Care Coordination and 360 Referrals (Proof of Concept)
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Care Coordination and 360 Referrals (Proof of Concept) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Questionnaire: Care Assessment (Experimental)

Official URL: https://fhir.acmeexample.org.uk/PatientCareCoordination/Questionnaire/CareAssessment Version: 0.1.0
Draft as of 2026-11-03 Computable Name: CareAssessment

A care assessment - the person's needs, risks and what matters to them - completed before a care and support plan is agreed. In the NHS this form is often called a "care plan"; it is not one. The completed form (QuestionnaireResponse) is the input to a Care Plan, which records who does what. See Composition, Archetypes and Templates.

Based on the PRSB Hospital Referral for Assessment for Community Care and Support standard v1.1. Social context is captured with the Social Context questionnaire.

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
CareAssessment A **care assessment** - the person's needs, risks and what matters to them - completed before a care and support plan is agreed. In the NHS this form is often called a "care plan"; it is not one. The completed form (`QuestionnaireResponse`) is the input to a [Care Plan](StructureDefinition-PatientCarePlan.html), which records who does what. See [Composition, Archetypes and Templates](Templates.html#care-assessment-and-care-plan). Based on the PRSB [Hospital Referral for Assessment for Community Care and Support](https://theprsb.org/standards/hospitalrefferalforassessmenforcommunitycare) standard v1.1. Social context is captured with the [Social Context](Questionnaire-SocialContext.html) questionnaire. Questionnaire https://fhir.acmeexample.org.uk/PatientCareCoordination/Questionnaire/CareAssessment#0.1.0
CareAssessment / ABOUT-ME About me - what the person wants professionals to know (PRSB About Me) 0..1 group Value Set:
CareAssessment / ABOUT-ME / ABOUT-ME/important What is most important to me 0..1 text Value Set:
CareAssessment / ABOUT-ME / ABOUT-ME/people People who are important to me 0..1 text Value Set:
CareAssessment / ABOUT-ME / ABOUT-ME/communication How I communicate and how to communicate with me 0..1 text Value Set:
CareAssessment / ABOUT-ME / ABOUT-ME/do-dont Please do and please don't 0..1 text Value Set:
CareAssessment / ABOUT-ME / ABOUT-ME/support How and when to support me 0..1 text Value Set:
CareAssessment / INDIVIDUAL-REQUIREMENTS Individual requirements 0..1 group Value Set:
CareAssessment / INDIVIDUAL-REQUIREMENTS / INDIVIDUAL-REQUIREMENTS/reasonable-adjustment Reasonable adjustments required (Equality Act 2010), e.g. specific contact method, communication professional 0..* string Value Set:
CareAssessment / INDIVIDUAL-REQUIREMENTS / INDIVIDUAL-REQUIREMENTS/impairment Impairments relating to reasonable adjustments 0..* string Value Set:
CareAssessment / INDIVIDUAL-REQUIREMENTS / INDIVIDUAL-REQUIREMENTS/mobility Mobility needs 0..1 text Value Set:
CareAssessment / INDIVIDUAL-REQUIREMENTS / INDIVIDUAL-REQUIREMENTS/other Other individual requirements 0..1 text Value Set:
CareAssessment / CARE-NEEDS Care needs summary - nursing and care needs, e.g. continence, catheter or stoma care, skin care (wounds, ulcers), tracheostomy, nutrition and fluids, behavioural care and support 1..1 text Value Set:
CareAssessment / LEVEL-OF-CARE Level of enhanced care observation needed during the admission and before discharge 0..1 choice Value Set:
Options: 4 options
CareAssessment / PRIMARY-SUPPORT-REASON Primary support reason for social care 0..1 group Value Set:
CareAssessment / PRIMARY-SUPPORT-REASON / PRIMARY-SUPPORT-REASON/reason Primary support reason (as used for social care national reporting) 0..1 string Value Set:
CareAssessment / PRIMARY-SUPPORT-REASON / PRIMARY-SUPPORT-REASON/active Currently active 0..1 boolean Value Set:
CareAssessment / RISKS Risks 0..1 group Value Set:
CareAssessment / RISKS / RISKS/self Risk to self (e.g. self-harm, self-neglect) 0..1 text Value Set:
CareAssessment / RISKS / RISKS/others Risk to others 0..1 text Value Set:
CareAssessment / RISKS / RISKS/from-others Risk from others 0..1 text Value Set:
CareAssessment / RISKS / RISKS/accidents Risk of accidents (e.g. falls) 0..1 text Value Set:
CareAssessment / RISKS / RISKS/infection Infection risk needing special handling 0..1 text Value Set:
CareAssessment / RISKS / RISKS/other Other risks 0..1 text Value Set:
CareAssessment / CONCERNS Person and carer concerns, expectations and wishes 0..1 text Value Set:

doco Documentation for this format

Options Sets

Answer options for LEVEL-OF-CARE

  • A - General: usual inpatient observation
  • B - Intermittent observation (every 30 to 60 minutes)
  • C - Continuous observation within eyesight (e.g. cohort bay)
  • D - High level multi-professional continuous observation

