{ "resourceType" : "Questionnaire", "id" : "DHOPreoperativeQuestionnaireDaySurgeryDunedinHospital", "text" : { "status" : "extensions", "div" : "

Generated Narrative: Questionnaire DHOPreoperativeQuestionnaireDaySurgeryDunedinHospital

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LinkIDTextCardinalityTypeFlagsDescription & Constraints\"doco\"
\".\"\".\" DHOPreoperativeQuestionnaireDaySurgeryDunedinHospitalPre-operative assessment questionnaire for day surgery patients at Dunedin Hospital.Questionnairehttps://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/DHOPreoperativeQuestionnaireDaySurgeryDunedinHospital#1.0
\".\"\".\"\".\" patientInfoPatient Information0..1group
\".\"\".\"\".\"\".\" surname_01Surname0..1string
\".\"\".\"\".\"\".\" nhi_02NHI0..1string
\".\"\".\"\".\"\".\" othernames_03Other Names0..1string
\".\"\".\"\".\"\".\" dob_04DOB0..1date
\".\"\".\"\".\"\".\" age_05Age0..1integer
\".\"\".\"\".\"\".\" ward_06Ward0..1string
\".\"\".\"\".\"\".\" consultant_07Consultant0..1string
\".\"\".\"\".\"\".\" adreess_08Address0..1string
\".\"\".\"\".\"\".\" phonenumber_09Phone Number0..1string
\".\"\".\"\".\" sectioone_01Section One0..1group
\".\"\".\"\".\"\".\" operation_10Have you ever had an operation and/or anaesthetic?1..1boolean
\".\"\".\"\".\"\".\" closerelativeHave you or a close relative ever had problems with an anaesthetic?1..1boolean
\".\"\".\"\".\"\".\" problemdescribeIf YES, describe the problem:1..1stringEnable When: closerelative =
\".\"\".\"\".\"\".\" medicationsallergyAre you allergic to any medications or other substances?1..1boolean
\".\"\".\"\".\"\".\" answerallergyIf YES, please list:1..1stringEnable When: medicationsallergy =
\".\"\".\"\".\"\".\" anymedicationsAre you taking or have you taken any medications in the last 6 months?1..1boolean
\".\"\".\"\".\"\".\" allmedicationsIf YES, please list all medications:0..1stringEnable When: anymedications =
\".\"\".\"\".\"\".\" hadmdroHave you ever had MDRO? (Superbug infection)0..1boolean
\".\"\".\"\".\"\".\" workedorpatientHave you worked or been a patient in a hospital in NZ or overseas in the last 6 months? 0..1boolean
\".\"\".\"\".\"\".\" answerwhenIf YES, state when and where:0..1stringEnable When: workedorpatient =
\".\"\".\"\".\"\".\" artificialjointDo you have an artificial joint, heart valve or a pacemaker?0..1boolean
\".\"\".\"\".\"\".\" looseteethDo you have dentures, partial plate, loose teeth?0..1boolean
\".\"\".\"\".\"\".\" smokeDo you smoke?0..1boolean
\".\"\".\"\".\"\".\" howmanysmokeIf YES, how many per day?0..1stringEnable When: smoke =
\".\"\".\"\".\"\".\" sufferingcoldAre you suffering from or recovering from a cold, sore throat, flu or covid19?0..1boolean
\".\"\".\"\".\"\".\" pregnantAre you or could you be pregnant?0..1boolean
\".\"\".\"\".\" sectiontwoSection Two0..1group
\".\"\".\"\".\"\".\" symptomsHave you suffered from any of these symptoms or medical conditions?0..1display
\".\"\".\"\".\"\".\" heartconditionHeart condition1..1boolean
\".\"\".\"\".\"\".\" anginaChest pain/angina1..1boolean
\".\"\".\"\".\"\".\" bloodpressureHigh blood pressure1..1boolean
\".\"\".\"\".\"\".\" ankleswellingAnkle swelling1..1boolean
\".\"\".\"\".\"\".\" shortnessbreathAbnormal shortness of breath1..1boolean
\".\"\".\"\".\"\".\" bloodclotsBlood clots in legs/lungs1..1boolean
