IHE ACDC Implementation Guide
0.1.0 - CI Build

IHE ACDC Implementation Guide, published by Integrating the Healthcare Enterprise (IHE). This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/IHE/ACDC/ and changes regularly. See the Directory of published versions

StructureDefinition: ACDCQuestionnaireResponse

Defines constraints and extensions on the QuestionnaireResponse Resource for responses used with the IHE ACDC Profile

The official URL for this profile is: 

http://ihe.net/fhir/ACDC/StructureDefinition/ihe-acdc-questionnaireresponse

The IHE ACDC QuestionnaireResponse Profile defines the constraints on QuestionnaireResponse resources returned by the PCC-73 transaction. This resource describes the QuestionnaireResponse that represents the results of an Assessment that was performed on a patient.

Constraints

At a minimum, QuestionnaireResponse resources that comply with this provide must provide:

questionnaire
The canonical url of the questionnaire used to assess the patient must be present.
subject
The patient that was assessed must be reported.
status
On a create, the status must be “completed”. On update the status must be either “entered-in-error” or “amended”. The “in-progress” status is not used by this profile.
encounter
When there is a known encounter, it must be reported (an implementation Must Support reporting of encounters).
authored
The authored date time must be reported with precision to at least the day.
author
The person who received and reported the answers must be reported. If the patient or their representative reported the answers directly (e.g., into a device or through an application), a reference to that individual shall be provided.
source
The person who provided the answers must be reported when known (an implementation Must Support reporting of the source).
item
At least one item must be present unless the status is “entered-in-error” or “stopped”.

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from QuestionnaireResponse

Summary

Mandatory: 4 elements
Must-Support: 2 elements

Extensions

This structure refers to these extensions:

This structure is derived from QuestionnaireResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. QuestionnaireResponse 0..*QuestionnaireResponseA structured set of questions and their answers
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... questionnaireresponse-signature 0..1SignatureA signature attesting to the content
URL: http://hl7.org/fhir/StructureDefinition/questionnaireresponse-signature
... questionnaire 1..1canonical(Questionnaire)Form being answered
.... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... ihe-acdc-contained-questionnairereference 0..*Reference(Questionnaire)Extension
URL: http://ihe.net/fhir/ACDC/StructureDefinition/ihe-acdc-contained-questionnairereference
... subject 1..1Reference(Patient)The subject of the questions
... encounter S0..1Reference(Encounter)Encounter created as part of
... authored 1..1dateTimeDate the answers were gathered
... author 1..1Reference(Device | Practitioner | PractitionerRole | Patient | RelatedPerson | Organization)Person who received and recorded the answers
... source S0..1Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)The person who answered the questions

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. QuestionnaireResponse I0..*QuestionnaireResponseA structured set of questions and their answers
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionExtension
Slice: Unordered, Open by value:url
... questionnaireresponse-signature I0..1SignatureA signature attesting to the content
URL: http://hl7.org/fhir/StructureDefinition/questionnaireresponse-signature
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..1IdentifierUnique id for this set of answers
... basedOn ΣI0..*Reference(CarePlan | ServiceRequest)Request fulfilled by this QuestionnaireResponse
... partOf ΣI0..*Reference(Observation | Procedure)Part of this action
... questionnaire ΣI1..1canonical(Questionnaire)Form being answered
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension I0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... ihe-acdc-contained-questionnairereference I0..*Reference(Questionnaire)Optional Extensions Element
URL: http://ihe.net/fhir/ACDC/StructureDefinition/ihe-acdc-contained-questionnairereference
.... value 0..1stringPrimitive value for canonical
... status ?!ΣI1..1codein-progress | completed | amended | entered-in-error | stopped
Binding: Status Values allowed in a QuestionnaireResponse resource (required)
... subject ΣI1..1Reference(Patient)The subject of the questions
... encounter SΣI0..1Reference(Encounter)Encounter created as part of
... authored ΣI1..1dateTimeDate the answers were gathered
... author ΣI1..1Reference(Device | Practitioner | PractitionerRole | Patient | RelatedPerson | Organization)Person who received and recorded the answers
... source SΣI0..1Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)The person who answered the questions
... item I0..*BackboneElementGroups and questions
qrs-1: Nested item can't be beneath both item and answer
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... linkId I1..1stringPointer to specific item from Questionnaire
.... definition I0..1uriElementDefinition - details for the item
.... text I0..1stringName for group or question text
.... answer I0..*BackboneElementThe response(s) to the question
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... value[x] I0..1Single-valued answer to the question
Binding: QuestionnaireAnswerCodes (example)
...... valueBooleanboolean
...... valueDecimaldecimal
...... valueIntegerinteger
...... valueDatedate
...... valueDateTimedateTime
...... valueTimetime
...... valueStringstring
...... valueUriuri
...... valueAttachmentAttachment
...... valueCodingCoding
...... valueQuantityQuantity
...... valueReferenceReference(Resource)
..... item I0..*Unknown reference to #QuestionnaireResponse.item
Nested groups and questions
.... item I0..*Unknown reference to #QuestionnaireResponse.item
Nested questionnaire response items

doco Documentation for this format

This structure is derived from QuestionnaireResponse

Summary

Mandatory: 4 elements
Must-Support: 2 elements

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from QuestionnaireResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. QuestionnaireResponse 0..*QuestionnaireResponseA structured set of questions and their answers
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... questionnaireresponse-signature 0..1SignatureA signature attesting to the content
URL: http://hl7.org/fhir/StructureDefinition/questionnaireresponse-signature
... questionnaire 1..1canonical(Questionnaire)Form being answered
.... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... ihe-acdc-contained-questionnairereference 0..*Reference(Questionnaire)Extension
URL: http://ihe.net/fhir/ACDC/StructureDefinition/ihe-acdc-contained-questionnairereference
... subject 1..1Reference(Patient)The subject of the questions
... encounter S0..1Reference(Encounter)Encounter created as part of
... authored 1..1dateTimeDate the answers were gathered
... author 1..1Reference(Device | Practitioner | PractitionerRole | Patient | RelatedPerson | Organization)Person who received and recorded the answers
... source S0..1Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)The person who answered the questions

