<status value="active" /> <experimental value="true" /> <subjectType value="Patient" /> <publisher value="Ontario Health" /> <description value="Ontario Health–authored cardiology referral questionnaire example. This is the manually refined example based on the OH Form Designer output, updated to better align with the profile, terminology, intended rendering expectations, and note-info usage." /> <jurisdiction> <coding> <system value="urn:iso:std:iso:3166" /> <code value="CA" /> </coding> </jurisdiction> <effectivePeriod> <start value="2025-02-03" /> </effectivePeriod> <code> <system value="http://snomed.info/sct" /> <code value="789718008" /> <display value="Cardiology service" /> </code> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="list" /> <display value="List" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="patient_header" /> <text value="Patient Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="group" /> <item> <linkId value="patient_surname" /> <text value="Surname:" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="patient_firstname" /> <text value="First Name:" /> <type value="string" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/entryFormat"> <valueString value="yyyy/MM/dd" /> </extension> <linkId value="patient_date_of_birth" /> <text value="DOB:" /> <type value="date" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="radio-button" /> <display value="Radio Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="patient_gender" /> <text value="Gender:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="male" /> <display value="Male" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="female" /> <display value="Female" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="other" /> <display value="Other" /> </valueCoding> </answerOption> </item> <item> <linkId value="patient_hc_pc" /> <text value="HN PC:" /> <type value="string" /> <maxLength value="2" /> <item> <linkId value="patient_hc_number" /> <text value="HN:" /> <type value="string" /> <maxLength value="10" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="2" /> </extension> <linkId value="patient_hc_vc" /> <text value="HN VC:" /> <type value="string" /> </item> </item> <item> <linkId value="patient_address_line1" /> <text value="Address (Line 1):" /> <type value="string" /> <required value="true" /> <item> <linkId value="patient_address_line2" /> <text value="Address (Line 2):" /> <type value="string" /> </item> <item> <linkId value="patient_address_city" /> <text value="City:" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="patient_address_province" /> <text value="Province:" /> <type value="string" /> <required value="true" /> <maxLength value="2" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="pat-pcode" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_address_postalcode').answer.all(value.matches('^(?!.*[DFIOQU])[A-VXY][0-9][A-Z] ?[0-9][A-Z][0-9]$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid Canadian postal-code" /> </extension> </extension> <linkId value="patient_address_postalcode" /> <text value="Postal Code:" /> <type value="string" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="mobilephone" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_phone_mobile').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <linkId value="patient_phone_mobile" /> <text value="Mobile #:" /> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="homephone" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_phone_home').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <linkId value="patient_phone_home" /> <text value="Home #:" /> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="busphone" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_phone_business').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <linkId value="patient_phone_business" /> <text value="Business #:" /> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="patemail" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_email').answer.all(value.matches('(?:[a-z0-9!#$%&'*+/=?^_`{|}~-]+(?:\.[a-z0-9!#$%&'*+/=?^_`{|}~-]+)*|"(?:[\x01-\x08\x0b\x0c\x0e-\x1f\x21\x23-\x5b\x5d-\x7f]|\\[\x01-\x09\x0b\x0c\x0e-\x7f])*")@(?:(?:[a-z0-9](?:[a-z0-9-]*[a-z0-9])?\.)+[a-z0-9](?:[a-z0-9-]*[a-z0-9])?|\[(?:(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9]))\.){3}(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9])|[a-z0-9-]*[a-z0-9]:(?:[\x01-\x08\x0b\x0c\x0e-\x1f\x21-\x5a\x53-\x7f]|\\[\x01-\x09\x0b\x0c\x0e-\x7f])+)\])'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid email address" /> </extension> </extension> <linkId value="patient_email" /> <text value="Email:" /> <type value="string" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="additionalinfo_header" /> <text value="[Optional] Additional Patient Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="[Optional] Additional Patient Information " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_sexassignedatbirth" /> <text value="Sex assigned at birth:" /> <type value="choice" /> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA3-6" /> <display value="Female" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA2-8" /> <display value="Male" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://example.org/CodeSystem/exampleCS" /> <code value="Intersex" /> <display value="Intersex" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA4489-6" /> <display value="Unknown" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_pronouns" /> <text value="Pronouns:" /> <type value="choice" /> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA29519-8" /> <display value="she/her/her/hers/herself" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA29518-0" /> <display value="he/him/his/his/himself" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA29520-6" /> <display value="they/them/their/theirs/themselves" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </valueCoding> </answerOption> <item> <linkId value="additionalinfo_pronouns_other" /> <text value="Other pronouns:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_pronouns" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_preferredlanguage" /> <text value="Preferred language:" /> <type value="choice" /> <required value="false" /> <answerOption> <valueCoding> <system value="urn:ietf:bcp:47" /> <code value="en" /> <display value="English" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="urn:ietf:bcp:47" /> <code value="fr" /> <display value="French" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </valueCoding> </answerOption> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_preferredlanguage_specify" /> <text value="Specify:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_preferredlanguage" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_preferredlanguage_translatorrequired" /> <text value="Translator required"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <enableWhen> <question value="additionalinfo_preferredlanguage" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </answerCoding> </enableWhen> <repeats value="true" /> <answerOption> <valueString value="Translator Required" /> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_bestmethodofcontact" /> <text value="Best method of contact:" /> <type value="choice" /> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="mobile" /> <display value="Mobile" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="home" /> <display value="Home" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="work" /> <display value="Work" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-system" /> <code value="email" /> <display value="Email" /> </valueCoding> </answerOption> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_bestmethodofcontact_voicemails" /> <text value="Voicemails acceptable"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <enableWhen> <question value="additionalinfo_bestmethodofcontact" /> <operator value="=" /> <answerCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="mobile" /> <display value="Mobile" /> </answerCoding> </enableWhen> <enableBehavior value="any" /> <repeats value="true" /> <answerOption> <valueString value="Voicemails acceptable" /> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_preferredname_select" /> <text value="Preferred name"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Preferred Name" /> </answerOption> </item> <item> <linkId value="additionalinfo_preferredname" /> <text value="Prefered name String"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <enableWhen> <question value="additionalinfo_preferredname_select" /> <operator value="=" /> <answerString value="Preferred Name" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_alternatecontact_select" /> <text value="Alternate contact"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Alternate contact" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_alternatecontact_name" /> <text value="Name:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_alternatecontact_select" /> <operator value="=" /> <answerString value="Alternate contact" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="altphone" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='additionalinfo_alternatecontact_phone').