Generated Narrative: QuestionnaireResponse questionnaire-response-02
| LinkID | Text | Definition |
Answer
|
|---|---|---|---|
 questionnaire-response-02 |
Questionnaire:urn:uuid:1b12e576-c039-4395-ad20-2d7e8633fe70|0.0.1 | ||
patient_header |
Patient Information | ||
patient_surname |
Surname: | Patel | |
|
patient_firstname |
First Name: | Alisha | |
|
patient_date_of_birth |
DOB: | 1987-04-12 | |
|
patient_gender |
Gender: | AdministrativeGender: female (Female) | |
|
patient_hc_number |
HN: | 1234567890 | |
|
patient_hc_vc |
HN VC: | AB | |
|
patient_address_line1 |
Address (Line 1): | 2453 Dundas St W | |
|
patient_address_line2 |
Address (Line 2): | Apt 708 | |
|
patient_address_city |
City: | Toronto | |
|
patient_address_province |
Province: | ON | |
|
patient_address_postalcode |
Postal Code: | M6P 1X3 | |
|
patient_phone_mobile |
Mobile #: | 416-555-0198 | |
|
patient_phone_home |
Home #: | 416-555-0131 | |
patient_email |
Email: | alisha.patel87@example.com | |
|
additionalinfo_header |
[Optional] Additional Patient Information | ||
|
additionalinfo_sexassignedatbirth |
Sex assigned at birth: | LOINC: LA3-6 (Female) | |
|
additionalinfo_pronouns |
Pronouns: | LOINC: LA29519-8 (she/her/her/hers/herself) | |
|
additionalinfo_preferredlanguage |
Preferred language: | Other | |
|
additionalinfo_preferredlanguage_specify |
Specify: | Urdu | |
|
additionalinfo_preferredlanguage_translatorrequired |
Translator required | Translator Required | |
|
additionalinfo_bestmethodofcontact |
Best method of contact: | ContactPointSystem: phone (Phone) | |
|
additionalinfo_bestmethodofcontact_voicemails |
Voicemails acceptable | Voicemails acceptable | |
|
additionalinfo_alternatecontact_select |
Alternate contact | Alternate contact | |
|
additionalinfo_alternatecontact_name |
Name: | Imran Patel | |
|
additionalinfo_alternatecontact_phone |
Alternate contact phone #: | 416-555-0144 | |
|
additionalinfo_alternatecontact_relationship |
Relationship: | Spouse | |
|
additionalinfo_alternatecontact_bookingcontact |
Is Alternate contact the appointment booking contact?: | Yes | |
|
additionalinfo_accessibilityconcernsordisability_selectt |
Accessibility concerns or disability | Accessibility concerns or disability | |
|
additionalinfo_accessibilityconcernsordisability |
Accessibility concerns Options | SNOMED CT: 105503008 (Dependence on wheelchair) | |
|
additionalinfo_specialconsiderations_select |
Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues) | Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues) | |
|
additionalinfo_specialconsiderations |
Details of special considerations: | Patient has significant anxiety in medical settings. Please explain steps in advance; prefers a quiet waiting area when possible. | |
|
additionalinfo_sendcopiestoadditionalproviders |
Send copies of reports to additional providers | Send copies of reports to additional providers | |
|
additionalinfo_sendcopiestoadditionalproviders_names |
Name(s): | Dr. Farah Alvi (Endocrinology) | |
|
additionalinfo_sendcopiestoadditionalproviders_contactinfo |
Contact information: | Fax 416-555-0187 | |
|
274716928898 |
Referral Details | ||
|
836886186557 |
Triage Considerations | ||
|
referral_requestedpriority |
Requested Priority: | RequestPriority: urgent (Urgent) | |
|
referral_requestedpriority_urgentreason |
Reason for urgent triage: | Progressive exertional chest tightness with reduced exercise tolerance over the past 3 weeks. | |
|
200848944281 |
Name of the suspected diagnosis/problem triggering referral: | New exertional chest tightness; rule out stable angina / ischemic heart disease. | |
|
602158378622 |
Brief Description of Referral, History, Management, and Investigations | 38F with 3-month history of exertional substernal chest tightness when climbing stairs, relieved by rest in 3–5 minutes. No syncope. Occasional palpitations. Risk factors: type 2 diabetes (A1c 7.6%), hypertension, dyslipidemia, strong family history (father MI at 52). Vitals today: BP 146/92, HR 82. Physical exam unremarkable. Baseline ECG in clinic: normal sinus rhythm, no acute ischemic changes. Started ASA 81 mg daily and optimized statin (rosuvastatin 20 mg). | |
|
preferredconsultlocation_header |
Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered. | ||
|
preferredconsultlocation_selector |
Preferred consultant or location | Preferred consultant or location | |
|
preferredconsultlocation_specify |
Please specify either a preferred consultant or location | ||
|
preferredconsultlocation_consultant |
Consultant: | Dr. Samantha Chen | |
|
preferredconsultlocation_location |
Location: | Toronto General Hospital – Cardiology Clinic | |
|
preferredconsultlocation_willingtotravel |
Patient willing to travel for shorter wait time | Patient willing to travel for shorter wait time | |
|
preferredconsultlocation_otherconsiderations |
Other considerations: | Prefers weekday mornings; relies on translator services. | |
|
referrer_header |
Referrer's Information | ||
referrer_sitename |
Site Name: | Parkdale Family Health Team | |
|
referrer_address_line1 |
Address (Line 1): | 123 Brock Ave | |
|
referrer_address_line2 |
Address (Line 2): | Suite 401 | |
|
referrer_address_city |
City: | Toronto | |
|
referrer_address_province |
Province: | ON | |
|
referrer_address_postalcode |
Postal Code: | M6K 2L5 | |
|
referrer_phone |
Phone #: | 416-555-0101 | |
|
referrer_fax |
Fax #: | 416-555-0102 | |
|
referrer_professionalid |
Professional ID: | 7654321 | |
|
referrer_signature |
Signed: | Dr. Nadia Rahman, MD CCFP | |
|
referrer_role |
Role: | SNOMED CT: 449161006 (Physician assistant) | |
|
Documentation for this format
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