",
                    "text": "Was the individual offered the opportunity to have a representative such as a family member or other advocate present when the checklist was completed?",
                    "answer":  [
                        {
                            "valueBoolean": true
                        }
                    ]
                },
                {
                    "linkId": "1.5",
                    "text": "If yes, did the representative attend the completion of the Checklist?",
                    "answer":  [
                        {
                            "valueBoolean": false
                        }
                    ]
                },
                {
                    "linkId": "1.6",
                    "text": "Please give the contact details of the representative (name, address and telephone number)",
                    "answer":  [
                        {
                            "valueString": "Representative contact details"
                        }
                    ]
                },
                {
                    "linkId": "1.7",
                    "text": "Did you explain to the individual how their personal information will be shared with the different organisations involved in their care, and did they consent to this information sharing?",
                    "answer":  [
                        {
                            "valueBoolean": true
                        }
                    ]
                },
                {
                    "linkId": "2.1",
                    "text": "'Behaviour' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "A",
                                "display": "Meets/exceeds the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.2",
                    "text": "Evidence to support 'Behaviour' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Behaviour evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.3",
                    "text": "'Cognition' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "B",
                                "display": "Borderline/nearly meets the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.4",
                    "text": "Evidence to support 'Cognition' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Cognition evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.5",
                    "text": "'Psychological/Emotional' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "C",
                                "display": "Clearly does not meet the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.6",
                    "text": "Evidence to support 'Psychological/Emotional' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Psychological/Emotional evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.7",
                    "text": "'Communication' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "A",
                                "display": "Meets/exceeds the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.8",
                    "text": "Evidence to support 'Communication' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Communication evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.9",
                    "text": "'Mobility' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "B",
                                "display": "Borderline/nearly meets the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.10",
                    "text": "Evidence to support 'Mobility' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Mobility evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.11",
                    "text": "'Nutrition' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "C",
                                "display": "Clearly does not meet the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.12",
                    "text": "Evidence to support 'Nutrition' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Nutrition evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.13",
                    "text": "'Continence' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "A",
                                "display": "Meets/exceeds the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.14",
                    "text": "Evidence to support 'Continence' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Continence evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.15",
                    "text": "'Skin integrity' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "B",
                                "display": "Borderline/nearly meets the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.16",
                    "text": "Evidence to support 'Skin integrity' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Skin integrity evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.17",
                    "text": "'Breathing' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "C",
                                "display": "Clearly does not meet the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.18",
                    "text": "Evidence to support 'Breathing' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Breathing evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.19",
                    "text": "'Drug therapies and medication: symptom control' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "A",
                                "display": "Meets/exceeds the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.20",
                    "text": "Evidence to support 'Drug therapies and medication: symptom control' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Drug therapies and medication: symptom control evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.21",
                    "text": "'Altered states of consciousness' Domain Level Score",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore",
                                "code": "B",
                                "display": "Borderline/nearly meets the described need"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.22",
                    "text": "Evidence to support 'Altered states of consciousness' Domain Level",
                    "answer":  [
                        {
                            "valueString": "Altered states of consciousness evidence"
                        }
                    ]
                },
                {
                    "linkId": "2.23",
                    "text": "Total Score from Checklist",
                    "answer":  [
                        {
                            "valueString": "Score"
                        }
                    ]
                },
                {
                    "linkId": "2.24",
                    "text": "Outcome indicated by the Checklist",
                    "answer":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-Outcome",
                                "code": "2",
                                "display": "No referral for full assessment for NHS Continuing Healthcare is necessary"
                            }
                        }
                    ]
                },
                {
                    "linkId": "2.25",
                    "text": "Rationale for decision",
                    "answer":  [
                        {
                            "valueString": "Optional textual note detailing the rationale for decision, i.e. why a referral for full assessment for NHS Continuing Healthcare is or isn't necessary"
                        }
                    ]
                }
            ]
        }
    ],
    "status": "active",
    "intent": "plan",
    "type": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "715591000000108",
                "display": "Hospital Discharge Notification to Social Care"
            }
        ],
        "text": "Hospital Discharge Notification to Social Care"
    },
    "subject": {
        "reference": "#patient"
    },
    "context": {
        "reference": "#encounter"
    },
    "authoredOn": "2020-04-29T09:45:42+00:00",
    "requester": {
        "agent": {
            "reference": "#referring-clinician"
        },
        "onBehalfOf": {
            "reference": "#acute-hospital"
        }
    },
    "reasonCode":  [
        {
            "text": "Supported discharge required"
        }
    ],
    "supportingInfo":  [
        {
            "reference": "#preliminary-needs-questionnaire-response"
        },
        {
            "reference": "#covid-19-questionnaire-response"
        },
        {
            "reference": "#chc-checklist-questionnaire-response"
        }
    ],
    "note":  [
        {
            "text": "27/04/2020 09:42 - Rose Smith\nDetail of actual comment added by IDT Worker\nDownload a copy as XML or JSON to see appropriate XML/JSON ‘character coding’ for new lines/carriage returns"
        },
        {
            "text": "28/04/2020 17:11\nA Comment without an author that is quite long and goes into a detailed description that will span multiple lines in the form field.\n\nMaybe the comment even has multiple paragraphs."