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_alternatecontact_phone" /> <text value="Alternate contact phone #:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_alternatecontact_select" /> <operator value="=" /> <answerString value="Alternate contact" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_alternatecontact_relationship" /> <text value="Relationship:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_alternatecontact_select" /> <operator value="=" /> <answerString value="Alternate contact" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="radio-button" /> <display value="Radio Button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_alternatecontact_bookingcontact" /> <text value="Is Alternate contact the appointment booking contact?:" /> <type value="choice" /> <enableWhen> <question value="additionalinfo_alternatecontact_select" /> <operator value="=" /> <answerString value="Alternate contact" /> </enableWhen> <enableBehavior value="all" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_unsafecontacts_select" /> <text value="Unsafe contact persons (do not speak with)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Unsafe contact persons (do not speak with)" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_unsafecontacts_speakwithpatientdirectly" /> <text value="Only speak with patient directly"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <enableWhen> <question value="additionalinfo_unsafecontacts_select" /> <operator value="=" /> <answerString value="Unsafe contact persons (do not speak with)" /> </enableWhen> <enableBehavior value="all" /> <repeats value="true" /> <answerOption> <valueString value="Only speak with patient directly" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_unsafecontacts_donotspeakwith" /> <text value="Do not speak with:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_unsafecontacts_select" /> <operator value="=" /> <answerString value="Unsafe contact persons (do not speak with)" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_accessibilityconcernsordisability_selectt" /> <text value="Accessibility concerns or disability"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Accessibility concerns or disability" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_accessibilityconcernsordisability" /> <text value="Accessibility concerns Options"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> </text> <type value="choice" /> <enableWhen> <question value="additionalinfo_accessibilityconcernsordisability_selectt" /> <operator value="=" /> <answerString value="Accessibility concerns or disability" /> </enableWhen> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="129839007" /> <display value="At risk for falls" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="301621006" /> <display value="Uses lift" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="105503008" /> <display value="Dependence on wheelchair" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="15188001" /> <display value="Hearing impaired" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_specialconsiderations_select" /> <text value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_specialconsiderations" /> <text value="Details of special considerations:" /> <type value="text" /> <enableWhen> <question value="additionalinfo_specialconsiderations_select" /> <operator value="=" /> <answerString value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)" /> </enableWhen> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_sendcopiestoadditionalproviders" /> <text value="Send copies of reports to additional providers"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Send copies of reports to additional providers" /> </answerOption> </item> <item> <linkId value="additionalinfo_sendcopiestoadditionalproviders_names" /> <text value="Name(s):" /> <type value="string" /> <enableWhen> <question value="additionalinfo_sendcopiestoadditionalproviders" /> <operator value="=" /> <answerString value="Send copies of reports to additional providers" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <item> <linkId value="additionalinfo_sendcopiestoadditionalproviders_contactinfo" /> <text value="Contact information:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_sendcopiestoadditionalproviders" /> <operator value="=" /> <answerString value="Send copies of reports to additional providers" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_sendcopiestoadditionalproviders_ispcp" /> <text value="This is the Primary Care Provider"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <enableWhen> <question value="additionalinfo_sendcopiestoadditionalproviders" /> <operator value="=" /> <answerString value="Send copies of reports to additional providers" /> </enableWhen> <enableBehavior value="all" /> <repeats value="true" /> <answerOption> <valueString value="This is the Primary Care Provider" /> </answerOption> </item> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="sortIndex"> <valuePositiveInt value="1" /> </extension> <extension url="text"> <valueString value="Referral Details"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" Referral Details " /> </extension> </valueString> </extension> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <linkId value="102173268919" /> <text value="Referral Details"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Referral Details " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;color:#202035;" /> </extension> </text> <type value="group" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="true" /> </valueExpression> </extension> <extension url="sortIndex"> <valuePositiveInt value="1" /> </extension> <extension url="text"> <valueString value="Triage Considerations" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="cardio_triagecons" /> <text value="Triage Considerations"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Triage Considerations " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sortIndex"> <valuePositiveInt value="1" /> </extension> <extension url="text"> <valueString value="Requested Priority:" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#EE6B00;" /> </extension> </extension> <linkId value="referral_requestedpriority" /> <text value="Requested Priority:" /> <type value="choice" /> <required value="true" /> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="text"> <valueString value="Routine" /> </extension> <extension url="style"> <valueString value="font-weight:bold;color:#EE6B00;" /> </extension> </extension> <valueCoding> <system value="http://hl7.org/fhir/request-priority" /> <code value="routine" /> <display value="Routine" /> </valueCoding> <initialSelected value="true" /> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/request-priority" /> <code value="urgent" /> <display value="Urgent" /> </valueCoding> </answerOption> <item> <linkId value="referral_requestedpriority_urgentreason" /> <text value="Reason for urgent triage" /> <type value="string" /> <enableWhen> <question value="referral_requestedpriority" /> <operator value="=" /> <answerCoding> <system value="http://hl7.org/fhir/request-priority" /> <code value="urgent" /> <display value="Urgent" /> </answerCoding> </enableWhen> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sortIndex"> <valuePositiveInt value="2" /> </extension> <extension url="suppressQuestionText"> <valueBoolean value="true" /> </extension> <extension url="text"> <valueString value="Second Opinion" /> </extension> </extension> <linkId value="referral_secondopinion" /> <text value="Second Opinion"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="77406008" /> <display value="Second or third medical opinion" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="referral_secondopinion_reason" /> <text value="Reason for second opinion:" /> <type value="text" /> <enableWhen> <question value="referral_secondopinion" /> <operator value="=" /> <answerCoding> <system value="http://snomed.info/sct" /> <code value="77406008" /> <display value="Second or third medical opinion" /> </answerCoding> </enableWhen> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="sortIndex"> <valuePositiveInt value="2" /> </extension> <extension url="text"> <valueString value="Service(s) Requested" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="695991571585" /> <text value="Service(s) Requested Select all that apply:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Service(s) Requested Select all that apply: " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="color:Gray20;" /> </extension> </text> <type value="group" /> <required value="true" /> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression"> <valueExpression> <description value="Calculates HSC services based on selected checkboxes for cardiac testing and cardiology consult" /> <language value="text/fhirpath" /> <expression value="iif(%resource.item.where(linkId='223886162384').answer.value.exists(), 'CARDIOLOGY_SERVICES', '') + iif(%resource.item.where(linkId='223886162384').answer.value.exists() and %resource.item.where(linkId='785727177547').answer.value.exists(), '|', '') + iif(%resource.item.where(linkId='785727177547').answer.value.exists(), 'CARDIOLOGY', '')" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="HSCs Assigned:" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <linkId value="referralService" /> <text value="HSCs Assigned:" /> <type value="string" /> <readOnly value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="223886162384" /> <text