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

Referral Forms

Many services need a form completed as part of a referral: a pre-participation screening such as the PAR-Q+ for exercise referral, eligibility criteria for a virtual ward or weight management service, a cancer referral proforma, or the "ask at order entry" questions on a genomic test order. The form is part of the referral's supporting information. It is the same pattern wherever it appears, so this page defines it once.

References

Where Forms Appear

Referral Form Completed by When
Exercise on referral, physical activity, cardiac or pulmonary rehabilitation Pre-participation screening (e.g. PAR-Q+), referrer's clinical details and medical clearance Patient; referrer Before the referral (referrer) and before the first session (patient)
Virtual ward Eligibility / acceptance criteria, baseline observations (e.g. NEWS2) Referrer At referral
Urgent suspected cancer Tumour-site referral proforma Referrer At referral (often attached to the eRS referral today)
Genomic test Ask at order entry questions Referrer At ordering (NW GMSA)
Social prescribing, weight management, diabetes prevention Eligibility, patient goals and preferences Referrer; patient At referral, or at the first contact
Any service More information requested during triage Referrer After referral

Two Patterns

sequenceDiagram
    participant RI as Referral Initiator<br/>(referrer)
    participant RR as Referral Recipient<br/>(service)
    participant PT as Patient<br/>(app or paper)

    Note over RI,RR: A - completed at referral (ask at order entry)
    RI ->> RI: Get the service's form (Questionnaire)
    RI ->> RR: Referral Request [PCC-55]<br/>supportingInfo: QuestionnaireResponse + Observations
    RR -->> RI: Accept / decline

    Note over RI,PT: B - requested after referral
    RR ->> RI: Task businessStatus information-requested<br/>input: Questionnaire (for the referrer)
    RR ->> PT: Task input: Questionnaire (for the patient)
    PT ->> RR: QuestionnaireResponse (Task output)
    RI ->> RR: QuestionnaireResponse (Task output)
    RR -->> RI: Task in progress / accepted
  A - Completed at referral B - Requested after referral
Who asks The service publishes the form; the referrer's system shows it when referring The service, during triage or before the first contact
Who completes Referrer Patient, carer or referrer
360X step Referral Request [PCC-55] Between Accept [PCC-55] and the first appointment [PCC-60]; or before accepting
FHIR ServiceRequest.supportingInfo → QuestionnaireResponse, Observation; or DocumentReference (attached form) Referral Task input (Questionnaire) → output (QuestionnaireResponse); businessStatus information-requested, status on-hold until it is returned
HL7 v2 OBX segments in OMG^O19 (ask at order entry, as in LTW and the 360X referral question); OBX type ED for an attached PDF form No 360X equivalent - Open; a returned form can be an ORU^R01 or MDM^T02 with the Referral ID
Example Referrer's form on the exercise referral Form requested, patient's form, Task in progress

Form, Data or Attachment

A completed form can be sent three ways. In order of preference:

Level FHIR HL7 v2 Use
Data Observation (and Condition), with derivedFrom the QuestionnaireResponse OBX with coded OBX-3 (LOINC / SNOMED CT) Answers the receiving system needs as data: vital signs, scores, activity level. Extracted from the form (SDC extraction)
Form QuestionnaireResponse, with questionnaire the service's canonical Questionnaire OBX per question (ask at order entry) The record of what was asked and answered, including free text and declarations
Attachment DocumentReference with the form as PDF OBX type ED (base64) or RP Paper or PDF forms - the Document Messaging level, as eRS attachments are today

Send the form and the data together: the QuestionnaireResponse records what was asked; the Observations make the answers usable (for example the blood pressure in the exercise referral, or the Exercise Vital Sign baseline). Coding the questions (Questionnaire.item.code) is what makes extraction possible.

Publishing the Form

The Referral Recipient owns its form. It SHOULD publish it as a Questionnaire with a canonical URL and version, so referrers' systems can render it and the response can say which version was answered (QuestionnaireResponse.questionnaire). How a service advertises its form - on its HealthcareService entry, in a service directory, or with an ActivityDefinition / PlanDefinition for the service - is Open.

Example forms: referrer's form and physical activity readiness, completed by the patient (response).