        },
        {
            "text": "29/04/2020 09:45 - Jack Jones\nSome comments made by IDT worker during initial assessment"
        }
    ]
}

XML example of a CareConnect-SHD-ReferralRequest-1

<ReferralRequest xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-ReferralRequest-1" />
    </meta>
    <contained>
        <Practitioner>
            <id value="patient-gp" />
            <meta>
                <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Practitioner-1" />
            </meta>
            <name>
                <use value="official" />
                <text value="Doctor GP" />
            </name>
            <address>
                <use value="work" />
                <text value="The Medical Centre, Arnold, Nottingham, NG5 7GH" />
            </address>
        </Practitioner>
    </contained>
    <contained>
        <Practitioner>
            <id value="lead-clinician" />
            <meta>
                <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Practitioner-1" />
            </meta>
            <name>
                <use value="official" />
                <text value="Lead Clinician" />
            </name>
        </Practitioner>
    </contained>
    <contained>
        <Location>
            <id value="ward" />
            <meta>
                <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Location-1" />
            </meta>
            <name value="KMH-17" />
            <managingOrganization>
                <reference value="#acute-hospital" />
            </managingOrganization>
        </Location>
    </contained>
    <contained>
        <Organization>
            <id value="acute-hospital" />
            <meta>
                <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Organization-1" />
            </meta>
            <identifier>
                <system value="https://fhir.nhs.uk/Id/ods-site-code" />
                <value value="RK5BC" />
            </identifier>
            <name value="King&#39;s Mill Hospital" />
        </Organization>
    </contained>
    <contained>
        <Patient>
            <id value="patient" />
            <meta>
                <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Patient-1" />
            </meta>
            <extension url="https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-NHSCommunication-1">
                <extension url="language">
                    <valueCodeableConcept>
                        <coding>
                            <system value="https://fhir.hl7.org.uk/STU3/CodeSystem/CareConnect-HumanLanguage-1" />
                            <code value="en" />
                            <display value="English" />
                        </coding>
                        <text value="English" />
                    </valueCodeableConcept>
                </extension>
                <extension url="preferred">
                    <valueBoolean value="true" />
                </extension>
                <extension url="interpreterRequired">
                    <valueBoolean value="false" />
                </extension>
            </extension>
            <identifier>
                <extension url="https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-NHSNumberVerificationStatus-1">
                    <valueCodeableConcept>
                        <coding>
                            <system value="https://fhir.hl7.org.uk/STU3/CodeSystem/CareConnect-NHSNumberVerificationStatus-1" />
                            <code value="01" />
                            <display value="Number present and verified" />
                        </coding>
                    </valueCodeableConcept>
                </extension>
                <use value="official" />
                <system value="https://fhir.nhs.uk/Id/nhs-number" />
                <value value="9111111704" />
            </identifier>
            <identifier>
                <use value="secondary" />
                <system value="https://localsystem/indentifier" />
                <value value="D12345678" />
            </identifier>
            <name>
                <use value="official" />
                <family value="Oyl" />
                <given value="Olive" />
            </name>
            <telecom>
                <system value="phone" />
                <value value="0115 97712345" />
                <use value="home" />
            </telecom>
            <telecom>
                <system value="phone" />
                <value value="07771 1234567" />
                <use value="mobile" />
            </telecom>
            <telecom>
                <system value="email" />
                <value value="olive.oyl@gmail.com" />
                <use value="home" />
            </telecom>
            <gender value="female" />
            <birthDate value="1938-08-05" />
            <address>
                <use value="home" />
                <text value="23 Deer Park Drive, Nottingham" />
                <line value="23 Deer Park Drive" />
                <line value="Nottingham" />
                <postalCode value="NG5 8SA" />
            </address>
            <maritalStatus>
                <coding>
                    <system value="http://hl7.org/fhir/v3/NullFlavor" />
                    <code value="UNK" />
                    <display value="unknown" />
                </coding>
                <text value="Married" />
            </maritalStatus>
            <contact>
                <relationship>
                    <coding>
                        <system value="https://fhir.hl7.org.uk/CareConnect-PersonRelationshipType-1" />
                        <code value="04" />
                        <display value="Next of kin" />