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. QuestionnaireResponse I0..*QuestionnaireResponseA structured set of questions and their answers
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionExtension
Slice: Unordered, Open by value:url
... questionnaireresponse-signature I0..1SignatureA signature attesting to the content
URL: http://hl7.org/fhir/StructureDefinition/questionnaireresponse-signature
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..1IdentifierUnique id for this set of answers
... basedOn ΣI0..*Reference(CarePlan | ServiceRequest)Request fulfilled by this QuestionnaireResponse
... partOf ΣI0..*Reference(Observation | Procedure)Part of this action
... questionnaire ΣI1..1canonical(Questionnaire)Form being answered
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension I0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... ihe-acdc-contained-questionnairereference I0..*Reference(Questionnaire)Optional Extensions Element
URL: http://ihe.net/fhir/ACDC/StructureDefinition/ihe-acdc-contained-questionnairereference
.... value 0..1stringPrimitive value for canonical
... status ?!ΣI1..1codein-progress | completed | amended | entered-in-error | stopped
Binding: Status Values allowed in a QuestionnaireResponse resource (required)
... subject ΣI1..1Reference(Patient)The subject of the questions
... encounter SΣI0..1Reference(Encounter)Encounter created as part of
... authored ΣI1..1dateTimeDate the answers were gathered
... author ΣI1..1Reference(Device | Practitioner | PractitionerRole | Patient | RelatedPerson | Organization)Person who received and recorded the answers
... source SΣI0..1Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)The person who answered the questions
... item I0..*BackboneElementGroups and questions
qrs-1: Nested item can't be beneath both item and answer
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... linkId I1..1stringPointer to specific item from Questionnaire
.... definition I0..1uriElementDefinition - details for the item
.... text I0..1stringName for group or question text
.... answer I0..*BackboneElementThe response(s) to the question
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... value[x] I0..1Single-valued answer to the question
Binding: QuestionnaireAnswerCodes (example)
...... valueBooleanboolean
...... valueDecimaldecimal
...... valueIntegerinteger
...... valueDatedate
...... valueDateTimedateTime
...... valueTimetime
...... valueStringstring
...... valueUriuri
...... valueAttachmentAttachment
...... valueCodingCoding
...... valueQuantityQuantity
...... valueReferenceReference(Resource)
..... item I0..*Unknown reference to #QuestionnaireResponse.item
Nested groups and questions
.... item I0..*Unknown reference to #QuestionnaireResponse.item
Nested questionnaire response items

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

Terminology Bindings

PathConformanceValueSet
QuestionnaireResponse.languagepreferredCommonLanguages
Max Binding: AllLanguages
QuestionnaireResponse.statusrequiredACDCQuestionnaireResponseStatus
QuestionnaireResponse.item.answer.value[x]exampleQuestionnaireAnswerCodes

Constraints

Constraints

IdPathDetailsRequirements
qrs-1QuestionnaireResponse.itemNested item can't be beneath both item and answer
: (answer.exists() and item.exists()).not()

Referencing the Questionnaire Inline

The Assessor actor may with to return a copy of the Questionnaire with the response as a contained resource. This enables the Assessment Requestor actor to operate with complete knowledge of the assessment being performed, which can aid in operations, and prevent the need to retrieve a copy of the assessment instrument. It also insures that the assessor has a copy of the exact instrument used, given that assessment instruments may be updated over time.

Because the reference to the Questionnaire at QuestionnaireResponse.questionnaire must be the canonical URL of the resource, the ACDC Contained Questionnaire Reference extension has been provided which allows the contained reference to be pointed to in the QuestionnaireResponse resource.

In JSON, this is represented using a special syntax to support the extension because Reference is a primitive type. An example is given below.

  "questionnaire": "http://example.com/PHQ-2",
  "_questionnaire": {
    "extension": [
      {
        "url": "http://ihe.net/fhir/ACDC/StructureDefinition/ihe-acdc-contained-questionnairereference",
        "valueReference": {
          "reference": "#contained-questionnaire"
        }
      }
    ]
  }

In XML, this would be represented as shown below:

   <questionnaire value="http://example.com/PHQ-2">
      <extension url="http://ihe.net/fhir/ACDC/StructureDefinition/ihe-acdc-contained-questionnairereference">
         <valueReference value="#contained-questionnaire"/>
      </extension>
   </questionnaire>

This extension is provided because some FHIR implementations do not send contained resources which are not directly referenced by the resource in which they are contained (e.g., HAPI on FHIR). This does not represent an error on behalf of those implementations, but rather an interpretation of the FHIR requirements that state that contained resources must be referenced by the resource that contains them.

Security Concerns

Assessment results contained in a QuestionnaireResponse often have very sensitive data, not just health data, but also sensitive data regarding information such as social determinants of health, which could include education level, income level, access to housing or food, et cetera. Such data should be encrypted in transit (e.g., using TLS as per the requirements of the ATNA Secure Node actor), and may also need to be encrypted or marked sensitive when stored.