Structured Data Capture
4.0.0-ci-build - STU 4 CI-build International flag

Structured Data Capture, published by HL7 International / FHIR Infrastructure. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/sdc/ and changes regularly. See the Directory of published versions

Questionnaire: Cardiology Form

Official URL: urn:uuid:d7176d16-5fd4-48a7-b7e6-b488e8df763d Version: 4.0.0-ci-build
Standards status: Trial-use Maturity Level: 4 Computable Name:
Other Identifiers: OID:2.16.840.1.113883.4.642.40.17.35.43

Language: en

Structure
LinkIDTextCardinalityTypeFlagsDescription & Constraintsdoco
.. Questionnaire urn:uuid:d7176d16-5fd4-48a7-b7e6-b488e8df763d#4.0.0-ci-build
... patient_header Patient Information 0..1 group Value Set:
.... patient_surname Surname: 1..1 string Value Set:
.... patient_firstname First Name: 1..1 string Value Set:
.... patient_date_of_birth DOB: 1..1 date Value Set:
.... patient_gender Gender: 1..1 choice Value Set:
Options: 3 options
.... patient_hc_pc HN PC: 0..1 string Max Length: 2
Value Set:
..... patient_hc_number HN: 0..1 string Max Length: 10
Value Set:
..... patient_hc_vc HN VC: 0..1 string Value Set:
.... patient_address_line1 Address (Line 1): 1..1 string Value Set:
..... patient_address_line2 Address (Line 2): 0..1 string Value Set:
..... patient_address_city City: 1..1 string Value Set:
..... patient_address_province Province: 1..1 string Max Length: 2
Value Set:
..... patient_address_postalcode Postal Code: 1..1 string Value Set:
.... patient_phone_mobile Mobile #: 0..1 string Value Set:
.... patient_phone_home Home #: 0..1 string Value Set:
.... patient_phone_business Business #: 0..1 string Value Set:
.... patient_email Email: 0..1 string Value Set:
... additionalinfo_header [Optional] Additional Patient Information 0..1 group Value Set:
.... additionalinfo_sexassignedatbirth Sex assigned at birth: 0..1 choice iconicon Value Set:
Options: 4 options
.... additionalinfo_pronouns Pronouns: 0..1 choice Value Set:
Options: 4 options
..... additionalinfo_pronouns_other Other pronouns: 1..1 string Enable When: additionalinfo_pronouns = other (v3 Code System NullFlavor#OTH)
Value Set:
.... additionalinfo_preferredlanguage Preferred language: 0..1 choice iconicon Value Set:
Options: 3 options
..... additionalinfo_preferredlanguage_specify Specify: 1..1 string Enable When: additionalinfo_preferredlanguage = other (v3 Code System NullFlavor#OTH)
Value Set:
..... additionalinfo_preferredlanguage_translatorrequired Translator required 0..* string Enable When: additionalinfo_preferredlanguage = other (v3 Code System NullFlavor#OTH)
Value Set:
Options: 1 option
.... additionalinfo_bestmethodofcontact Best method of contact: 0..1 choice Value Set:
Options: 4 options
..... additionalinfo_bestmethodofcontact_voicemails Voicemails acceptable 0..* string Enable When: additionalinfo_bestmethodofcontact = Mobile (ContactPointUse#mobile)
Value Set:
Options: 1 option
.... additionalinfo_preferredname_select Preferred name 0..* string Value Set:
Options: 1 option
.... additionalinfo_preferredname Prefered name String 0..1 string Enable When: additionalinfo_preferredname_select = Preferred Name
Value Set:
.... additionalinfo_alternatecontact_select Alternate contact 0..* string Value Set:
Options: 1 option
.... additionalinfo_alternatecontact_name Name: 1..1 string Enable When: additionalinfo_alternatecontact_select = Alternate contact
Value Set:
.... additionalinfo_alternatecontact_phone Alternate contact phone #: 0..1 string Enable When: additionalinfo_alternatecontact_select = Alternate contact
Value Set:
.... additionalinfo_alternatecontact_relationship Relationship: 0..1 string Enable When: additionalinfo_alternatecontact_select = Alternate contact
Value Set:
.... additionalinfo_alternatecontact_bookingcontact Is Alternate contact the appointment booking contact?: 0..1 choice iconicon Enable When: additionalinfo_alternatecontact_select = Alternate contact
Value Set:
Options: 2 options
.... additionalinfo_unsafecontacts_select Unsafe contact persons (do not speak with) 0..* string Value Set:
Options: 1 option
.... additionalinfo_unsafecontacts_speakwithpatientdirectly Only speak with patient directly 0..* string Enable When: additionalinfo_unsafecontacts_select = Unsafe contact persons (do not speak with)
Value Set:
Options: 1 option
.... additionalinfo_unsafecontacts_donotspeakwith Do not speak with: 0..1 string Enable When: additionalinfo_unsafecontacts_select = Unsafe contact persons (do not speak with)
Value Set:
.... additionalinfo_accessibilityconcernsordisability_selectt Accessibility concerns or disability 0..* string Value Set:
Options: 1 option