                    </coding>
                    <text value="Next of kin" />
                </relationship>
                <relationship>
                    <text value="Wife" />
                </relationship>
                <name>
                    <use value="usual" />
                    <text value="Next Of Kin" />
                </name>
                <telecom>
                    <system value="phone" />
                    <value value="0115098765" />
                </telecom>
                <telecom>
                    <system value="email" />
                    <value value="next.of.kin@gmail.com" />
                </telecom>
                <address>
                    <text value="4 Vale View, Vale View, Newark, Nottinghamshire" />
                </address>
            </contact>
            <contact>
                <relationship>
                    <coding>
                        <system value="https://fhir.hl7.org.uk/CareConnect-PersonRelationshipType-1" />
                        <code value="20" />
                        <display value="Carer" />
                    </coding>
                    <text value="Carer" />
                </relationship>
                <relationship>
                    <text value="Brother" />
                </relationship>
                <name>
                    <use value="usual" />
                    <text value="Patient Carer" />
                </name>
                <telecom>
                    <system value="phone" />
                    <value value="01154444412" />
                </telecom>
                <telecom>
                    <system value="email" />
                    <value value="patient.carer@gmail.com" />
                </telecom>
                <address>
                    <text value="105 Park Street, Arnold, Nottingham, NG5 1SA" />
                </address>
            </contact>
            <generalPractitioner>
                <reference value="#patient-gp" />
            </generalPractitioner>
        </Patient>
    </contained>
    <contained>
        <Encounter>
            <id value="encounter" />
            <meta>
                <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Encounter-1" />
            </meta>
            <extension url="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/Extension-SHD-MedicallyFitDetails">
                <extension url="medicallyFitStatus">
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/SHD-MedicallyFitStatus" />
                        <code value="03" />
                        <display value="Unknown" />
                    </valueCoding>
                </extension>
            </extension>
            <identifier>
                <system value="https://fhir.nottinghamshire.gov.uk/encounter/identifier" />
                <value value="42c2ecff-9b2f-4bdb-aebd-86c6118b4571" />
            </identifier>
            <status value="in-progress" />
            <type>
                <coding>
                    <system value="https://fhir.nottinghamshire.gov.uk/encounter/type" />
                    <code value="supported-discharge" />
                </coding>
            </type>
            <participant>
                <individual>
                    <reference value="#lead-clinician" />
                </individual>
            </participant>
            <period>
                <start value="2020-04-27T00:00:00+00:00" />
                <end value="2020-05-01T00:00:00+00:00" />
            </period>
            <reason>
                <text value="Admitted with diarrhoea. Treated for diarrhoea" />
            </reason>
            <location>
                <location>
                    <reference value="#ward" />
                </location>
            </location>
        </Encounter>
    </contained>
    <contained>
        <Practitioner>
            <id value="referring-clinician" />
            <meta>
                <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/CareConnect-SHD-Practitioner-1" />
            </meta>
            <name>
                <use value="official" />
                <text value="Referrer Clinician" />
            </name>
            <telecom>
                <system value="phone" />
                <value value="011500000000" />
                <use value="work" />
            </telecom>
            <telecom>
                <system value="email" />
                <value value="hospital.liaison@nhs.net" />
                <use value="work" />
            </telecom>
            <address>
                <use value="work" />
                <text value="IDAT" />
            </address>
            <qualification>
                <code>
                    <text value="Discharge Nurse" />
                </code>
            </qualification>
        </Practitioner>
    </contained>
    <contained>
        <QuestionnaireResponse>
            <id value="preliminary-needs-questionnaire-response" />
            <meta>
                <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/SHD-QuestionnaireResponse-PreliminaryNeedsAssessment" />
            </meta>
            <questionnaire>
                <reference value="https://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/SHD-Questionnaire-PreliminaryNeedsAssessment" />
            </questionnaire>
            <status value="completed" />
            <authored value="2020-04-29T14:31:00.896Z" />
            <item>
                <linkId value="1" />
                <text value="Capacity" />
                <item>
                    <linkId value="1.1" />
                    <text value="Is the person able to give informed consent to their discharge arrangements?" />
                    <answer>