About me - what the person wants professionals to know (PRSB About Me)

  • linkId: ABOUT-ME
  • Answers:

What is most important to me

  • linkId: ABOUT-ME/important
  • Answers:

People who are important to me

  • linkId: ABOUT-ME/people
  • Answers:

How I communicate and how to communicate with me

  • linkId: ABOUT-ME/communication
  • Answers:

Please do and please don't

  • linkId: ABOUT-ME/do-dont
  • Answers:

How and when to support me

  • linkId: ABOUT-ME/support
  • Answers:

Individual requirements

  • linkId: INDIVIDUAL-REQUIREMENTS
  • Answers:

Reasonable adjustments required (Equality Act 2010), e.g. specific contact method, communication professional

  • linkId: INDIVIDUAL-REQUIREMENTS/reasonable-adjustment
  • Answers:

Impairments relating to reasonable adjustments

  • linkId: INDIVIDUAL-REQUIREMENTS/impairment
  • Answers:

Mobility needs

  • linkId: INDIVIDUAL-REQUIREMENTS/mobility
  • Answers:

Other individual requirements

  • linkId: INDIVIDUAL-REQUIREMENTS/other
  • Answers:

Care needs summary - nursing and care needs, e.g. continence, catheter or stoma care, skin care (wounds, ulcers), tracheostomy, nutrition and fluids, behavioural care and support*

  • linkId: CARE-NEEDS
  • Answers:

Level of enhanced care observation needed during the admission and before discharge

Primary support reason for social care

  • linkId: PRIMARY-SUPPORT-REASON
  • Answers:

Primary support reason (as used for social care national reporting)

  • linkId: PRIMARY-SUPPORT-REASON/reason
  • Answers:

Currently active

  • linkId: PRIMARY-SUPPORT-REASON/active
  • Answers:

Risks

  • linkId: RISKS
  • Answers:

Risk to self (e.g. self-harm, self-neglect)

  • linkId: RISKS/self
  • Answers:

Risk to others

  • linkId: RISKS/others
  • Answers:

Risk from others

  • linkId: RISKS/from-others
  • Answers:

Risk of accidents (e.g. falls)

  • linkId: RISKS/accidents
  • Answers:

Infection risk needing special handling

  • linkId: RISKS/infection
  • Answers:

Other risks

  • linkId: RISKS/other
  • Answers:

Person and carer concerns, expectations and wishes

  • linkId: CONCERNS
  • Answers:

LinkIDDescription & Constraintsdoco
ABOUT-ME Value Set:
ABOUT-ME / ABOUT-ME/important Value Set:
ABOUT-ME / ABOUT-ME/people Value Set:
ABOUT-ME / ABOUT-ME/communication Value Set:
ABOUT-ME / ABOUT-ME/do-dont Value Set:
ABOUT-ME / ABOUT-ME/support Value Set:
INDIVIDUAL-REQUIREMENTS Value Set:
INDIVIDUAL-REQUIREMENTS / INDIVIDUAL-REQUIREMENTS/reasonable-adjustment Value Set:
INDIVIDUAL-REQUIREMENTS / INDIVIDUAL-REQUIREMENTS/impairment Value Set:
INDIVIDUAL-REQUIREMENTS / INDIVIDUAL-REQUIREMENTS/mobility Value Set:
INDIVIDUAL-REQUIREMENTS / INDIVIDUAL-REQUIREMENTS/other Value Set:
CARE-NEEDS Value Set:
LEVEL-OF-CARE Value Set:
Options: 4 options
PRIMARY-SUPPORT-REASON Value Set:
PRIMARY-SUPPORT-REASON / PRIMARY-SUPPORT-REASON/reason Value Set:
PRIMARY-SUPPORT-REASON / PRIMARY-SUPPORT-REASON/active Value Set:
RISKS Value Set:
RISKS / RISKS/self Value Set:
RISKS / RISKS/others Value Set:
RISKS / RISKS/from-others Value Set:
RISKS / RISKS/accidents Value Set:
RISKS / RISKS/infection Value Set:
RISKS / RISKS/other Value Set:
CONCERNS Value Set:

doco Documentation for this format

Test this Questionnaire

Try this questionnaire out:

Responses for this Questionnaire