SDOH Clinical Care
3.0.0-ballot - STU 3 Ballot United States of America flag

SDOH Clinical Care, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 3.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-sdoh-clinicalcare/ and changes regularly. See the Directory of published versions

Questionnaire: SDOHCC Questionnaire PRAPARE

Official URL: http://hl7.org/fhir/us/sdoh-clinicalcare/Questionnaire/SDOHCC-QuestionnairePRAPARE Version: 3.0.0-ballot
Standards status: Informative Draft as of 2021-04-01 Computable Name: SDOHCCQuestionnairePRAPARE

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. SDOHCCQuestionnairePRAPARE Questionnaire http://hl7.org/fhir/us/sdoh-clinicalcare/Questionnaire/SDOHCC-QuestionnairePRAPARE#3.0.0-ballot
... /93025-5 Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE] 0..1 group Value Set:
.... /93043-8 Personal characteristics 0..1 group Value Set:
..... /93043-8/56051-6 Hispanic or Latino 0..1 choice Value Set:
Options: 3 options
..... /93043-8/32624-9 Race 0..* choice Value Set:
Options: 8 options
..... /93043-8/93035-4 Has season or migrant farm work been your or your family's main source of income at any point in past 2 years? 0..1 choice Value Set:
Options: 3 options
..... /93043-8/93034-7 Have you been discharged from the armed forces of the United States? 0..1 choice Value Set:
Options: 3 options
..... /93043-8/54899-0 Preferred language 0..1 choice Value Set:
Options: 3 options
.... /93042-0 Family and home 0..1 group Value Set:
..... /93042-0/63512-8 How many people are living or staying at this address? 0..1 integer Value Set:
..... /93042-0/71802-3 Housing status 0..1 choice Value Set:
Options: 3 options
...... /93042-0/71802-3-help Describes patients living arrangement 0..1 display Value Set:
..... /93042-0/93033-9 Are you worried about losing your housing? 0..1 choice Value Set:
Options: 3 options
..... /93042-0/56799-0 Address 0..1 string Value Set:
.... /93041-2 Money and resources 0..1 group Value Set:
..... /93041-2/82589-3 Highest level of educ 0..1 choice Value Set:
Options: 4 options
..... /93041-2/67875-5 Employment status current 0..1 choice Value Set:
Options: 5 options
..... /93041-2/76437-3 Primary insurance 0..1 choice Value Set:
Options: 7 options
..... /93041-2/63586-2 What was your best estimate of the total income of all family members from all sources, before taxes, in last year? 0..1 decimal Value Set:
..... /93041-2/93031-3 In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? 0..* choice Value Set:
Options: 8 options
..... /93041-2/93030-5 Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? 0..* choice Value Set:
Options: 4 options
.... /93040-4 Social and emotional health 0..1 group Value Set:
..... /93040-4/93029-7 How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)? 0..1 choice Value Set:
Options: 5 options
..... /93040-4/93038-8 Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you? 0..1 choice Value Set:
Options: 6 options
.... /93039-6 Optional additional questions 0..1 group Value Set:
..... /93039-6/93028-9 In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility? 0..1 choice Value Set:
Options: 3 options
..... /93039-6/93027-1 Are you a refugee? 0..1 choice Value Set:
Options: 3 options
..... /93039-6/93026-3 Do you feel physically and emotionally safe where you currently live? 0..1 choice Value Set:
Options: 4 options
..... /93039-6/76501-6 Within the last year, have you been afraid of your partner or ex-partner? 0..1 choice Value Set:
Options: 2 options

doco Documentation for this format

Options Sets

Answer options for /93043-8/56051-6

  • http://loinc.org#LA33-6 ("Yes")
  • http://loinc.org#LA32-8 ("No")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93043-8/32624-9

  • http://loinc.org#LA6156-9 ("Asian")
  • http://loinc.org#LA14045-1 ("Native Hawaiian")
  • http://loinc.org#LA30187-1 ("Pacific Islander")
  • http://loinc.org#LA14042-8 ("Black/African American")
  • http://loinc.org#LA4457-3 ("White")
  • http://loinc.org#LA4-4 ("American Indian/Alaskan Native")
  • http://loinc.org#LA46-8 ("Other")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93043-8/93035-4

  • http://loinc.org#LA33-6 ("Yes")
  • http://loinc.org#LA32-8 ("No")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93043-8/93034-7

  • http://loinc.org#LA33-6 ("Yes")
  • http://loinc.org#LA32-8 ("No")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93043-8/54899-0

  • http://loinc.org#LA43-5 ("English")
  • http://loinc.org#LA30188-9 ("Language other than English")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93042-0/71802-3

  • http://loinc.org#LA30189-7 ("I have housing")
  • http://loinc.org#LA30190-5 ("I do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, or in a park)")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93042-0/93033-9

  • http://loinc.org#LA33-6 ("Yes")
  • http://loinc.org#LA32-8 ("No")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93041-2/82589-3

  • http://loinc.org#LA30191-3 ("Less than high school degree")
  • http://loinc.org#LA30192-1 ("High school diploma or GED")
  • http://loinc.org#LA30193-9 ("More than high school")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93041-2/67875-5

  • http://loinc.org#LA17956-6 ("Unemployed")
  • http://loinc.org#LA30138-4 ("Part-time or temporary work")
  • http://loinc.org#LA30136-8 ("Full-time work")
  • http://loinc.org#LA30137-6 ("Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93041-2/76437-3