                        <valueCoding>
                            <code value="unable" />
                            <display value="Unable" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="1.1.1" />
                    <text value="If not, give details and a mental capacity assessment is needed" />
                    <answer>
                        <valueString value="If not, give details and a mental capacity assessment is needed" />
                    </answer>
                </item>
                <item>
                    <linkId value="1.2" />
                    <text value="Deprivation of Liberty Safeguards: Will the person be deprived of their liberty? – i.e. under continuous supervision and control and not free to leave and not able to give informed consent to these arrangements." />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="1.2.1" />
                    <text value="If Yes- give details" />
                    <answer>
                        <valueString value="DOLs" />
                    </answer>
                </item>
                <item>
                    <linkId value="1.3" />
                    <text value="Are there any cognition or other risks? Any risks being left alone or with others" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="1.3.1" />
                    <text value="If Yes- give details" />
                    <answer>
                        <valueString value="Cognition Risks" />
                    </answer>
                </item>
            </item>
            <item>
                <linkId value="2" />
                <text value="Current Medical Needs to support discharge arrangements" />
                <item>
                    <linkId value="2.1" />
                    <text value="Details of currently prescribed medications" />
                    <answer>
                        <valueString value="Details of currently prescribed medications" />
                    </answer>
                </item>
                <item>
                    <linkId value="2.2" />
                    <text value="Medical Equipment e.g. oxygen" />
                    <answer>
                        <valueString value="Medical Equipment e.g. oxygen" />
                    </answer>
                </item>
                <item>
                    <linkId value="2.3" />
                    <text value="Is support with medication required?" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="2.3.1" />
                    <text value="If Yes- give details, e.g Mediwallet" />
                    <answer>
                        <valueString value="Mediwallet" />
                    </answer>
                </item>
                <item>
                    <linkId value="2.4" />
                    <text value="Known Allergies" />
                    <answer>
                        <valueString value="Allergies" />
                    </answer>
                </item>
                <item>
                    <linkId value="2.5" />
                    <text value="Other medical needs which impact discharge arrangements. Past Medical history e.g. COPD, Diabetes" />
                    <answer>
                        <valueString value="Other medical needs which impact discharge arrangements. Past Medical history e.g. COPD, Diabetes" />
                    </answer>
                </item>
                <item>
                    <linkId value="2.6" />
                    <text value="Details of any tests or awaiting results for after discharge" />
                    <answer>
                        <valueString value="Details of any tests or awaiting results for after discharge" />
                    </answer>
                </item>
                <item>
                    <linkId value="2.7" />
                    <text value="Has a respect form been completed?" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="2.7.1" />
                    <text value="If Yes- details of Respect form" />
                    <answer>
                        <valueString value="Do not resuscitate" />
                    </answer>
                </item>
            </item>
            <item>
                <linkId value="3" />
                <text value="Living arrangements" />
                <item>
                    <linkId value="3.1" />
                    <text value="Does the patient live alone?" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="3.2" />
                    <text value="Accommodation type and living arrangements. E.g. bungalow, who lives with, etc" />
                    <answer>
                        <valueString value="Flat, floor 6" />
                    </answer>
                </item>
                <item>
                    <linkId value="3.3" />
                    <text value="Keysafe including number?" />
                    <answer>
                        <valueString value="Yes 123456KS" />
                    </answer>
                </item>
                <item>
                    <linkId value="3.4" />
                    <text value="Lifeline or similar monitoring equipment?" />
                    <answer>
                        <valueString value="Lifeline Alarm" />
                    </answer>
                </item>
                <item>
                    <linkId value="3.5" />
                    <text value="Urgent accommodation risks and issues if known – only if this will prevent the discharge going ahead. E.g. EMAS concerns raised, family refusing discharge" />
                    <answer>
                        <valueString value="Urgent accommodation risks and issues if known – only if this will prevent the discharge going ahead. E.g. EMAS concerns raised, family refusing discharge" />