\".\"\".\"\".\"\".\" rheumaticfeverRheumatic fever1..1boolean
\".\"\".\"\".\"\".\" pcoughPersistent cough1..1boolean
\".\"\".\"\".\"\".\" asthmaAsthma1..1boolean
\".\"\".\"\".\"\".\" lungproblemOther lung problems1..1boolean
\".\"\".\"\".\"\".\" refluxHeartburn/reflux1..1boolean
\".\"\".\"\".\"\".\" sulcerStomach ulcer1..1boolean
\".\"\".\"\".\"\".\" bleedingdisorderBleeding disorders1..1boolean
\".\"\".\"\".\"\".\" anaemiaAnaemia1..1boolean
\".\"\".\"\".\"\".\" strokeStroke/blackouts1..1boolean
\".\"\".\"\".\"\".\" kidneydisorderKidney disorders1..1boolean
\".\"\".\"\".\"\".\" jaundiceHepatitis/jaundice1..1boolean
\".\"\".\"\".\"\".\" efitsEpilepsy/fits1..1boolean
\".\"\".\"\".\"\".\" migraine_01Migraine1..1boolean
\".\"\".\"\".\"\".\" diabetestypeDiabetes type 1 / 21..1boolean
\".\"\".\"\".\"\".\" depressionnervesDepression/nerves1..1boolean
\".\"\".\"\".\"\".\" arthritisArthritis1..1boolean
\".\"\".\"\".\"\".\" alcoholrelatedAlcohol related problems1..1boolean
\".\"\".\"\".\"\".\" motionsicknessMotion sickness1..1boolean
\".\"\".\"\".\"\".\" otherOther1..1string
\".\"\".\"\".\" sectionthreeSection Three0..1group
\".\"\".\"\".\"\".\" adultdriveFollowing surgery I will have a responsible adult drive me home and stay with me for 24hrs.0..1display
\".\"\".\"\".\"\".\" supportpersonnameSupport Person Name:1..1string
\".\"\".\"\".\"\".\" contactphoneContact Phone:1..1string
\".\"\".\"\".\"\".\" patientsignaturePatient Signature:1..1string
\".\"\".\"\".\"\".\" dateDate1..1date
\".\"\".\"\".\"\".\" smokingcessationABC for Smoking Cessation0..1display
\".\"\".\"\".\"\".\" eversmokedHas the patient ever smoked?1..1boolean
\".\"\".\"\".\"\".\" lastsmokeWhen did they last smoke?1..1string
\".\"\".\"\".\"\".\" quitadviseAdvised to quit?1..1boolean
\".\"\".\"\".\"\".\" vapeDoes the patient vape?1..1boolean
\".\"\".\"\".\"\".\" withnicotinewith nicotine?1..1boolean
\".\"\".\"\".\"\".\" quitsupportSupported to quit (tick all that apply)0..1display
\".\"\".\"\".\"\".\" quitcardNRT or Quitcard provided1..1boolean
\".\"\".\"\".\"\".\" referraltossssReferral to SSSS1..1boolean
\".\"\".\"\".\"\".\" supportdeclinedSupport declined1..1boolean
\".\"\".\"\".\"\".\" cessationprogrammeAlready on cessation programme1..1boolean
\".\"\".\"\".\"\".\" date_11Date1..1date
\".\"\".\"\".\"\".\" sign_12Sign1..1string
\".\"\".\"\".\"\".\" fallsriskassessmentFalls Risk Assessment0..1display
\".\"\".\"\".\"\".\" fallsriskalertIf “yes” to the last question, write ‘falls risk’ in orange alert box on the front of the Day Surgery Clinical Pathway & place a red bracelet on pt.0..1display
\".\"\".\"\".\"\".\" agemore55>55yrs & Maori or Pacific Islander1..1boolean
\".\"\".\"\".\"\".\" agemore75>75yrs (Other Ethnicity)1..1boolean
\".\"\".\"\".\"\".\" ptfallenpastPt has fallen in past year1..1boolean
\".\"\".\"\".\"\".\" assessordeemsptAssessor deems pt requires a full assessment1..1boolean
\".\"\".\"\".\"\".\" date_21Date1..1date
\".\"\".\"\".\"\".\" sign_22Sign:0..1string

\"doco\" Documentation for this format