Clinical Data Forms

General purpose forms for clinical data that referrals often need, with coded items so the answers can be extracted as Observations:

Form Content Source Used with
Vital Signs Respiratory rate, oxygen saturation and target, air or oxygen (flow rate, delivery route), blood pressure, heart rate, level of consciousness (ACVPU), temperature, weight, height, BMI, head circumference, pain score - each with its unit Codes and answer lists from the NHS England Clinical Observations guide; item definitions point to this guide's Observation profile Baseline observations for virtual ward and exercise referrals; monitoring
Social Context Household composition, accommodation, occupation, education, lifestyle, smoking, alcohol, drug / substance use, social circumstances (including carers), access, dependants, household environment PRSB Core Information Standard v2.01 Social context section Social prescribing, community, virtual ward and exercise referrals

The Social Context form follows the PRSB elements and their code sets: household composition (SNOMED CT refset 1027891000000106), occupation (refset 999001571000000109), smoking status (refset 999000891000000102, date ceased smoking 160625004), and the PRSB alcohol and drug / substance use findings. Accommodation status (NHS Data Dictionary ACCOMMODATION STATUS CODE) is free text until a FHIR code system is available - To confirm. The PRSB "person completing the record", date and location for each element map to QuestionnaireResponse.author, authored and the extracted Observations.

Example: Physical Activity Readiness (PAR-Q+ Structure)

The patient's form follows the structure of the PAR-Q+ for individuals (2025), a widely used, validated pre-participation screening:

PAR-Q+ part FHIR Questionnaire
Seven general health questions (yes / no), two with a list of conditions group "general" with boolean items; the condition and medication lists are string items shown with enableWhen when the answer is yes
Follow-up questions about medical conditions, completed only if any general answer is yes group "follow-up" with enableBehavior any and an enableWhen per general question
Ten condition sections, each with a yes / no and sub-questions answered only if yes Nested group per condition, sub-questions with enableWhen; one section (cardiovascular) is included
Participant declaration (clearance valid for up to 12 months) group "declaration": agreement, name, date
Outcome: cleared, or seek advice from a doctor or qualified exercise professional Not encoded - an SDC calculated expression or the service's assessment

In the example response the patient (with coronary artery disease, on medication and not regularly active) answers yes to two general questions and to the cardiovascular follow-up, so he should get advice from a qualified exercise professional before becoming more active - which the exercise on referral programme provides.

HL7 Physical Activity IG

The Physical Activity IG is a recent example of a referral workflow designed on the general FHIR standards. It fits this guide's FHIR RESTful Task option:

Physical Activity IG This guide
Care Manager - creates and owns the ServiceRequest Referral Initiator
Full Service Provider (own FHIR endpoint) / Light Service Provider (records held on the Care Manager) Referral Recipient - with or without its own FHIR server
Patient Engagement App Patient completing forms and recording activity
ServiceRequest - "the official referral"; only its author updates it Referral Request
Task - "to give the ability to accept or refuse, convey progress and link to results", even for directed referrals; several Tasks may solicit providers for one referral Referral Task - 360X is a directed referral (one recipient)
Task status requested, accepted, rejected (with reason), on-hold, cancelled, failed, completed Task status with the 360X businessStatus - see Referral Status
Observations (exercise vital signs) pushed or queried Progress observations in Task.output
PA Intervention Report - a DiagnosticReport (PDF) in Task.output Referral Outcome [PCC-57] - HL7 Europe HDR or outpatient letter
Subscription for new Tasks; email / SMS prompt for light participants Event notification (FHIR Subscription, NHS MNS)
Cancel by setting the Task to cancelled; changes to the referral as Task notes Referral Cancellation [PCC-58]

Differences to note: the Physical Activity IG is US realm; it solicits providers with undirected Tasks, where 360X directs the referral to one recipient; and its outcome is a DiagnosticReport rather than a clinical document. Its Questionnaire use is for patient feedback; the form pattern above is this guide's addition.

Clinical Process

Clinical process Form
Assessment The referrer records the observations the form asks for
Implement The form is sent with the referral (pattern A)
Start (service) The service asks for the patient's form before the first contact (pattern B)
Evaluate Progress observations (e.g. weekly activity) and the outcome report come back