                    </answer>
                </item>
            </item>
            <item>
                <linkId value="4" />
                <text value="Input from the person’s discharge care needs" />
                <item>
                    <linkId value="4.1" />
                    <text value="Mobility Status - Can the person mobilise?" />
                    <answer>
                        <valueCoding>
                            <code value="with-aid" />
                            <display value="With aid" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.1.1" />
                    <text value="If with aid please state the level of assistance required?" />
                    <answer>
                        <valueString value="A frame" />
                    </answer>
                </item>
                <item>
                    <linkId value="4.2" />
                    <text value="Is the patient able to safely /independently manage stairs?" />
                    <answer>
                        <valueCoding>
                            <code value="no" />
                            <display value="No" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.3" />
                    <text value="Are there any steps at the person’s property?" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.4" />
                    <text value="Is the patient able to transfer off the bed?" />
                    <answer>
                        <valueCoding>
                            <code value="with-equipment" />
                            <display value="With Equipment" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.5" />
                    <text value="Is the patient able to transfer off the chair?" />
                    <answer>
                        <valueCoding>
                            <code value="with-equipment" />
                            <display value="With Equipment" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.6" />
                    <text value="Is the patient able to transfer off the toilet?" />
                    <answer>
                        <valueCoding>
                            <code value="with-equipment" />
                            <display value="With Equipment" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.7" />
                    <text value="If equipment selected on any of the above, has this equipment been ordered to ensure a safe discharge?" />
                    <answer>
                        <valueCoding>
                            <code value="no" />
                            <display value="No" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.8" />
                    <text value="How does the person feel they will transfer between areas of their home?  (between bed and chair and toilet or bathroom, any steps at their property, between rooms etc)?" />
                    <answer>
                        <valueString value="How does the person feel they will transfer between areas of their home? (between bed and chair and toilet or bathroom, any steps at their property, between rooms etc)?" />
                    </answer>
                </item>
                <item>
                    <linkId value="4.9" />
                    <text value="Can the person bear their own weight fully?" />
                    <answer>
                        <valueCoding>
                            <code value="no" />
                            <display value="No" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.9.1" />
                    <text value="Details if No or Partially" />
                    <answer>
                        <valueString value="Needs an A Frame" />
                    </answer>
                </item>
                <item>
                    <linkId value="4.10" />
                    <text value="Can the person prepare drinks or a meal for themselves at home?" />
                    <answer>
                        <valueCoding>
                            <code value="no" />
                            <display value="No" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.10.1" />
                    <text value="Please give details of alternative (e.g. meals delivery/ family support)" />
                    <answer>
                        <valueString value="Needs help cooking and feeding" />
                    </answer>
                </item>
                <item>
                    <linkId value="4.11" />
                    <text value="Does the person have any difficulty swallowing?" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.11.1" />
                    <text value="If Yes- give details" />
                    <answer>
                        <valueString value="Needs pureed food" />
                    </answer>
                </item>
                <item>
                    <linkId value="4.12" />
                    <text value="Is the person able to wash and dress themselves on discharge?" />
                    <answer>
                        <valueCoding>
                            <code value="no" />
                            <display value="No" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="4.12.1" />
                    <text value="If No- give details" />
                    <answer>
                        <valueString value="Will need help washing" />
                    </answer>
                </item>
                <item>
                    <linkId value="4.13" />
                    <text value="What does the person want to ideally achieve? e.g. return to independence, support at home etc" />
                    <answer>
