Generated Narrative: Questionnaire MI-SplittingExample

Language: en

Structure
LinkID Text Cardinality Type Flags Description & Constraints doco
Standardized medical imaging referral questionnaire used as a splitting/sectioning example for implementation and testing. Questionnaire http://ontariohealth.ca/fhir/eforms/Questionnaire/MI-SplittingExample#1.2.0
283714301370 Please note that screening programs such the Ontario Breast Screening Program (OBSP) and Ontario Lung Screening Program (OLSP) have dedicated provincial intake forms and eligibility criteria. Please check program website for referral forms. 0..1 display
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_number HN: 0..1 string Max Length: 10
patient_header / patient_hc_vc HN VC: 0..1 string
patient_header / patient_address_line1 Address (Line 1): 1..1 string
patient_header / patient_address_line2 Address (Line 2): 0..1 string
patient_header / patient_address_city City: 1..1 string
patient_header / patient_address_province Province: 1..1 string Max Length: 2
patient_header / 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_other Other pronouns: 1..1 string Enable When: additionalinfo_pronouns = Other
additionalinfo_header / additionalinfo_preferredlanguage Preferred language: 0..1 choice Options: 3 options
additionalinfo_header / additionalinfo_preferredlanguage_specify Specify: 1..1 string Enable When: additionalinfo_preferredlanguage = Other
additionalinfo_header / additionalinfo_preferredlanguage_translatorrequired Translator required 0..* choice Enable When: additionalinfo_preferredlanguage = Other
Options: 1 option
additionalinfo_header / additionalinfo_preferredname_select Preferred name 0..* choice Options: 1 option
additionalinfo_header / additionalinfo_preferredname Prefered name String 0..1 string Enable When: additionalinfo_preferredname_select = Preferred Name
additionalinfo_header / additionalinfo_bestmethodofcontact Best method of contact: 0..1 choice Options: 4 options
additionalinfo_header / additionalinfo_bestmethodofcontact_voicemails Voicemails acceptable 0..* choice Options: 1 option
additionalinfo_header / additionalinfo_alternatecontact_select Alternate contact 0..* choice 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..* choice Options: 1 option
additionalinfo_header / additionalinfo_unsafecontacts_speakwithpatientdirectly Only speak with patient directly 0..* choice 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..* choice 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..* choice 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 / 780152781664 Payer Type 0..1 choice Options: 6 options
additionalinfo_header / 273459321091 Other 0..1 string Enable When: 780152781664 = Other
274716928898 Select Exam Request(s) 0..1 group
274716928898 / 966479448516 Radiology modality selection 1..* choice Options: 5 options
324277291256 Triage Considerations Information appear on summary note for ALL child referrals 0..1 group Enable When:
  • 966479448516 = Computerized axial tomography (SNOMED CT#77477000)
  • 966479448516 = Magnetic resonance imaging (SNOMED CT#113091000)
  • 966479448516 = Radiographic imaging procedure (SNOMED CT#363680008)
  • 966479448516 = Ultrasound scan (SNOMED CT#16310003)
  • 966479448516 = Dual energy X-ray absorptiometry (procedure) (SNOMED CT#241686001)
324277291256 / 649843000897 Requested Priority: 1..1 choice Options: 2 options
324277291256 / 871328372177 Reason for urgent triage 1..1 string Enable When: 649843000897 = Urgent (RequestPriority#urgent)
751330438729 CT Request: Clinical History / Indication - Information appear on summary note for CT child referrals 0..1 group Enable When: 966479448516 = Computerized axial tomography (SNOMED CT#77477000)
751330438729 / 573180718837 Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable) 0..1 text
234264354051 MRI Request: Clinical History / Indication - Information appear on summary note for MRI child referrals 0..1 group Enable When: 966479448516 = Magnetic resonance imaging (SNOMED CT#113091000)
234264354051 / 980027687215 Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable) 0..1 text
674405234837 X-Ray Request: Clinical History / Indication - Information appear on summary note for XRAY child referrals 0..1 group Enable When: 966479448516 = Radiographic imaging procedure (SNOMED CT#363680008)
674405234837 / 510703120136 Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable) 0..1 text
536888455666 Ultrasound Request: Clinical History / Indication - Information appear on summary note for Ultrasound child referrals 0..1 group Enable When: 966479448516 = Ultrasound scan (SNOMED CT#16310003)
536888455666 / 296349058128 Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable) 0..1 text
189996950901 BMD Request: Clinical History / Indication - Information appear on summary note for BMD child referrals 0..1 group Enable When: 966479448516 = Dual energy X-ray absorptiometry (procedure) (SNOMED CT#241686001)
189996950901 / 799876967585 Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable) 0..1 text
351905130587 Supporting Documentation 0..1 group
351905130587 / 707642937857 Previous Relevant Imaging (if applicable) 0..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..* choice Options: 1 option
cpp_header / cpp_currentprob Current Problem List: 0..1 text Enable When: cpp_separate != CPP attached separately (if not entered below)
cpp_header / cpp_pastmedicalhistory Past Medical History: 0..1 text Enable When: cpp_separate != CPP attached separately (if not entered below)
cpp_header / cpp_currentmedications Current Medications: 0..1 text Enable When: cpp_separate != CPP attached separately (if not entered below)
cpp_header / cpp_familyhistory Family History: 0..1 text Enable When: cpp_separate != CPP attached separately (if not entered below)
cpp_header / cpp_allergies Allergies: 0..1 text Enable When: cpp_separate != CPP attached separately (if not entered below)
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..* choice 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..* choice 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..* choice Options: 1 option
supportingdocumentation_attachment Add Attachments 0..1 attachment
feedbacksurvey_universal 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_line2 Address (Line 2): 0..1 string
referrer_header / referrer_address_city City: 1..1 string
referrer_header / referrer_address_province Province: 1..1 string Max Length: 2
referrer_header / 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