value="Cardiac Testing"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20001" /> <display value="Cardiac Testing" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="660331267409" /> <text value="Exam(s) Requested"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Exam(s) Requested " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="color:Gray20;font-weight:bold;" /> </extension> </text> <type value="group" /> <enableWhen> <question value="223886162384" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20001" /> <display value="Cardiac Testing" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="720409326878" /> <text value="24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20003" /> <display value="24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered)" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="960455115596" /> <text value="Coronary Angiogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20004" /> <display value="Coronary Angiogram" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="297634898828" /> <text value="Echocardiogram - Resting"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20005" /> <display value="Echocardiogram - Resting" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="443484577720" /> <text value="sub Echocardiogram - Resting"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="group" /> <enableWhen> <question value="297634898828" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20005" /> <display value="Echocardiogram - Resting" /> </answerCoding> </enableWhen> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="165530569567" /> <text value="Echocardiogram (2D)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20012" /> <display value="Echocardiogram (2D)" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="286552421895" /> <text value="Echocardiogram with Contrast"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20013" /> <display value="Echocardiogram with Contrast" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="910527687300" /> <text value="Echocardiogram with Saline (Bubble)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20014" /> <display value="Echocardiogram with Saline (Bubble)" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="657824763133" /> <text value="Pediatric Echocardiogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20015" /> <display value="Pediatric Echocardiogram" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="992743200182" /> <text value="Transesophageal Echocardiogram (TEE)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20016" /> <display value="Transesophageal Echocardiogram (TEE)" /> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="894277763438" /> <text value="Electrocardiogram (ECG)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20006" /> <display value="Electrocardiogram (ECG)" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="279226023495" /> <text value="Holter Monitoring"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20007" /> <display value="Holter Monitoring" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="440449731882" /> <text value="sub holter monitoring"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="group" /> <enableWhen> <question value="279226023495" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20007" /> 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Days" /> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="374742834400" /> <text value="Loop / Event Monitor"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20008" /> 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<valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="307107493993" /> <text value="ECG - Dobutamine/Persantine Stress Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20023" /> <display value="ECG - Dobutamine/Persantine Stress Test" /> </valueCoding> </answerOption> </item> <item> <extension 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</answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="892165959617" /> <text value="Myocardial perfusion scan"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20028" /> <display value="MIBI Scans / 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<text value="Tilt Table Testing"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20011" /> <display value="Tilt Table Testing" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="cardiology_referral_services_cardiactesting_other" /> <text value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </valueCoding> </answerOption> </item> <item> <linkId value="cardiology_referral_services_cardiactesting_other_specify" /> <text value="Specify" /> <type value="text" /> <enableWhen> <question value="cardiology_referral_services_cardiactesting_other" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="785727177547" /> <text value="Cardiology Consultation"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20002" /> <display value="Cardiology Consultation" /> </valueCoding> </answerOption> </item> </item> <item> <linkId value="186952778859" /> <text value="Concern(s) / Indication(s) Triggering Referral Select all that apply:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Concern(s) / Indication(s) Triggering Referral Select all that apply: " /> </extension> </text> <type value="group" /> <required value="true" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="219569805461" /> <text value="Arrhythmias or Palpitations"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="698247007" /> <display value="Cardiac arrhythmia" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="571934328499" /> <text value="Cardiovascular Risk Assessment"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20033" /> <display value="Cardiovascular Risk Assessment" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="459737733395" /> <text value="Chest Pain or Angina"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20034" /> <display value="Chest Pain or Angina" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="929919815516" /> <text value="Congenital Heart Disease"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20035" /> <display value="Congenital Heart Disease" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="832263816528" /> <text value="Congestive Heart Failure"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20036" /> <display value="Congestive Heart Failure" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="803760213460" /> <text value="Coronary Artery Disease"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20037" /> <display value="Coronary Artery Disease" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="129767162379" /> <text value="Dyspnea"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20038" /> <display value="Dyspnea" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="116150628533" /> <text value="Hypertension"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20039" /> <display value="Hypertension" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="513825527027" /> <text value="Murmur"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20040" /> <display value="Murmur" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="975075898688" /> <text value="Pericardial Disease"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20041" /> <display value="Pericardial Disease" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="704148928571" /> <text value="Peripheral Edema"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20042" /> <display value="Peripheral Edema" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="886489617115" /> <text value="Post-Myocardial Infarction"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20043" /> <display value="Post-Myocardial Infarction" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="621745958993" /> <text value="Pre-operative Consultation"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20044" /> <display value="Pre-operative Consultation" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="873024527134" /> <code> <system value="http://snomed.info/sct" /> <code value="439272007" /> <display value="Date of procedure" /> </code> <text value="Procedure Date (if known)" /> <type value="date" /> <enableWhen> <question value="621745958993" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20044" /> <display value="Pre-operative Consultation" /> </answerCoding> </enableWhen> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="197975129599" /> <text value="Syncope"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20045" /> <display value="Syncope" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="675849150752" /> <text value="Valvular Heart Disease or Prosthetic Heart Valve"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="368009" /> <display value="Valvular heart disease" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="721982740516" /> <text value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="720594942482" /> <text value="Specify" /> <type value="text" /> <enableWhen> <question value="721982740516" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </answerCoding> </enableWhen> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="Descriptionofclinicalquestion" /> <text