                        <valueString value="What does the person want to ideally achieve? e.g. return to independence, support at home etc" />
                    </answer>
                </item>
            </item>
            <item>
                <linkId value="5" />
                <text value="Specialist Input needed after discharge" />
                <item>
                    <linkId value="5.1" />
                    <text value="Does the person have any wounds or sores that need to be dressed or managed? (awareness for providers on bed sores etc)" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="5.1.1" />
                    <text value="If Yes give details" />
                    <answer>
                        <valueString value="Dressing will need changing daily" />
                    </answer>
                </item>
                <item>
                    <linkId value="5.2" />
                    <text value="Does the person have any Continence needs?" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="5.2.1" />
                    <text value="If Yes give details" />
                    <answer>
                        <valueString value="Pads required at night" />
                    </answer>
                </item>
                <item>
                    <linkId value="5.3" />
                    <text value="How will the person support themselves overnight between visits? (e.g. if needs toilet in the night)" />
                    <answer>
                        <valueString value="How will the person support themselves overnight between visits? (e.g. if needs toilet in the night)" />
                    </answer>
                </item>
                <item>
                    <linkId value="5.4" />
                    <text value="Can the person fully communicate their needs?" />
                    <answer>
                        <valueCoding>
                            <code value="no" />
                            <display value="No" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="5.4.1" />
                    <text value="If No please give communication needs. e.g. translator, carer support" />
                    <answer>
                        <valueString value="Translator for French" />
                    </answer>
                </item>
                <item>
                    <linkId value="5.5" />
                    <text value="Are you planning to organise hospital transport for this person?" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="5.5.1" />
                    <text value="If Yes date and time booked for" />
                    <answer>
                        <valueDateTime value="2020-05-01T12:10:00.000Z" />
                    </answer>
                </item>
            </item>
            <item>
                <linkId value="6" />
                <text value="Additional Information" />
                <item>
                    <linkId value="6.1" />
                    <text value="Please use this section to provide any other additional information that is relevant to the discharge" />
                    <answer>
                        <valueString value="Please use this section to provide any other additional information that is relevant to the discharge" />
                    </answer>
                </item>
            </item>
        </QuestionnaireResponse>
    </contained>
    <contained>
        <QuestionnaireResponse>
            <id value="covid-19-questionnaire-response" />
            <meta>
                <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/SHD-QuestionnaireResponse-COVID19" />
            </meta>
            <questionnaire>
                <reference value="https://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/SHD-Questionnaire-COVID19" />
            </questionnaire>
            <status value="completed" />
            <authored value="2020-04-29T14:48:01.228Z" />
            <item>
                <linkId value="1" />
                <text value="Covid 19 Emergency Humanitarian response" />
                <item>
                    <linkId value="1.1" />
                    <text value="What is the person’s Covid 19 Test result?" />
                    <answer>
                        <valueCoding>
                            <code value="awaiting-result" />
                            <display value="Awaiting Result" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="1.2" />
                    <text value="Will the person be self-isolating on discharge?" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="1.2.1" />
                    <text value="If Yes – Why and for how long? (E.g shielding or in a vulnerable category)" />
                    <answer>
                        <valueString value="In vulnerable category" />
                    </answer>
                </item>
                <item>
                    <linkId value="1.3" />
                    <text value="Does the person need food delivery or shopping support?" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="1.3.1" />
                    <text value="If Yes- give details" />
                    <answer>
                        <valueString value="Will need weekly shopping - no freezer in home" />
                    </answer>
                </item>
                <item>
                    <linkId value="1.4" />
                    <text value="Does the person need medication delivery support?" />
                    <answer>
                        <valueCoding>
                            <code value="yes" />
                            <display value="Yes" />
                        </valueCoding>
                    </answer>
                </item>