" }, "url" : "https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/DHOPreoperativeQuestionnaireDaySurgeryDunedinHospital", "version" : "1.0", "name" : "DHOPreoperativeQuestionnaireDaySurgeryDunedinHospital", "title" : "Preoperative Questionnaire Day Surgery Dunedin Hospital", "status" : "active", "date" : "2026-04-16T21:32:31+00:00", "publisher" : "Te Whatu Ora", "contact" : [{ "name" : "Te Whatu Ora", "telecom" : [{ "system" : "url", "value" : "https://www.tewhatuora.govt.nz/" }] }, { "name" : "Te Whatu Ora Integration Team", "telecom" : [{ "system" : "email", "value" : "integration@tewhatuora.govt.nz", "use" : "work" }] }], "description" : "Pre-operative assessment questionnaire for day surgery patients at Dunedin Hospital.", "jurisdiction" : [{ "coding" : [{ "system" : "urn:iso:std:iso:3166", "code" : "NZ", "display" : "New Zealand" }] }], "purpose" : "To collect pre-operative clinical and risk information prior to day surgery.", "item" : [{ "linkId" : "patientInfo", "text" : "Patient Information", "type" : "group", "item" : [{ "linkId" : "surname_01", "text" : "Surname", "type" : "string" }, { "linkId" : "nhi_02", "text" : "NHI", "type" : "string" }, { "linkId" : "othernames_03", "text" : "Other Names", "type" : "string" }, { "linkId" : "dob_04", "text" : "DOB", "type" : "date" }, { "linkId" : "age_05", "text" : "Age", "type" : "integer" }, { "linkId" : "ward_06", "text" : "Ward", "type" : "string" }, { "linkId" : "consultant_07", "text" : "Consultant", "type" : "string" }, { "linkId" : "adreess_08", "text" : "Address", "type" : "string" }, { "linkId" : "phonenumber_09", "text" : "Phone Number", "type" : "string" }] }, { "linkId" : "sectioone_01", "text" : "Section One", "type" : "group", "readOnly" : false, "item" : [{ "linkId" : "operation_10", "text" : "Have you ever had an operation and/or anaesthetic?", "type" : "boolean", "required" : true, "repeats" : false }, { "linkId" : "closerelative", "text" : "Have you or a close relative ever had problems with an anaesthetic?", "type" : "boolean", "required" : true, "repeats" : false }, { "linkId" : "problemdescribe", "text" : "If YES, describe the problem:", "type" : "string", "enableWhen" : [{ "question" : "closerelative", "operator" : "=", "answerBoolean" : true }], "enableBehavior" : "any", "required" : true, "repeats" : false }, { "linkId" : "medicationsallergy", "text" : "Are you allergic to any medications or other substances?", "type" : "boolean", "required" : true, "repeats" : false }, { "linkId" : "answerallergy", "text" : "If YES, please list:", "type" : "string", "enableWhen" : [{ "question" : "medicationsallergy", "operator" : "=", "answerBoolean" : true }], "enableBehavior" : "all", "required" : true, "repeats" : false }, { "linkId" : "anymedications", "text" : "Are you taking or have you taken any medications in the last 6 months?", "type" : "boolean", "required" : true, "repeats" : false }, { "linkId" : "allmedications", "text" : "If YES, please list all medications:", "type" : "string", "enableWhen" : [{ "question" : "anymedications", "operator" : "=", "answerBoolean" : true }], "enableBehavior" : "all", "repeats" : false }, { "linkId" : "hadmdro", "text" : "Have you ever had MDRO? (Superbug infection)", "type" : "boolean", "repeats" : false }, { "linkId" : "workedorpatient", "text" : "Have you worked or been a patient in a hospital in NZ or overseas in the last 6 months? ", "type" : "boolean", "repeats" : false }, { "linkId" : "answerwhen", "text" : "If YES, state when and where:", "type" : "string", "enableWhen" : [{ "question" : "workedorpatient", "operator" : "=", "answerBoolean" : true }], "enableBehavior" : "all", "repeats" : false }, { "linkId" : "artificialjoint", "text" : "Do you have an artificial joint, heart valve or a pacemaker?", "type" : "boolean", "repeats" : false }, { "linkId" : "looseteeth", "text" : "Do you have dentures, partial plate, loose teeth?", "type" : "boolean", "repeats" : false }, { "linkId" : "smoke", "text" : "Do you smoke?", "type" : "boolean", "repeats" : false }, { "linkId" : "howmanysmoke", "text" : "If YES, how many per day?", "type" : "string", "enableWhen" : [{ "question" : "smoke", "operator" : "=", "answerBoolean" : true }], "enableBehavior" : "all", "repeats" : false }, { "linkId" : "sufferingcold", "text" : "Are you suffering from or recovering from a cold, sore throat, flu or covid19?", "type" : "boolean", "repeats" : false }, { "linkId" : "pregnant", "text" : "Are you or could you be pregnant?", "type" : "boolean", "repeats" : false }] }, { "linkId" : "sectiontwo", "text" : "Section Two", "type" : "group", "required" : false, "repeats" : false, "item" : [{ "linkId" : "symptoms", "text" : "Have you suffered from any of these symptoms or medical conditions?", "type" : "display" }, { "linkId" : "heartcondition", "text" : "Heart condition", "type" : "boolean", "required" : true }, { "linkId" : "angina", "text" : "Chest pain/angina", "type" : "boolean", "required" : true }, { "linkId" : "bloodpressure", "text" : "High blood pressure", "type" : "boolean", "required" : true }, { "linkId" : "ankleswelling", "text" : "Ankle swelling", "type" : "boolean", "required" : true }, { "linkId" : "shortnessbreath", "text" : "Abnormal shortness of breath", "type" : "boolean", "required" : true }, { "linkId" : "bloodclots", "text" : "Blood clots in legs/lungs", "type" : "boolean", "required" : true }, { "linkId" : "rheumaticfever", "text" : "Rheumatic fever", "type" : "boolean", "required" : true }, { "linkId" : "pcough", "text" : "Persistent cough", "type" : "boolean", "required" : true, "repeats" : false }, { "linkId" : "asthma", "text" : "Asthma", "type" : "boolean", "required" : true, "repeats" : false }, { "linkId" : "lungproblem", "text" : "Other lung problems", "type" : "boolean", "required" : true, "repeats" : false }, { "linkId" : "reflux", "text" : "Heartburn/reflux", "type" : "boolean", "required" : true, "repeats" : false }, { "linkId" : "sulcer", "text" : "Stomach ulcer", "type" : "boolean", "required" : true, "repeats" : false }, { "linkId" : "bleedingdisorder", "text" : "Bleeding disorders", "type" : "boolean", "required" : true, "repeats" : false }, { "linkId" : "anaemia", "text" : "Anaemia", "type" : "boolean", "required" : true }, { "linkId" : "stroke", "text" : "Stroke/blackouts", "type" : "boolean", "required" : true }, { "linkId" : "kidneydisorder", "text" : "Kidney disorders", "type" : "boolean", "required" : true }, { "linkId" : "jaundice", "text" : "Hepatitis/jaundice", "type" : "boolean", "required" : true }, { "linkId" : "efits", "text" : "Epilepsy/fits", "type" : "boolean", "required" : true }, { "linkId" : "migraine_01", "text" : "Migraine", "type" : "boolean", "required" : true }, { "linkId" : "diabetestype", "text" : "Diabetes type 1 / 2", "type" : "boolean", "required" : true }, { "linkId" : "depressionnerves", "text" : "Depression/nerves", "type" : "boolean", "required" : true }, { "linkId" : "arthritis", "text" : "Arthritis", "type" : "boolean", "required" : true }, { "linkId" : "alcoholrelated", "text" : "Alcohol related problems", "type" : "boolean", "required" : true }, { "linkId" : "motionsickness", "text" : "Motion sickness", "type" : "boolean", "required" : true }, { "linkId" : "other", "text" : "Other", "type" : "string", "required" : true }] }, { "linkId" : "sectionthree", "text" : "Section Three", "type" : "group", "required" : false, "repeats" : false, "item" : [{ "linkId" : "adultdrive", "text" : "Following surgery I will have a responsible adult drive me home and stay with me for 24hrs.", "type" : "display" }, { "linkId" : "supportpersonname", "text" : "Support Person Name:", "type" : "string", "required" : true }, { "linkId" : "contactphone", "text" : "Contact Phone:", "type" : "string", "required" : true }, { "linkId" : "patientsignature", "text" : "Patient Signature:", "type" : "string", "required" : true }, { "linkId" : "date", "text" : "Date", "type" : "date", "required" : true }, { "linkId" : "smokingcessation", "text" : "ABC for Smoking Cessation", "type" : "display" }, { "linkId" : "eversmoked", "text" : "Has the patient ever smoked?", "type" : "boolean", "required" : true }, { "linkId" : "lastsmoke", "text" : "When did they last smoke?", "type" : "string", "required" : true }, { "linkId" : "quitadvise", "text" : "Advised to quit?", "type" : "boolean", "required" : true }, { "linkId" : "vape", "text" : "Does the patient vape?", "type" : "boolean", "required" : true }, { "linkId" : "withnicotine", "text" : "with nicotine?", "type" : "boolean", "required" : true }, { "linkId" : "quitsupport", "text" : "Supported to quit (tick all that apply)", "type" : "display" }, { "linkId" : "quitcard", "text" : "NRT or Quitcard provided", "type" : "boolean", "required" : true }, { "linkId" : "referraltossss", "text" : "Referral to SSSS", "type" : "boolean", "required" : true }, { "linkId" : "supportdeclined", "text" : "Support declined", "type" : "boolean", "required" : true }, { "linkId" : "cessationprogramme", "text" : "Already on cessation programme", "type" : "boolean", "required" : true }, { "linkId" : "date_11", "text" : "Date", "type" : "date", "required" : true }, { "linkId" : "sign_12", "text" : "Sign", "type" : "string", "required" : true }, { "linkId" : "fallsriskassessment", "text" : "Falls Risk Assessment", "type" : "display" }, { "linkId" : "fallsriskalert", "text" : "If “yes” to the last question, write ‘falls risk’ in orange alert box on the front of the Day Surgery Clinical Pathway & place a red bracelet on pt.", "type" : "display" }, { "linkId" : "agemore55", "text" : ">55yrs & Maori or Pacific Islander", "type" : "boolean", "required" : true }, { "linkId" : "agemore75", "text" : ">75yrs (Other Ethnicity)", "type" : "boolean", "required" : true }, { "linkId" : "ptfallenpast", "text" : "Pt has fallen in past year", "type" : "boolean", "required" : true }, { "linkId" : "assessordeemspt", "text" : "Assessor deems pt requires a full assessment", "type" : "boolean", "required" : true }, { "linkId" : "date_21", "text" : "Date", "type" : "date", "required" : true }, { "linkId" : "sign_22", "text" : "Sign:", "type" : "string" }] }] }