value="Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="text" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="cpp_header" /> <text value="Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="cpp_separate" /> <text value="CPP attached separately (if not entered below)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="CPP attached separately (if not entered below)" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="cpp_currentprob" /> <code> <system value="http://snomed.info/sct" /> <code value="55607006" /> <display value="Problem" /> </code> <text value="Current Problem List:" /> <type value="text" /> <enableWhen> <question value="cpp_separate" /> <operator value="exists" /> <answerBoolean value="false" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="cpp_pastmedicalhistory" /> <code> <system value="http://snomed.info/sct" /> <code value="417662000" /> <display value="History of clinical finding in subject" /> </code> <text value="Past Medical History:" /> <type value="text" /> <enableWhen> <question value="cpp_separate" /> <operator value="exists" /> <answerBoolean value="false" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="cpp_currentmedications" /> <code> <system value="http://snomed.info/sct" /> <code value="129019007" /> <display value="Taking medication" /> </code> <text value="Current Medications :" /> <type value="text" /> <enableWhen> <question value="cpp_separate" /> <operator value="exists" /> <answerBoolean value="false" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="cpp_familyhistory" /> <code> <system value="http://snomed.info/sct" /> <code value="57177007" /> <display value="Family history with explicit context" /> </code> <text value="Family History:" /> <type value="text" /> <enableWhen> <question value="cpp_separate" /> <operator value="exists" /> <answerBoolean value="false" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="cpp_allergies" /> <code> <system value="http://snomed.info/sct" /> <code value="609328004" /> <display value="Allergic disposition" /> </code> <text value="Allergies:" /> <type value="text" /> <enableWhen> <question value="cpp_separate" /> <operator value="exists" /> <answerBoolean value="false" /> </enableWhen> <enableBehavior value="all" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="preferredconsultlocation_header" /> <text value="Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered." /> </extension> </text> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="preferredconsultlocation_selector" /> <text value="Preferred consultant or location"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Preferred consultant or location" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="preferredconsultlocation_specify" /> <text value="Please specify either a preferred consultant or location"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Please specify either a preferred consultant or location" /> </extension> </text> <type value="group" /> <enableWhen> <question value="preferredconsultlocation_selector" /> <operator value="=" /> <answerString value="Preferred consultant or location" /> </enableWhen> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="preferredconsultlocation_consultant" /> <text value="Consultant:" /> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="preferredconsultlocation_location" /> <text value="Location:" /> <type value="string" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="preferredconsultlocation_willingtotravel" /> <text value="Patient willing to travel for shorter wait time"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Patient willing to travel for shorter wait time" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="preferredconsultlocation_otherconsiderations" /> <text value="Other considerations:" /> <type value="string" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="supportingdocumentation_header" /> <text value="Supporting Documentation Please attach all relevant laboratory and diagnostic investigations."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Supporting Documentation Please attach all relevant laboratory and diagnostic investigations. " /> </extension> </text> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="supportingdocumentation_details" /> <text value="Personal Health Information that is medically relevant has not been disclosed at the request of the patient."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Personal Health Information that is medically relevant has not been disclosed at the request of the patient." /> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/pdf" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/gif" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/bmp" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/vnd.openxmlformats-officedocument.spreadsheetml.sheet" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="video/mp4" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="text/csv" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/jpeg" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/msword" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/png" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/vnd.openxmlformats-officedocument.wordprocessingml.document" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/vnd.ms-excel" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="text/plain" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="audio/mp4" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="audio/mpeg" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/tiff" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/maxSize"> <valueDecimal value="5000000" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="positiveText"> <valueString value="Attachment Provided" /> </extension> </extension> <linkId value="supportingdocumentation_attachment" /> <text value="Add Attachments" /> <type value="attachment" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="feedbacksurvey_cardiology" /> <text value="Click here to provide feedback on this form"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<a href="https://www.surveymonkey.com/r/cardioSRF">Click here to provide feedback on this form</a> " /> </extension> </text> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="referrer_header" /> <text value="Referrer's Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="group" /> <item> <linkId value="referrer_sitename" /> <text value="Site Name:" /> <type value="string" /> </item> <item> <linkId value="referrer_address_line1" /> <text value="Address (Line 1):" /> <type value="string" /> <required value="true" /> <item> <linkId value="referrer_address_line2" /> <text value="Address (Line 2):" /> <type value="string" /> </item> <item> <linkId value="referrer_address_city" /> <text value="City:" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="referrer_address_province" /> <text value="Province:" /> <type value="string" /> <required value="true" /> <maxLength value="2" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="ref-pcode" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='referrer_address_postalcode').answer.all(value.matches('^(?!.*[DFIOQU])[A-VXY][0-9][A-Z] ?[0-9][A-Z][0-9]$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid Canadian postal-code" /> </extension> </extension> <linkId value="referrer_address_postalcode" /> <text value="Postal Code:" /> <type value="string" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="refphone" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='referrer_phone').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <linkId value="referrer_phone" /> <text value="Phone #:" /> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="reffax" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='referrer_fax').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <linkId value="referrer_fax" /> <text value="Fax #:" /> <type value="string" /> </item> <item> <linkId value="referrer_billing" /> <text value="Billing Number:" /> <type value="integer" /> </item> <item> <linkId value="referrer_professionalid" /> <text value="Professional ID:" /> <type value="integer" /> </item> <item> <linkId value="referrer_signature" /> <text value="Signed:" /> <type value="text" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="drop-down" /> <display value="Drop down" /> </coding> </valueCodeableConcept> </extension> <linkId value="referrer_role" /> <text value="Role:" /> <type value="choice" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="309398001" /> <display value="Profession allied to medicine" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="62247001" /> <display value="Family doctor" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="449161006" /> <display value="Physician assistant" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="398130009" /> <display value="Medical student" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="106292003" /> <display value="Nurse" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="224571005" /> <display value="Nurse practitioner" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="405277009" /> <display value="Resident physician" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="69280009" /> <display value="Specialized physician" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </valueCoding> </answerOption> </item> </item> </Questionnaire>

