{
    "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": "04/27/2020 00:00:00",
                "end": "05/01/2020 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": "04/29/2020 14:31:00",
            "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": "05/01/2020 12:10:00"
                                }
                            ]
                        }
                    ]
                },
                {
                    "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": "04/29/2020 14:48:01",
            "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": "02/19/2020 08:30:00",
            "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": "04/29/2020 09:45:42",
    "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"
        }
    ]
}

<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>