Colorado BHA FHIR Implementation Guide
0.3.0-current - ci-build United States of America flag

Colorado BHA FHIR Implementation Guide, published by Colorado Behavioral Health Administration. This guide is not an authorized publication; it is the continuous build for version 0.3.0-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/CoBHA/CoBHRM-FHIR-IG/ and changes regularly. See the Directory of published versions

Questionnaire: BHA Admission Questionnaire

Official URL: http://bha.colorado.gov/fhir/bha-ig/Questionnaire/BHAAdmissionQuestionnaire Version: 0.3.0-current
Standards status: Trial-use Maturity Level: 1 Computable Name: BHAAdmissionQuestionnaire

Questionnaire used during admission process to collect demographic, social, clinical, and administrative information from patients entering behavioral health services

Profile: SDC Base Questionnaire version: 4.0.0-ci-build

LinkIDTextCardinalityTypeDescription & Constraintsdoco
BHAAdmissionQuestionnaire Questionnaire used during admission process to collect demographic, social, clinical, and administrative information from patients entering behavioral health services Questionnaire http://bha.colorado.gov/fhir/bha-ig/Questionnaire/BHAAdmissionQuestionnaire#0.3.0-current
BHAAdmissionQuestionnaire / lastUpdated Last Updated DateTime of the data in the QuestionnaireResponse 1..1 dateTime Value Set:
BHAAdmissionQuestionnaire / SERVICE_IDENTIFIER Service Identifier 1..1 choice Value Set: ValueSet for BHA Service Identifier Codes
BHAAdmissionQuestionnaire / FIRST_CONTACT_DATE Date of First Contact 1..1 date Value Set:
BHAAdmissionQuestionnaire / FIRST_APPOINTMENT_OFFERED_DATE Date of First Appointment Offered 1..1 date Value Set:
BHAAdmissionQuestionnaire / MEDICATION_ASSISTED_THERAPY Medication Assisted Therapy 1..1 boolean Value Set:
BHAAdmissionQuestionnaire / REFERRAL_SOURCE Referral Source 1..1 choice Value Set: ValueSet for BHA Referral Source
BHAAdmissionQuestionnaire / ARRESTS_PAST_30_DAYS Arrests in Past 30 Days 1..1 integer Value Set:
BHAAdmissionQuestionnaire / EMPLOYMENT_STATUS Employment Status 1..1 choice Value Set: ValueSet for BHA Employment Status
BHAAdmissionQuestionnaire / LIVING_SITUATION Living Situation 1..1 choice Value Set: ValueSet for BHA Living Situation
BHAAdmissionQuestionnaire / MONTHLY_INCOME Monthly Income 0..1 decimal Value Set:
BHAAdmissionQuestionnaire / PRIMARY_INCOME_SOURCE Primary Source of income/support for client (or for client's parent if client >18 years of age) 1..1 choice Value Set: ValueSet for BHA Income Source
BHAAdmissionQuestionnaire / PREGNANCY_STATUS Pregnancy Status 1..1 boolean Value Set:
BHAAdmissionQuestionnaire / WITHIN_1_YEAR_POSTPARTUM_STATUS Within 1 Year Postpartum Status 1..1 boolean Value Set:
BHAAdmissionQuestionnaire / SPECIAL_CONNECTIONS_ENROLLMENT Enrollment in Special Connections 1..1 boolean Value Set:
BHAAdmissionQuestionnaire / ACT_ENROLLMENT Enrollment in ACT? 1..1 boolean Value Set:
BHAAdmissionQuestionnaire / ASCENT_ENROLLMENT Enrollment in Ascent (FEP)? 1..1 boolean Value Set:
BHAAdmissionQuestionnaire / NUMBER_DEPENDENT_CHILDREN Number of Dependent Children 1..1 integer Value Set:
BHAAdmissionQuestionnaire / SELF_HELP_ATTENDANCE Self Help Attendance (Last 30 days at admission)/ Peer Support Attendance 1..1 integer Value Set:
BHAAdmissionQuestionnaire / TOTAL_SUBSTANCE_USE_PRIOR_TREATMENT Substance Use Prior Treatment (Total Lifetime admissions) 1..1 integer Value Set:
BHAAdmissionQuestionnaire / PSYCHIATRIC_HOSPITAL_ADMISSION Psychiatric Hospital Admission (Last 30 days) 1..1 boolean Value Set:
BHAAdmissionQuestionnaire / LEGAL_STATUS Legal Status 1..1 choice Value Set: ValueSet for BHA Legal Status
BHAAdmissionQuestionnaire / INVOLUNTARY_COMMITMENT_REASON Involuntary Commitment Reason 0..1 choice Enable When:
  • LEGAL_STATUS = 72-hour evaluation and treatment (BHA Legal Status#04)
  • LEGAL_STATUS = Short-term certification (BHA Legal Status#05)
  • LEGAL_STATUS = Long-term certification (BHA Legal Status#06)
  • LEGAL_STATUS = Emergency/Involuntary Alcohol/Drug Commitment (BHA Legal Status#09)