Generated Narrative: Questionnaire CardiologyOHAuthored

Language: en

Structure

LinkID	Text	Cardinality	Type	Description & Constraints
	Ontario Health–authored cardiology referral questionnaire example. This is the manually refined example based on the OH Form Designer output, updated to better align with the profile, terminology, intended rendering expectations, and note-info usage.		Questionnaire	http://ontariohealth.ca/fhir/eforms/Questionnaire/CardiologyOHAuthored#1.2.0
patient_header	Patient Information	0..1	group
patient_header / patient_surname	Surname:	1..1	string
patient_header / patient_firstname	First Name:	1..1	string
patient_header / patient_date_of_birth	DOB:	1..1	date
patient_header / patient_gender	Gender:	1..1	choice	Options: 3 options
patient_header / patient_hc_pc	HN PC:	0..1	string	Max Length: 2
patient_header / patient_hc_pc / patient_hc_number	HN:	0..1	string	Max Length: 10
patient_header / patient_hc_pc / patient_hc_vc	HN VC:	0..1	string
patient_header / patient_address_line1	Address (Line 1):	1..1	string
patient_header / patient_address_line1 / patient_address_line2	Address (Line 2):	0..1	string
patient_header / patient_address_line1 / patient_address_city	City:	1..1	string
patient_header / patient_address_line1 / patient_address_province	Province:	1..1	string	Max Length: 2
patient_header / patient_address_line1 / patient_address_postalcode	Postal Code:	1..1	string
patient_header / patient_phone_mobile	Mobile #:	0..1	string
patient_header / patient_phone_home	Home #:	0..1	string
patient_header / patient_phone_business	Business #:	0..1	string
patient_header / patient_email	Email:	0..1	string
additionalinfo_header	[Optional] Additional Patient Information	0..1	group
additionalinfo_header / additionalinfo_sexassignedatbirth	Sex assigned at birth:	0..1	choice	Options: 4 options
additionalinfo_header / additionalinfo_pronouns	Pronouns:	0..1	choice	Options: 4 options
additionalinfo_header / additionalinfo_pronouns / additionalinfo_pronouns_other	Other pronouns:	1..1	string	Enable When: additionalinfo_pronouns = other (NullFlavor#OTH)
additionalinfo_header / additionalinfo_preferredlanguage	Preferred language:	0..1	choice	Options: 3 options
additionalinfo_header / additionalinfo_preferredlanguage / additionalinfo_preferredlanguage_specify	Specify:	1..1	string	Enable When: additionalinfo_preferredlanguage = other (NullFlavor#OTH)
additionalinfo_header / additionalinfo_preferredlanguage / additionalinfo_preferredlanguage_translatorrequired	Translator required	0..*	string	Enable When: additionalinfo_preferredlanguage = other (NullFlavor#OTH) Options: 1 option
additionalinfo_header / additionalinfo_bestmethodofcontact	Best method of contact:	0..1	choice	Options: 4 options
additionalinfo_header / additionalinfo_bestmethodofcontact / additionalinfo_bestmethodofcontact_voicemails	Voicemails acceptable	0..*	string	Enable When: additionalinfo_bestmethodofcontact = Mobile (ContactPointUse#mobile) Options: 1 option
additionalinfo_header / additionalinfo_preferredname_select	Preferred name	0..*	string	Options: 1 option
additionalinfo_header / additionalinfo_preferredname	Prefered name String	0..1	string	Enable When: additionalinfo_preferredname_select = Preferred Name
additionalinfo_header / additionalinfo_alternatecontact_select	Alternate contact	0..*	string	Options: 1 option
additionalinfo_header / additionalinfo_alternatecontact_name	Name:	1..1	string	Enable When: additionalinfo_alternatecontact_select = Alternate contact
additionalinfo_header / additionalinfo_alternatecontact_phone	Alternate contact phone #:	0..1	string	Enable When: additionalinfo_alternatecontact_select = Alternate contact
additionalinfo_header / additionalinfo_alternatecontact_relationship	Relationship:	0..1	string	Enable When: additionalinfo_alternatecontact_select = Alternate contact
additionalinfo_header / additionalinfo_alternatecontact_bookingcontact	Is Alternate contact the appointment booking contact?:	0..1	choice	Enable When: additionalinfo_alternatecontact_select = Alternate contact Options: 2 options
additionalinfo_header / additionalinfo_unsafecontacts_select	Unsafe contact persons (do not speak with)	0..*	string	Options: 1 option
additionalinfo_header / additionalinfo_unsafecontacts_speakwithpatientdirectly	Only speak with patient directly	0..*	string	Enable When: additionalinfo_unsafecontacts_select = Unsafe contact persons (do not speak with) Options: 1 option
additionalinfo_header / additionalinfo_unsafecontacts_donotspeakwith	Do not speak with:	0..1	string	Enable When: additionalinfo_unsafecontacts_select = Unsafe contact persons (do not speak with)
additionalinfo_header / additionalinfo_accessibilityconcernsordisability_selectt	Accessibility concerns or disability	0..*	string	Options: 1 option
additionalinfo_header / additionalinfo_accessibilityconcernsordisability	Accessibility concerns Options	0..*	choice	Enable When: additionalinfo_accessibilityconcernsordisability_selectt = Accessibility concerns or disability Options: 4 options
additionalinfo_header / additionalinfo_specialconsiderations_select	Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)	0..*	string	Options: 1 option
additionalinfo_header / additionalinfo_specialconsiderations	Details of special considerations:	1..1	text	Enable When: additionalinfo_specialconsiderations_select = Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)
additionalinfo_header / additionalinfo_sendcopiestoadditionalproviders	Send copies of reports to additional providers	0..*	string	Options: 1 option
additionalinfo_header / additionalinfo_sendcopiestoadditionalproviders_names	Name(s):	1..1	string	Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers
additionalinfo_header / additionalinfo_sendcopiestoadditionalproviders_names / additionalinfo_sendcopiestoadditionalproviders_contactinfo	Contact information:	1..1	string	Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers
additionalinfo_header / additionalinfo_sendcopiestoadditionalproviders_names / additionalinfo_sendcopiestoadditionalproviders_ispcp	This is the Primary Care Provider	0..*	string	Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers Options: 1 option
102173268919	Referral Details	0..1	group
102173268919 / cardio_triagecons	Triage Considerations	0..1	group
102173268919 / cardio_triagecons / referral_requestedpriority	Requested Priority:	1..1	choice	Options: 2 options
102173268919 / cardio_triagecons / referral_requestedpriority / referral_requestedpriority_urgentreason	Reason for urgent triage	1..1	string	Enable When: referral_requestedpriority = Urgent (RequestPriority#urgent)
102173268919 / cardio_triagecons / referral_secondopinion	Second Opinion	0..*	choice	Options: 1 option
102173268919 / cardio_triagecons / referral_secondopinion_reason	Reason for second opinion:	0..1	text	Enable When: referral_secondopinion = Second or third medical opinion (SNOMED CT#77406008)
102173268919 / 695991571585	Service(s) Requested Select all that apply:	1..1	group
102173268919 / 695991571585 / referralService	HSCs Assigned:	0..1	string
102173268919 / 695991571585 / 223886162384	Cardiac Testing	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409	Exam(s) Requested	0..1	group	Enable When: 223886162384 = Cardiac Testing (Example Referral Form Codes#20001)
102173268919 / 695991571585 / 660331267409 / 720409326878	24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered)	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 960455115596	Coronary Angiogram	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 297634898828	Echocardiogram - Resting	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 443484577720	sub Echocardiogram - Resting	0..1	group	Enable When: 297634898828 = Echocardiogram - Resting (Example Referral Form Codes#20005)
102173268919 / 695991571585 / 660331267409 / 443484577720 / 165530569567	Echocardiogram (2D)	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 443484577720 / 286552421895	Echocardiogram with Contrast	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 443484577720 / 910527687300	Echocardiogram with Saline (Bubble)	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 443484577720 / 657824763133	Pediatric Echocardiogram	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 443484577720 / 992743200182	Transesophageal Echocardiogram (TEE)	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 894277763438	Electrocardiogram (ECG)	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 279226023495	Holter Monitoring	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 440449731882	sub holter monitoring	0..1	group	Enable When: 279226023495 = Holter Monitoring (Example Referral Form Codes#20007)