                <item>
                    <linkId value="1.4.1" />
                    <text value="If Yes- give details" />
                    <answer>
                        <valueString value="Weekly meds delivery" />
                    </answer>
                </item>
            </item>
        </QuestionnaireResponse>
    </contained>
    <contained>
        <QuestionnaireResponse>
            <id value="chc-checklist-questionnaire-response" />
            <meta>
                <profile value="https://fhir.nottinghamshire.gov.uk/STU3/StructureDefinition/SHD-QuestionnaireResponse-CHCChecklist" />
            </meta>
            <questionnaire>
                <reference value="https://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/SHD-Questionnaire-CHCChecklist" />
            </questionnaire>
            <status value="completed" />
            <authored value="2020-02-19T08:30:00+00:00" />
            <item>
                <linkId value="1.1" />
                <text value="Name of the assessor(s) who completed the CHC Checklist" />
                <answer>
                    <valueString value="CHC Nurse" />
                </answer>
            </item>
            <item>
                <linkId value="1.2" />
                <text value="Contact details of assessors (name, role, organisation, telephone number, email address)" />
                <answer>
                    <valueString value="Nurse contact details" />
                </answer>
            </item>
            <item>
                <linkId value="1.3" />
                <text value="Was the individual involved in the completion of the Checklist?" />
                <answer>
                    <valueBoolean value="true" />
                </answer>
            </item>
            <item>
                <linkId value="1.4" />
                <text value="Was the individual offered the opportunity to have a representative such as a family member or other advocate present when the checklist was completed?" />
                <answer>
                    <valueBoolean value="true" />
                </answer>
            </item>
            <item>
                <linkId value="1.5" />
                <text value="If yes, did the representative attend the completion of the Checklist?" />
                <answer>
                    <valueBoolean value="false" />
                </answer>
            </item>
            <item>
                <linkId value="1.6" />
                <text value="Please give the contact details of the representative (name, address and telephone number)" />
                <answer>
                    <valueString value="Representative contact details" />
                </answer>
            </item>
            <item>
                <linkId value="1.7" />
                <text value="Did you explain to the individual how their personal information will be shared with the different organisations involved in their care, and did they consent to this information sharing?" />
                <answer>
                    <valueBoolean value="true" />
                </answer>
            </item>
            <item>
                <linkId value="2.1" />
                <text value="&#39;Behaviour&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="A" />
                        <display value="Meets/exceeds the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.2" />
                <text value="Evidence to support &#39;Behaviour&#39; Domain Level" />
                <answer>
                    <valueString value="Behaviour evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.3" />
                <text value="&#39;Cognition&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="B" />
                        <display value="Borderline/nearly meets the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.4" />
                <text value="Evidence to support &#39;Cognition&#39; Domain Level" />
                <answer>
                    <valueString value="Cognition evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.5" />
                <text value="&#39;Psychological/Emotional&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="C" />
                        <display value="Clearly does not meet the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.6" />
                <text value="Evidence to support &#39;Psychological/Emotional&#39; Domain Level" />
                <answer>
                    <valueString value="Psychological/Emotional evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.7" />
                <text value="&#39;Communication&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="A" />
                        <display value="Meets/exceeds the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.8" />
                <text value="Evidence to support &#39;Communication&#39; Domain Level" />
                <answer>
                    <valueString value="Communication evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.9" />
                <text value="&#39;Mobility&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="B" />
                        <display value="Borderline/nearly meets the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.10" />
                <text value="Evidence to support &#39;Mobility&#39; Domain Level" />
                <answer>
                    <valueString value="Mobility evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.11" />
                <text value="&#39;Nutrition&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="C" />
                        <display value="Clearly does not meet the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.12" />
