New Zealand Rheumatic Fever FHIR Implementation Guide - Local Development build (v0.4.9) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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: Secondary Prophylaxis Health Assessment Questionnaire - XML Representation

Draft as of 2023-11-10

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<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="SecondaryProphylaxisHealthAssessmentQuestionnaire"/>
  <url
       value="https://fhir-ig.digital.health.nz/rheumatic-fever/Questionnaire/SecondaryProphylaxisHealthAssessmentQuestionnaire"/>
  <identifier>
    <use value="official"/>
    <value value="SecondaryProphylaxisHealthAssessmentQuestionnaire"/>
    <period>
      <start value="2023-10-16"/>
    </period>
  </identifier>
  <version value="1.0.0"/>
  <name value="SecondaryProphylaxisHealthAssessmentQuestionnaire"/>
  <title value="Secondary Prophylaxis Health Assessment Questionnaire"/>
  <status value="draft"/>
  <experimental value="false"/>
  <subjectType value="Patient"/>
  <date value="2023-11-10"/>
  <publisher value="Te Whatu Ora"/>
  <contact>
    <name value="Te Whatu Ora"/>
    <telecom>
      <system value="url"/>
      <value value="https://www.tewhatuora.govt.nz/"/>
    </telecom>
  </contact>
  <contact>
    <name value="David Grainger"/>
    <telecom>
      <system value="email"/>
      <value value="david.grainger@middleware.co.nz"/>
      <use value="work"/>
    </telecom>
  </contact>
  <description
               value="Gathers information about patient health at a secondary prophylaxis medication appointment"/>
  <purpose
           value="Gathers information about patient health at a secondary prophylaxis medication appointment"/>
  <item>
    <linkId value="page1"/>
    <prefix value="page1"/>
    <text
          value="Please complete this questionnaire at the secondary prophylaxis appointment to assess a rheumatic fever patient's health."/>
    <type value="display"/>
  </item>
  <item>
    <linkId value="ReasonsInjectionOverdue"/>
    <prefix value="2)"/>
    <text value="Reason(s) injection was give late? (multiple choice)"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="true"/>
    <answerOption>
      <valueString value="Previously Care On-Hold"/>
    </answerOption>
    <answerOption>
      <valueString value="Unable to Contact Patient"/>
    </answerOption>
    <answerOption>
      <valueString value="Patient Not Available on the Day"/>
    </answerOption>
    <answerOption>
      <valueString value="Patient Declined Treatment"/>
    </answerOption>
    <answerOption>
      <valueString value="INR Too High"/>
    </answerOption>
    <answerOption>
      <valueString value="Patient Lost to Follow-Up"/>
    </answerOption>
    <answerOption>
      <valueString value="Service Delayed To Follow-Up"/>
    </answerOption>
    <answerOption>
      <valueString value="Service Unavailable on the Day"/>
    </answerOption>
    <answerOption>
      <valueString value="Service Error"/>
    </answerOption>
    <answerOption>
      <valueString value="Other"/>
    </answerOption>
  </item>
  <item>
    <linkId value="OverdueInjectionOtherDetail"/>
    <prefix value="3)"/>
    <text value="Other details for late injection (enter text)"/>
    <type value="text"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="OtherPainManagementToolsUsed"/>
    <prefix value="11)"/>
    <text value="Pain management tools used? (multiple choice)"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="true"/>
    <answerOption>
      <valueString value="Ice pack"/>
    </answerOption>
    <answerOption>
      <valueString value="Buzzy bee"/>
    </answerOption>
    <answerOption>
      <valueString value="Numbing cream (Emla)"/>
    </answerOption>
    <answerOption>
      <valueString value="Numbing spray"/>
    </answerOption>
    <answerOption>
      <valueString value="Distraction"/>
    </answerOption>
    <answerOption>
      <valueString value="Very slow injection"/>
    </answerOption>
    <answerOption>
      <valueString value="Other"/>
    </answerOption>
  </item>
  <item>
    <linkId value="PainManagementOtherDetails"/>
    <prefix value="11.1)"/>
    <text value="Details of other pain management (enter text)"/>
    <type value="text"/>
    <enableWhen>
      <question value="OtherPainManagementToolsUsed"/>
      <operator value="="/>
      <answerString value="Other"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="PostInjectionConcern"/>
    <prefix value="12)"/>
    <text value="Post injection concern or possible reaction identified?"/>
    <type value="boolean"/>
    <required value="true"/>
    <initial>
      <valueBoolean value="false"/>
    </initial>
  </item>
  <item>
    <linkId value="PostInjectionConcernDetails"/>
    <prefix value="12.1)"/>
    <text
          value="If Yes, Record Details, Symptoms, Actions Taken and Follow-Up Plan (enter text)"/>
    <type value="text"/>
    <enableWhen>
      <question value="PostInjectionConcern"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="AnyOtherConcerns"/>
    <prefix value="13)"/>
    <text
          value="Were There Any Other Concerns or Issues Identified During the Visit?"/>
    <type value="boolean"/>
    <required value="true"/>
    <initial>
      <valueBoolean value="false"/>
    </initial>
  </item>
  <item>
    <linkId value="OtherConcernsDetail"/>
    <prefix value="13.1)"/>
    <text
          value="If yes, describe details, actions taken, and follow-up planned (enter text)"/>
    <type value="text"/>
    <enableWhen>
      <question value="AnyOtherConcerns"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="HealthEducationTopicsDiscussed"/>
    <prefix value="14)"/>
    <text value="Health education topics discussed? (multiple choice)"/>
    <type value="choice"/>
    <required value="true"/>
    <repeats value="true"/>
    <answerOption>
      <valueString value="Secondary prophylaxis"/>
    </answerOption>
    <answerOption>
      <valueString value="Sore Throat Management"/>
    </answerOption>
    <answerOption>
      <valueString value="Skin Infection Management"/>
    </answerOption>
    <answerOption>
      <valueString value="Dental Health"/>
    </answerOption>
    <answerOption>
      <valueString value="Endocarditis Prophylaxis"/>
    </answerOption>
    <answerOption>
      <valueString value="Nutrition"/>
    </answerOption>
    <answerOption>
      <valueString value="Physical Activity"/>
    </answerOption>
    <answerOption>
      <valueString value="Healthy Home Environments"/>
    </answerOption>
    <answerOption>
      <valueString value="Sexual Health"/>
    </answerOption>
    <answerOption>
      <valueString value="Other"/>
    </answerOption>
  </item>
  <item>
    <linkId value="HealthEducationOtherDetail"/>
    <prefix value="14.1)"/>
    <text
          value="Enter details of other health education topic discussed (enter text)"/>
    <type value="text"/>
    <enableWhen>
      <question value="HealthEducationTopicsDiscussed"/>
      <operator value="="/>
      <answerString value="Other"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="RecentOrUpcomingAppointments"/>
    <prefix value="15)"/>
    <text value="Any recent or upcoming follow-up appointments?"/>
    <type value="boolean"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="RecentOrUpcomingAppointmentsDetails"/>
    <prefix value="15.1)"/>
    <text
          value="Enter details and dates of any recent or upcoming follow-up appointments (enter text)"/>
    <type value="text"/>
    <enableWhen>
      <question value="RecentOrUpcomingAppointments"/>
      <operator value="="/>
      <answerBoolean value="true"/>
    </enableWhen>
    <required value="true"/>
  </item>
  <item>
    <linkId value="PlanForNextMedicationAppointment"/>
    <prefix value="16)"/>
    <text value="Comments for the next appointment (enter text)"/>
    <type value="text"/>
    <required value="true"/>
  </item>
</Questionnaire>