102173268919 / 695991571585 / 660331267409 / 440449731882 / 671328703851	24 Hours	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 440449731882 / 423992261841	48 Hours	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 440449731882 / 419924239187	72 Hours	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 440449731882 / 731054417270	7 Days	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 440449731882 / 235876421044	14 Days	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 374742834400	Loop / Event Monitor	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 159161544747	Cardiovascular stress testing	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 370275060390	Sub Stress Testing	0..1	group	Enable When: 159161544747 = Stress Testing (Example Referral Form Codes#20009)
102173268919 / 695991571585 / 660331267409 / 370275060390 / 814218498309	ECG - Exercise Stress Test	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 370275060390 / 307107493993	ECG - Dobutamine/Persantine Stress Test	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 370275060390 / 805303414102	Echocardiogram - Exercise Stress Test	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 370275060390 / 193586908489	Echocardiogram - Dobutamine/Persantine Stress Test	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 918517139023	Nuclear Medicine	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 222686221935	sub Nuclear Medicine	0..1	group	Enable When: 918517139023 = Nuclear Medicine (Example Referral Form Codes#20010)
102173268919 / 695991571585 / 660331267409 / 222686221935 / 924189648184	MUGA - Resting	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 222686221935 / 857163514910	Cardiac Pyrophosphate	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 222686221935 / 892165959617	Myocardial perfusion scan	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 222686221935 / 538288549138	sub MIBI	0..1	group	Enable When: 892165959617 = MIBI Scans / Myocardial Perfusion Imaging (MPI): (Example Referral Form Codes#20028)
102173268919 / 695991571585 / 660331267409 / 222686221935 / 538288549138 / 373435981917	MIBI Scan - Exercise Stress Test	0..*	string	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 222686221935 / 538288549138 / 434394942688	MIBI Scan - Dobutamine/Persantine Stress Test	0..*	string	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 222686221935 / 538288549138 / 913594478162	Thallium Viability Test	0..*	string	Options: 1 option
102173268919 / 695991571585 / 660331267409 / 992682216482	Tilt Table Testing	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / cardiology_referral_services_cardiactesting_other	Other	0..*	choice	Options: 1 option
102173268919 / 695991571585 / 660331267409 / cardiology_referral_services_cardiactesting_other_specify	Specify	1..1	text	Enable When: cardiology_referral_services_cardiactesting_other = other (NullFlavor#OTH)
102173268919 / 695991571585 / 785727177547	Cardiology Consultation	0..*	choice	Options: 1 option
102173268919 / 186952778859	Concern(s) / Indication(s) Triggering Referral Select all that apply:	1..1	group
102173268919 / 186952778859 / 219569805461	Arrhythmias or Palpitations	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 571934328499	Cardiovascular Risk Assessment	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 459737733395	Chest Pain or Angina	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 929919815516	Congenital Heart Disease	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 832263816528	Congestive Heart Failure	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 803760213460	Coronary Artery Disease	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 129767162379	Dyspnea	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 116150628533	Hypertension	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 513825527027	Murmur	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 975075898688	Pericardial Disease	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 704148928571	Peripheral Edema	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 886489617115	Post-Myocardial Infarction	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 621745958993	Pre-operative Consultation	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 873024527134	Procedure Date (if known)	0..1	date	Enable When: 621745958993 = Pre-operative Consultation (Example Referral Form Codes#20044)
102173268919 / 186952778859 / 197975129599	Syncope	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 675849150752	Valvular Heart Disease or Prosthetic Heart Valve	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 721982740516	Other	0..*	choice	Options: 1 option
102173268919 / 186952778859 / 720594942482	Specify	1..1	text	Enable When: 721982740516 = other (NullFlavor#OTH)
102173268919 / Descriptionofclinicalquestion	Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations	1..1	text
cpp_header	Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP	0..1	group
cpp_header / cpp_separate	CPP attached separately (if not entered below)	0..*	string	Options: 1 option
cpp_header / cpp_currentprob	Current Problem List:	0..1	text	Enable When: cpp_separate exists false
cpp_header / cpp_pastmedicalhistory	Past Medical History:	0..1	text	Enable When: cpp_separate exists false
cpp_header / cpp_currentmedications	Current Medications :	0..1	text	Enable When: cpp_separate exists false
cpp_header / cpp_familyhistory	Family History:	0..1	text	Enable When: cpp_separate exists false
cpp_header / cpp_allergies	Allergies:	0..1	text	Enable When: cpp_separate exists false
preferredconsultlocation_header	Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.	0..1	group
preferredconsultlocation_header / preferredconsultlocation_selector	Preferred consultant or location	0..*	string	Options: 1 option
preferredconsultlocation_header / preferredconsultlocation_specify	Please specify either a preferred consultant or location	0..1	group	Enable When: preferredconsultlocation_selector = Preferred consultant or location
preferredconsultlocation_header / preferredconsultlocation_specify / preferredconsultlocation_consultant	Consultant:	0..1	string
preferredconsultlocation_header / preferredconsultlocation_specify / preferredconsultlocation_location	Location:	0..1	string
preferredconsultlocation_header / preferredconsultlocation_willingtotravel	Patient willing to travel for shorter wait time	0..*	string	Options: 1 option
preferredconsultlocation_header / preferredconsultlocation_otherconsiderations	Other considerations:	0..1	string
supportingdocumentation_header	Supporting Documentation Please attach all relevant laboratory and diagnostic investigations.	0..1	group
supportingdocumentation_header / supportingdocumentation_details	Personal Health Information that is medically relevant has not been disclosed at the request of the patient.	0..*	string	Options: 1 option
supportingdocumentation_attachment	Add Attachments	0..1	attachment
feedbacksurvey_cardiology	Click here to provide feedback on this form	0..1	display
referrer_header	Referrer's Information	0..1	group
referrer_header / referrer_sitename	Site Name:	0..1	string
referrer_header / referrer_address_line1	Address (Line 1):	1..1	string
referrer_header / referrer_address_line1 / referrer_address_line2	Address (Line 2):	0..1	string
referrer_header / referrer_address_line1 / referrer_address_city	City:	1..1	string
referrer_header / referrer_address_line1 / referrer_address_province	Province:	1..1	string	Max Length: 2
referrer_header / referrer_address_line1 / referrer_address_postalcode	Postal Code:	1..1	string
referrer_header / referrer_phone	Phone #:	0..1	string
referrer_header / referrer_fax	Fax #:	0..1	string
referrer_header / referrer_billing	Billing Number:	0..1	integer
referrer_header / referrer_professionalid	Professional ID:	0..1	integer
referrer_header / referrer_signature	Signed:	1..1	text
referrer_header / referrer_role	Role:	0..1	choice	Options: 9 options
Documentation for this format