Value Set: ValueSet for BHA Involuntary Commitment Reason
BHAAdmissionQuestionnaire / CRIMINAL_JUSTICE_INVOLVEMENT Criminal Justice Involvement 0..1 boolean Value Set:
BHAAdmissionQuestionnaire / EDUCATION_LEVEL Education Level 1..1 choice Value Set: ValueSet for BHA Education Level
BHAAdmissionQuestionnaire / SCHOOL_ATTENDANCE_STATUS School Attendance Status (in the previous 3 months) 1..1 choice Value Set: ValueSet for BHA School Attendance Status
BHAAdmissionQuestionnaire / PSYCHIATRIC_ER_VISIT_6_MONTHS Visit to Psychiatric ER in last 6 months 1..1 integer Value Set:
BHAAdmissionQuestionnaire / COMMUNICATION_ACCOMMODATIONS Communication Accommodations 0..1 boolean Value Set:
BHAAdmissionQuestionnaire / episodeOfCare Episode of Care Information 1..* reference Value Set:
BHAAdmissionQuestionnaire / diagnosis Diagnosis Information 1..* reference Value Set:

doco Documentation for this format

Profile: SDC Base Questionnaire version: 4.0.0-ci-build

Last Updated DateTime of the data in the QuestionnaireResponse*

  • linkId: lastUpdated
  • Answers:

Service Identifier*

Date of First Contact*

  • linkId: FIRST_CONTACT_DATE
  • Answers:

Date of First Appointment Offered*

  • linkId: FIRST_APPOINTMENT_OFFERED_DATE
  • Answers:

Medication Assisted Therapy*

  • linkId: MEDICATION_ASSISTED_THERAPY
  • Answers:

Referral Source*

Arrests in Past 30 Days*

  • linkId: ARRESTS_PAST_30_DAYS
  • Answers:

Employment Status*

Living Situation*

Monthly Income

  • linkId: MONTHLY_INCOME
  • Answers:

Primary Source of income/support for client (or for client's parent if client >18 years of age)*

Pregnancy Status*

  • linkId: PREGNANCY_STATUS
  • Answers:

Within 1 Year Postpartum Status*

  • linkId: WITHIN_1_YEAR_POSTPARTUM_STATUS
  • Answers:

Enrollment in Special Connections*

  • linkId: SPECIAL_CONNECTIONS_ENROLLMENT
  • Answers:

Enrollment in ACT?*

  • linkId: ACT_ENROLLMENT
  • Answers:

Enrollment in Ascent (FEP)?*

  • linkId: ASCENT_ENROLLMENT
  • Answers:

Number of Dependent Children*

  • linkId: NUMBER_DEPENDENT_CHILDREN
  • Answers:

Self Help Attendance (Last 30 days at admission)/ Peer Support Attendance*

  • linkId: SELF_HELP_ATTENDANCE
  • Answers:

Substance Use Prior Treatment (Total Lifetime admissions)*

  • linkId: TOTAL_SUBSTANCE_USE_PRIOR_TREATMENT
  • Answers:

Psychiatric Hospital Admission (Last 30 days)*

  • linkId: PSYCHIATRIC_HOSPITAL_ADMISSION
  • Answers:

Legal Status*

Involuntary Commitment Reason

Criminal Justice Involvement

  • linkId: CRIMINAL_JUSTICE_INVOLVEMENT
  • Answers:

Education Level*

School Attendance Status (in the previous 3 months)*

Visit to Psychiatric ER in last 6 months*

  • linkId: PSYCHIATRIC_ER_VISIT_6_MONTHS
  • Answers:

Communication Accommodations

  • linkId: COMMUNICATION_ACCOMMODATIONS
  • Answers:

Episode of Care Information*

  • linkId: episodeOfCare
  • Answers:

Diagnosis Information*

  • linkId: diagnosis
  • Answers:

Profile: SDC Base Questionnaire version: 4.0.0-ci-build

LinkIDDescription & Constraintsdoco
lastUpdated Value Set:
SERVICE_IDENTIFIER Value Set: ValueSet for BHA Service Identifier Codes
FIRST_CONTACT_DATE Value Set:
FIRST_APPOINTMENT_OFFERED_DATE Value Set:
MEDICATION_ASSISTED_THERAPY Value Set:
REFERRAL_SOURCE Value Set: ValueSet for BHA Referral Source
ARRESTS_PAST_30_DAYS Value Set:
EMPLOYMENT_STATUS Value Set: ValueSet for BHA Employment Status
LIVING_SITUATION Value Set: ValueSet for BHA Living Situation
MONTHLY_INCOME Value Set:
PRIMARY_INCOME_SOURCE Value Set: ValueSet for BHA Income Source
PREGNANCY_STATUS Value Set:
WITHIN_1_YEAR_POSTPARTUM_STATUS Value Set:
SPECIAL_CONNECTIONS_ENROLLMENT Value Set:
ACT_ENROLLMENT Value Set:
ASCENT_ENROLLMENT Value Set:
NUMBER_DEPENDENT_CHILDREN Value Set:
SELF_HELP_ATTENDANCE Value Set:
TOTAL_SUBSTANCE_USE_PRIOR_TREATMENT Value Set:
PSYCHIATRIC_HOSPITAL_ADMISSION Value Set:
LEGAL_STATUS Value Set: ValueSet for BHA Legal Status
INVOLUNTARY_COMMITMENT_REASON Enable When: Not done yet
Value Set: ValueSet for BHA Involuntary Commitment Reason
CRIMINAL_JUSTICE_INVOLVEMENT Value Set:
EDUCATION_LEVEL Value Set: ValueSet for BHA Education Level
SCHOOL_ATTENDANCE_STATUS Value Set: ValueSet for BHA School Attendance Status
PSYCHIATRIC_ER_VISIT_6_MONTHS Value Set:
COMMUNICATION_ACCOMMODATIONS Value Set:
episodeOfCare Value Set:
diagnosis Value Set:

doco Documentation for this format

Test this Questionnaire

Try this questionnaire out:

Responses for this Questionnaire