Care Coordination and 360 Referrals (Proof of Concept)
0.1.0 - proof-of-concept
Care Coordination and 360 Referrals (Proof of Concept)
0.1.0 - proof-of-concept
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
| Draft as of 2026-11-03 |
{
"resourceType" : "Questionnaire",
"id" : "ExerciseReferralForm",
"language" : "en",
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Questionnaire ExerciseReferralForm</b></p><a name=\"ExerciseReferralForm\"> </a><a name=\"hcExerciseReferralForm\"> </a><table border=\"1\" cellpadding=\"0\" cellspacing=\"0\" class=\"xhtTableBorder1\"><tr class=\"xhtRowBorder2\"><th scope=\"col\" style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"The linkID for the item\">LinkID</a></th><th scope=\"col\" style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Text for the item\">Text</a></th><th scope=\"col\" style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Minimum and Maximum # of times the item can appear in the instance\">Cardinality</a></th><th scope=\"col\" style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"The type of the item\">Type</a></th><th scope=\"col\" style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Additional information about the item\">Description & Constraints</a><span style=\"float: right\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64,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\" alt=\"doco\" style=\"background-color: inherit\"/></a></span></th></tr><tr class=\"xhtRowBorder1 xhtRowEven\"><td style=\"background-image: url(tbl_bck1.png)\" class=\"hierarchy xhtCellBorder1 xhtCellNoWrap\"><img src=\"tbl_spacer.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon_q_root.gif\" alt=\"\" style=\"background-color: white; background-color: inherit\" title=\"QuestionnaireRoot\" class=\"hierarchy\"/> ExerciseReferralForm</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">Illustrative referral form completed by the referring clinician when the referral is made (ask at order entry). Items with a LOINC code are also sent as Observations.</td><td style=\"\" class=\"hierarchy xhtCellBorder1\"/><td style=\"\" class=\"hierarchy xhtCellBorder1\">Questionnaire</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">https://fhir.acmeexample.org.uk/PatientCareCoordination/Questionnaire/ExerciseReferralForm#0.1.0</td></tr>\r\n<tr class=\"xhtRowBorder1 xhtRowOdd\"><td style=\"background-image: url(tbl_bck10.png)\" id=\"item.reason\" class=\"hierarchy xhtCellBorder1 xhtCellNoWrap\"><img src=\"tbl_spacer.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\"\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> <span style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0\" class=\"sr-only\">ExerciseReferralForm / </span>reason</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">Reason for referral</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">1..1</td><td style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"\" class=\"hierarchy xhtCellBorder1\"/></tr>\r\n<tr class=\"xhtRowBorder1 xhtRowEven\"><td style=\"background-image: url(tbl_bck10.png)\" id=\"item.systolic\" class=\"hierarchy xhtCellBorder1 xhtCellNoWrap\"><img src=\"tbl_spacer.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-integer.png\" alt=\"\" style=\"background-color: white; background-color: inherit\" title=\"integer\" class=\"hierarchy\"/> <span style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0\" class=\"sr-only\">ExerciseReferralForm / </span>systolic</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">Resting systolic blood pressure (mmHg)</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">1..1</td><td style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-integer\">integer</a></td><td style=\"\" class=\"hierarchy xhtCellBorder1\"/></tr>\r\n<tr class=\"xhtRowBorder1 xhtRowOdd\"><td style=\"background-image: url(tbl_bck10.png)\" id=\"item.diastolic\" class=\"hierarchy xhtCellBorder1 xhtCellNoWrap\"><img src=\"tbl_spacer.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-integer.png\" alt=\"\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"integer\" class=\"hierarchy\"/> <span style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0\" class=\"sr-only\">ExerciseReferralForm / </span>diastolic</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">Resting diastolic blood pressure (mmHg)</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">1..1</td><td style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-integer\">integer</a></td><td style=\"\" class=\"hierarchy xhtCellBorder1\"/></tr>\r\n<tr class=\"xhtRowBorder1 xhtRowEven\"><td style=\"background-image: url(tbl_bck10.png)\" id=\"item.heart-rate\" class=\"hierarchy xhtCellBorder1 xhtCellNoWrap\"><img src=\"tbl_spacer.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-integer.png\" alt=\"\" style=\"background-color: white; background-color: inherit\" title=\"integer\" class=\"hierarchy\"/> <span style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0\" class=\"sr-only\">ExerciseReferralForm / </span>heart-rate</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">Resting heart rate (beats per minute)</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">0..1</td><td style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-integer\">integer</a></td><td style=\"\" class=\"hierarchy xhtCellBorder1\"/></tr>\r\n<tr class=\"xhtRowBorder1 xhtRowOdd\"><td style=\"background-image: url(tbl_bck10.png)\" id=\"item.bmi\" class=\"hierarchy xhtCellBorder1 xhtCellNoWrap\"><img src=\"tbl_spacer.