Options Sets

Answer options for patient_gender

http://hl7.org/fhir/administrative-gender#male ("Male")
http://hl7.org/fhir/administrative-gender#female ("Female")
http://hl7.org/fhir/administrative-gender#other ("Other")

Answer options for additionalinfo_sexassignedatbirth

http://loinc.org#LA3-6 ("Female")
http://loinc.org#LA2-8 ("Male")
http://example.org/CodeSystem/exampleCS#Intersex ("Intersex")
http://loinc.org#LA4489-6 ("Unknown")

Answer options for additionalinfo_pronouns

http://loinc.org#LA29519-8 ("she/her/her/hers/herself")
http://loinc.org#LA29518-0 ("he/him/his/his/himself")
http://loinc.org#LA29520-6 ("they/them/their/theirs/themselves")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")

Answer options for additionalinfo_preferredlanguage

urn:ietf:bcp:47#en ("English")
urn:ietf:bcp:47#fr ("French")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")

Answer options for additionalinfo_preferredlanguage_translatorrequired

Translator Required

Answer options for additionalinfo_bestmethodofcontact

http://hl7.org/fhir/contact-point-use#mobile ("Mobile")
http://hl7.org/fhir/contact-point-use#home ("Home")
http://hl7.org/fhir/contact-point-use#work ("Work")
http://hl7.org/fhir/contact-point-system#email ("Email")

Answer options for additionalinfo_bestmethodofcontact_voicemails

Voicemails acceptable

Answer options for additionalinfo_preferredname_select

Preferred Name

Answer options for additionalinfo_alternatecontact_select

Alternate contact

Answer options for additionalinfo_alternatecontact_bookingcontact

http://terminology.hl7.org/CodeSystem/v2-0532#Y ("Yes")
http://terminology.hl7.org/CodeSystem/v2-0532#N ("No")