doco 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")
  • null#null ("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")
  • null#null ("Other")

Answer options for additionalinfo_preferredlanguage

  • urn:ietf:bcp:47#en ("English")
  • urn:ietf:bcp:47#fr ("French")
  • null#null ("Other")

Answer options for additionalinfo_preferredlanguage_translatorrequired

  • null#null ("Translator Required")

Answer options for additionalinfo_preferredname_select

  • null#null ("Preferred Name")

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

  • null#null (" Voicemails acceptable")

Answer options for additionalinfo_alternatecontact_select

  • null#null ("Alternate contact")

Answer options for additionalinfo_alternatecontact_bookingcontact

  • null#null ("Yes")
  • null#null ("No")

Answer options for additionalinfo_unsafecontacts_select

  • null#null ("Unsafe contact persons (do not speak with)")

Answer options for additionalinfo_unsafecontacts_speakwithpatientdirectly

  • null#null ("Only speak with patient directly")

Answer options for additionalinfo_accessibilityconcernsordisability_selectt

  • null#null ("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

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

Answer options for 780152781664

  • null#null ("OHIP")
  • null#null ("WSIB Case")
  • null#null ("DND")
  • null#null ("IFH")
  • null#null ("RAMQ")
  • null#null ("Other")

Answer options for 966479448516

  • http://snomed.info/sct#77477000 ("Computerized axial tomography")
  • http://snomed.info/sct#113091000 ("Magnetic resonance imaging")
  • http://snomed.info/sct#363680008 ("Radiographic imaging procedure")
  • http://snomed.info/sct#16310003 ("Ultrasound scan")
  • http://snomed.info/sct#241686001 ("Dual energy X-ray absorptiometry (procedure)")

Answer options for 649843000897

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

Answer options for cpp_separate

  • null#null ("CPP attached separately (if not entered below)")

Answer options for preferredconsultlocation_selector

  • null#null ("Preferred consultant or location")

Answer options for preferredconsultlocation_willingtotravel

  • null#null ("Patient willing to travel for shorter wait time")

Answer options for supportingdocumentation_details

  • null#null ("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")
  • null#null ("Other")

Contained Resources

Metadata
Experimental true
Description HTML with embedded [FHIRPath Liquid](https://confluence.hl7.org/spaces/FHIR/pages/66938964/FHIR+Liquid+Profile) that is intended to be executed against QuestionnaireResponses based on this Questionnaire.
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
<extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/core-short-string"> <valueString value="test short string" /> </extension>