  • http://loinc.org#LA30194-7 ("None/uninsured")
  • http://loinc.org#LA17849-3 ("Medicaid")
  • http://loinc.org#LA30195-4 ("CHIP Medicaid")
  • http://loinc.org#LA15652-3 ("Medicare")
  • http://loinc.org#LA30196-2 ("Other public insurance (not CHIP)")
  • http://loinc.org#LA30197-0 ("Other public insurance (CHIP)")
  • http://loinc.org#LA6350-8 ("Private insurance")

Answer options for /93041-2/93031-3

  • http://loinc.org#LA30125-1 ("Food")
  • http://loinc.org#LA30126-9 ("Clothing")
  • http://loinc.org#LA30124-4 ("Utilities")
  • http://loinc.org#LA30127-7 ("Child care")
  • http://loinc.org#LA30128-5 ("Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)")
  • http://loinc.org#LA30129-3 ("Phone")
  • http://loinc.org#LA46-8 ("Other")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93041-2/93030-5

  • http://loinc.org#LA30133-5 ("Yes, it has kept me from medical appointments or from getting my medications")
  • http://loinc.org#LA30134-3 ("Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need")
  • http://loinc.org#LA32-8 ("No")
  • http://loinc.org#LA30257-2 ("Patient unable to respond")

Answer options for /93040-4/93029-7

  • http://loinc.org#LA27722-0 ("Less than once a week")
  • http://loinc.org#LA30130-1 ("1 or 2 times a week")
  • http://loinc.org#LA30131-9 ("3 to 5 times a week")
  • http://loinc.org#LA30132-7 ("5 or more times a week")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93040-4/93038-8

  • http://loinc.org#LA6568-5 ("Not at all")
  • http://loinc.org#LA13863-8 ("A little bit")
  • http://loinc.org#LA13909-9 ("Somewhat")
  • http://loinc.org#LA13902-4 ("Quite a bit")
  • http://loinc.org#LA13914-9 ("Very much")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93039-6/93028-9

  • http://loinc.org#LA33-6 ("Yes")
  • http://loinc.org#LA32-8 ("No")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93039-6/93027-1

  • http://loinc.org#LA33-6 ("Yes")
  • http://loinc.org#LA32-8 ("No")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93039-6/93026-3

  • http://loinc.org#LA33-6 ("Yes")
  • http://loinc.org#LA32-8 ("No")
  • http://loinc.org#LA14072-5 ("Unsure")
  • http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93039-6/76501-6

  • http://loinc.org#LA33-6 ("Yes")
  • http://loinc.org#LA32-8 ("No")

Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]

  • linkId: /93025-5
  • Answers:

Personal characteristics

  • linkId: /93043-8
  • Answers:

Hispanic or Latino

Race

Has season or migrant farm work been your or your family's main source of income at any point in past 2 years?

Have you been discharged from the armed forces of the United States?

Preferred language

Family and home

  • linkId: /93042-0
  • Answers:

How many people are living or staying at this address?

  • linkId: /93042-0/63512-8
  • Answers:

Housing status

Describes patients living arrangement

  • linkId: /93042-0/71802-3-help
  • Answers:

Are you worried about losing your housing?

Address

  • linkId: /93042-0/56799-0
  • Answers:

Money and resources

  • linkId: /93041-2
  • Answers:

Highest level of educ

Employment status current

Primary insurance

What was your best estimate of the total income of all family members from all sources, before taxes, in last year?

  • linkId: /93041-2/63586-2
  • Answers:

In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?

Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Social and emotional health

  • linkId: /93040-4
  • Answers:

How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?

Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you?

Optional additional questions

  • linkId: /93039-6
  • Answers:

In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?

Are you a refugee?

Do you feel physically and emotionally safe where you currently live?

Within the last year, have you been afraid of your partner or ex-partner?

LinkIDDescription & Constraintsdoco
.. /93025-5 Value Set:
... /93043-8 Value Set:
.... /93043-8/56051-6 Value Set:
Options: 3 options
.... /93043-8/32624-9 Value Set:
Options: 8 options
.... /93043-8/93035-4 Value Set:
Options: 3 options
.... /93043-8/93034-7 Value Set:
Options: 3 options
.... /93043-8/54899-0 Value Set:
Options: 3 options
... /93042-0 Value Set:
.... /93042-0/63512-8 Value Set:
.... /93042-0/71802-3 Value Set:
Options: 3 options
..... /93042-0/71802-3-help Value Set:
.... /93042-0/93033-9 Value Set:
Options: 3 options
.... /93042-0/56799-0 Value Set:
... /93041-2 Value Set:
.... /93041-2/82589-3 Value Set:
Options: 4 options
.... /93041-2/67875-5 Value Set:
Options: 5 options
.... /93041-2/76437-3 Value Set:
Options: 7 options
.... /93041-2/63586-2 Value Set:
.... /93041-2/93031-3 Value Set:
Options: 8 options
.... /93041-2/93030-5 Value Set:
Options: 4 options
.... /93040-4/93029-7 Value Set:
Options: 5 options
.... /93040-4/93038-8 Value Set:
Options: 6 options
... /93039-6 Value Set:
.... /93039-6/93028-9 Value Set:
Options: 3 options
.... /93039-6/93027-1 Value Set:
Options: 3 options
.... /93039-6/93026-3 Value Set:
Options: 4 options
.... /93039-6/76501-6 Value Set:
Options: 2 options

doco Documentation for this format

Test this Questionnaire

Try this questionnaire out:

Responses for this Questionnaire