Answer options for additionalinfo_unsafecontacts_select

Unsafe contact persons (do not speak with)

Answer options for additionalinfo_unsafecontacts_speakwithpatientdirectly

Only speak with patient directly

Answer options for additionalinfo_accessibilityconcernsordisability_selectt

Accessibility concerns or disability

Answer options for additionalinfo_accessibilityconcernsordisability

http://snomed.info/sct#129839007 ("At risk for falls")
http://snomed.info/sct#301621006 ("Uses lift")
http://snomed.info/sct#105503008 ("Dependence on wheelchair")
http://snomed.info/sct#15188001 ("Hearing impaired")

Answer options for additionalinfo_specialconsiderations_select

Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)

Answer options for additionalinfo_sendcopiestoadditionalproviders

Send copies of reports to additional providers

Answer options for additionalinfo_sendcopiestoadditionalproviders_ispcp

This is the Primary Care Provider

Answer options for referral_requestedpriority

http://hl7.org/fhir/request-priority#routine ("Routine")
http://hl7.org/fhir/request-priority#urgent ("Urgent")

Answer options for referral_secondopinion

http://snomed.info/sct#77406008 ("Second or third medical opinion")

Answer options for 223886162384

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20001 ("Cardiac Testing")

Answer options for 720409326878

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20003 ("24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered)")

Answer options for 960455115596

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20004 ("Coronary Angiogram")

Answer options for 297634898828

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20005 ("Echocardiogram - Resting")

Answer options for 165530569567

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20012 ("Echocardiogram (2D)")

Answer options for 286552421895

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20013 ("Echocardiogram with Contrast")

Answer options for 910527687300

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20014 ("Echocardiogram with Saline (Bubble)")

Answer options for 657824763133

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20015 ("Pediatric Echocardiogram")

Answer options for 992743200182

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20016 ("Transesophageal Echocardiogram (TEE)")

Answer options for 894277763438

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20006 ("Electrocardiogram (ECG)")

Answer options for 279226023495

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20007 ("Holter Monitoring")

Answer options for 671328703851

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20017 ("24 Hours")

Answer options for 423992261841

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20018 ("48 Hours")

Answer options for 419924239187

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20019 ("72 Hours")

Answer options for 731054417270

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20020 ("7 Days")

Answer options for 235876421044

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20021 ("14 Days")

Answer options for 374742834400

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20008 ("Loop / Event Monitor")

Answer options for 159161544747

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20009 ("Stress Testing")

Answer options for 814218498309

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20022 ("ECG - Exercise Stress Test")

Answer options for 307107493993

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20023 ("ECG - Dobutamine/Persantine Stress Test")

Answer options for 805303414102

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20024 ("Echocardiogram - Exercise Stress Test")

Answer options for 193586908489

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20025 ("Echocardiogram - Dobutamine/Persantine Stress Test")

Answer options for 918517139023

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20010 ("Nuclear Medicine")

Answer options for 924189648184

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20026 ("MUGA - Resting")

Answer options for 857163514910

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20027 ("Cardiac Pyrophosphate")

Answer options for 892165959617

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20028 ("MIBI Scans / Myocardial Perfusion Imaging (MPI):")

Answer options for 373435981917

MIBI Scan - Exercise Stress Test

Answer options for 434394942688

MIBI Scan - Dobutamine/Persantine Stress Test

Answer options for 913594478162

Thallium Viability Test

Answer options for 992682216482

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20011 ("Tilt Table Testing")

Answer options for cardiology_referral_services_cardiactesting_other

http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")

Answer options for 785727177547

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20002 ("Cardiology Consultation")

Answer options for 219569805461

http://snomed.info/sct#698247007 ("Cardiac arrhythmia")

Answer options for 571934328499

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20033 ("Cardiovascular Risk Assessment")

Answer options for 459737733395

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20034 ("Chest Pain or Angina")

Answer options for 929919815516

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20035 ("Congenital Heart Disease")

Answer options for 832263816528

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20036 ("Congestive Heart Failure")

Answer options for 803760213460

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20037 ("Coronary Artery Disease")

Answer options for 129767162379

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20038 ("Dyspnea")

Answer options for 116150628533

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20039 ("Hypertension")

Answer options for 513825527027

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20040 ("Murmur")

Answer options for 975075898688

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20041 ("Pericardial Disease")

Answer options for 704148928571

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20042 ("Peripheral Edema")

Answer options for 886489617115

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20043 ("Post-Myocardial Infarction")

Answer options for 621745958993

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20044 ("Pre-operative Consultation")

Answer options for 197975129599

http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes#20045 ("Syncope")

Answer options for 675849150752

http://snomed.info/sct#368009 ("Valvular heart disease")

Answer options for 721982740516

http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")

Answer options for cpp_separate

CPP attached separately (if not entered below)

Answer options for preferredconsultlocation_selector

Preferred consultant or location

Answer options for preferredconsultlocation_willingtotravel

Patient willing to travel for shorter wait time

Answer options for supportingdocumentation_details

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

Answer options for referrer_role

http://snomed.info/sct#309398001 ("Profession allied to medicine")
http://snomed.info/sct#62247001 ("Family doctor")
http://snomed.info/sct#449161006 ("Physician assistant")
http://snomed.info/sct#398130009 ("Medical student")
http://snomed.info/sct#106292003 ("Nurse")
http://snomed.info/sct#224571005 ("Nurse practitioner")
http://snomed.info/sct#405277009 ("Resident physician")
http://snomed.info/sct#69280009 ("Specialized physician")
http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")

Contained Resources

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Type	http://ontariohealth.ca/fhir/eforms/CodeSystem/library-types#qr-narrative-liquid
Parameters
Parameter	None
Library Content
text/htmlContent	`Encoded data`
Generated using version 0.5.6 of the sample-content-ig Liquid templates