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-decimal.png\" alt=\"\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"decimal\" class=\"hierarchy\"/> <span style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0\" class=\"sr-only\">ExerciseReferralForm / </span>bmi</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">Body mass index</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">0..1</td><td style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-decimal\">decimal</a></td><td style=\"\" class=\"hierarchy xhtCellBorder1\"/></tr>\r\n<tr class=\"xhtRowBorder1 xhtRowEven\"><td style=\"background-image: url(tbl_bck10.png)\" id=\"item.conditions\" class=\"hierarchy xhtCellBorder1 xhtCellNoWrap\"><img src=\"tbl_spacer.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\"\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> <span style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0\" class=\"sr-only\">ExerciseReferralForm / </span>conditions</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">Relevant conditions</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">0..*</td><td style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"\" class=\"hierarchy xhtCellBorder1\"/></tr>\r\n<tr class=\"xhtRowBorder1 xhtRowOdd\"><td style=\"background-image: url(tbl_bck10.png)\" id=\"item.suitable\" class=\"hierarchy xhtCellBorder1 xhtCellNoWrap\"><img src=\"tbl_spacer.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\"\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> <span style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0\" class=\"sr-only\">ExerciseReferralForm / </span>suitable</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">Is the patient medically suitable for supervised exercise?</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">1..1</td><td style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"\" class=\"hierarchy xhtCellBorder1\"/></tr>\r\n<tr class=\"xhtRowBorder1 xhtRowEven\"><td style=\"background-image: url(tbl_bck00.png)\" id=\"item.precautions\" class=\"hierarchy xhtCellBorder1 xhtCellNoWrap\"><img src=\"tbl_spacer.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\"\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-text.png\" alt=\"\" style=\"background-color: white; background-color: inherit\" title=\"text\" class=\"hierarchy\"/> <span style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0\" class=\"sr-only\">ExerciseReferralForm / </span>precautions</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">Precautions or exercise restrictions</td><td style=\"\" class=\"hierarchy xhtCellBorder1\">0..1</td><td style=\"\" class=\"hierarchy xhtCellBorder1\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-text\">text</a></td><td style=\"\" class=\"hierarchy xhtCellBorder1\"/></tr>\r\n<tr><td colspan=\"5\" class=\"hierarchy\"><br/><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64,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\" alt=\"doco\" style=\"background-color: inherit\"/> Documentation for this format</a></td></tr></table></div>"
},
"url" : "https://fhir.acmeexample.org.uk/PatientCareCoordination/Questionnaire/ExerciseReferralForm",
"version" : "0.1.0",
"name" : "ExerciseReferralForm",
"title" : "Exercise on referral - referrer's form",
"status" : "draft",
"experimental" : true,
"subjectType" : [
"Patient"
],
"date" : "2026-11-03T05:48:20+00:00",
"publisher" : "Kevin Mayfield",
"contact" : [
{
"telecom" : [
{
"system" : "url",
"value" : "https://github.com/KevinMayfield/PatientCareCoordination"
}
]
}
],
"description" : "Illustrative referral form completed by the referring clinician when the referral is made (ask at order entry). Items with a LOINC code are also sent as Observations.",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "GB",
"display" : "United Kingdom of Great Britain and Northern Ireland"
}
]
}
],
"item" : [
{
"linkId" : "reason",
"text" : "Reason for referral",
"type" : "string",
"required" : true
},
{
"linkId" : "systolic",
"code" : [
{
"system" : "http://loinc.org",
"code" : "8480-6",
"display" : "Systolic blood pressure"
}
],
"text" : "Resting systolic blood pressure (mmHg)",
"type" : "integer",
"required" : true
},
{
"linkId" : "diastolic",
"code" : [
{
"system" : "http://loinc.org",
"code" : "8462-4",
"display" : "Diastolic blood pressure"
}
],
"text" : "Resting diastolic blood pressure (mmHg)",
"type" : "integer",
"required" : true
},
{
"linkId" : "heart-rate",
"code" : [
{
"system" : "http://loinc.org",
"code" : "8867-4",
"display" : "Heart rate"
}
],
"text" : "Resting heart rate (beats per minute)",
"type" : "integer"
},
{
"linkId" : "bmi",
"code" : [
{
"system" : "http://loinc.org",
"code" : "39156-5",
"display" : "Body mass index (BMI) [Ratio]"
}
],
"text" : "Body mass index",
"type" : "decimal"
},
{
"linkId" : "conditions",
"text" : "Relevant conditions",
"type" : "string",
"repeats" : true
},
{
"linkId" : "suitable",
"text" : "Is the patient medically suitable for supervised exercise?",
"type" : "boolean",
"required" : true
},
{
"linkId" : "precautions",
"text" : "Precautions or exercise restrictions",
"type" : "text"
}
]
}