                <text value="Evidence to support &#39;Nutrition&#39; Domain Level" />
                <answer>
                    <valueString value="Nutrition evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.13" />
                <text value="&#39;Continence&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="A" />
                        <display value="Meets/exceeds the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.14" />
                <text value="Evidence to support &#39;Continence&#39; Domain Level" />
                <answer>
                    <valueString value="Continence evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.15" />
                <text value="&#39;Skin integrity&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="B" />
                        <display value="Borderline/nearly meets the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.16" />
                <text value="Evidence to support &#39;Skin integrity&#39; Domain Level" />
                <answer>
                    <valueString value="Skin integrity evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.17" />
                <text value="&#39;Breathing&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="C" />
                        <display value="Clearly does not meet the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.18" />
                <text value="Evidence to support &#39;Breathing&#39; Domain Level" />
                <answer>
                    <valueString value="Breathing evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.19" />
                <text value="&#39;Drug therapies and medication: symptom control&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="A" />
                        <display value="Meets/exceeds the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.20" />
                <text value="Evidence to support &#39;Drug therapies and medication: symptom control&#39; Domain Level" />
                <answer>
                    <valueString value="Drug therapies and medication: symptom control evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.21" />
                <text value="&#39;Altered states of consciousness&#39; Domain Level Score" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-DomainLevelScore" />
                        <code value="B" />
                        <display value="Borderline/nearly meets the described need" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.22" />
                <text value="Evidence to support &#39;Altered states of consciousness&#39; Domain Level" />
                <answer>
                    <valueString value="Altered states of consciousness evidence" />
                </answer>
            </item>
            <item>
                <linkId value="2.23" />
                <text value="Total Score from Checklist" />
                <answer>
                    <valueString value="Score" />
                </answer>
            </item>
            <item>
                <linkId value="2.24" />
                <text value="Outcome indicated by the Checklist" />
                <answer>
                    <valueCoding>
                        <system value="https://fhir.nottinghamshire.gov.uk/STU3/codesystem/CHC-Outcome" />
                        <code value="2" />
                        <display value="No referral for full assessment for NHS Continuing Healthcare is necessary" />
                    </valueCoding>
                </answer>
            </item>
            <item>
                <linkId value="2.25" />
                <text value="Rationale for decision" />
                <answer>
                    <valueString value="Optional textual note detailing the rationale for decision, i.e. why a referral for full assessment for NHS Continuing Healthcare is or isn&#39;t necessary" />
                </answer>
            </item>
        </QuestionnaireResponse>
    </contained>
    <status value="active" />
    <intent value="plan" />
    <type>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="715591000000108" />
            <display value="Hospital Discharge Notification to Social Care" />
        </coding>
        <text value="Hospital Discharge Notification to Social Care" />
    </type>
    <subject>
        <reference value="#patient" />
    </subject>
    <context>
        <reference value="#encounter" />
    </context>
    <authoredOn value="2020-04-29T09:45:42+00:00" />
    <requester>
        <agent>
            <reference value="#referring-clinician" />
        </agent>
        <onBehalfOf>
            <reference value="#acute-hospital" />
        </onBehalfOf>
    </requester>
    <reasonCode>
        <text value="Supported discharge required" />
    </reasonCode>
    <supportingInfo>
        <reference value="#preliminary-needs-questionnaire-response" />
    </supportingInfo>
    <supportingInfo>
        <reference value="#covid-19-questionnaire-response" />
    </supportingInfo>
    <supportingInfo>
        <reference value="#chc-checklist-questionnaire-response" />
    </supportingInfo>
    <note>
        <text value="27/04/2020 09:42 - Rose Smith\nDetail of actual comment added by IDT Worker\nDownload a copy as XML or JSON to see appropriate XML/JSON ‘character coding’ for new lines/carriage returns" />
    </note>
    <note>
        <text value="28/04/2020 17:11\nA Comment without an author that is quite long and goes into a detailed description that will span multiple lines in the form field.\n\nMaybe the comment even has multiple paragraphs." />
    </note>
    <note>
        <text value="29/04/2020 09:45 - Jack Jones\nSome comments made by IDT worker during initial assessment" />
    </note>
</ReferralRequest>