.... additionalinfo_accessibilityconcernsordisability Accessibility concerns Options 0..* choice iconicon Enable When: additionalinfo_accessibilityconcernsordisability_selectt = Accessibility concerns or disability
Value Set:
Options: 4 options
.... additionalinfo_specialconsiderations_select Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues) 0..* string Value Set:
Options: 1 option
.... additionalinfo_specialconsiderations Details of special considerations: 1..1 text Enable When: additionalinfo_specialconsiderations_select = Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)
Value Set:
.... additionalinfo_sendcopiestoadditionalproviders Send copies of reports to additional providers 0..* string Value Set:
Options: 1 option
.... additionalinfo_sendcopiestoadditionalproviders_names Name(s): 1..1 string Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers
Value Set:
..... additionalinfo_sendcopiestoadditionalproviders_contactinfo Contact information: 1..1 string Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers
Value Set:
..... additionalinfo_sendcopiestoadditionalproviders_ispcp This is the Primary Care Provider 0..* string Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers
Value Set:
Options: 1 option
... 102173268919 Referral Details 0..1 group Value Set:
.... cardio_triagecons Triage Considerations 0..1 group Value Set:
..... referral_requestedpriority Requested Priority: 1..1 choice iconicon Value Set:
Options: 2 options
...... referral_requestedpriority_urgentreason Reason for urgent triage 1..1 string Enable When: referral_requestedpriority = Urgent (RequestPriority#urgent)
Value Set:
..... referral_secondopinion Second Opinion 0..* choice iconicon Value Set:
Options: 1 option
..... referral_secondopinion_reason Reason for second opinion: 0..1 text Enable When: referral_secondopinion = Second or third medical opinion (SNOMED CT#77406008)
Value Set:
.... 695991571585 Service(s) Requested Select all that apply: 1..1 group Value Set:
..... referralService HSCs Assigned: 0..1 string iconiconiconicon Value Set:
..... 223886162384 Cardiac Testing 0..* choice iconicon Value Set:
Options: 1 option
..... 660331267409 Exam(s) Requested 0..1 group Enable When: 223886162384 = Cardiac Testing (standardized-referral-form-codes#20001)
Value Set:
...... 720409326878 24 Hour Ambulatory Blood Pressure Monitoring 0..* choice iconicon Value Set:
Options: 1 option
...... 960455115596 Coronary Angiogram 0..* choice iconicon Value Set:
Options: 1 option
...... 297634898828 Echocardiogram - Resting 0..* choice iconicon Value Set:
Options: 1 option
...... 443484577720 sub Echocardiogram - Resting 0..1 group Enable When: 297634898828 = Echocardiogram - Resting (standardized-referral-form-codes#20005)
Value Set:
....... 165530569567 Echocardiogram (2D) 0..* choice Value Set:
Options: 1 option
....... 286552421895 Echocardiogram with Contrast 0..* choice iconicon Value Set:
Options: 1 option
....... 910527687300 Echocardiogram with Saline (Bubble) 0..* choice iconicon Value Set:
Options: 1 option
....... 657824763133 Pediatric Echocardiogram 0..* choice iconicon Value Set:
Options: 1 option
....... 992743200182 Transesophageal Echocardiogram (TEE) 0..* choice iconicon Value Set:
Options: 1 option
...... 894277763438 Electrocardiogram (ECG) 0..* choice iconicon Value Set:
Options: 1 option
...... 279226023495 Holter Monitoring 0..* choice iconicon Value Set:
Options: 1 option
...... 440449731882 sub holter monitoring 0..1 group Enable When: 279226023495 = Holter Monitoring (standardized-referral-form-codes#20007)
Value Set:
....... 671328703851 24 Hours 0..* choice iconicon Value Set:
Options: 1 option
....... 423992261841 48 Hours 0..* choice iconicon Value Set:
Options: 1 option
....... 419924239187 72 Hours 0..* choice iconicon Value Set:
Options: 1 option
....... 731054417270 7 Days 0..* choice iconicon Value Set:
Options: 1 option
....... 235876421044 14 Days 0..* choice iconicon Value Set:
Options: 1 option
...... 374742834400 Loop / Event Monitor 0..* choice iconicon Value Set:
Options: 1 option
...... 159161544747 Cardiovascular stress testing 0..* choice iconicon Value Set:
Options: 1 option
...... 370275060390 Sub Stress Testing 0..1 group Enable When: 159161544747 = Stress Testing (standardized-referral-form-codes#20009)
Value Set:
....... 814218498309 ECG - Exercise Stress Test 0..* choice iconicon Value Set:
Options: 1 option
....... 307107493993 ECG - Dobutamine/Persantine Stress Test 0..* choice iconicon Value Set:
Options: 1 option
....... 805303414102 Echocardiogram - Exercise Stress Test 0..* choice iconicon Value Set:
Options: 1 option
....... 193586908489 Echocardiogram - Dobutamine/Persantine Stress Test 0..* choice iconicon Value Set:
Options: 1 option
...... 918517139023 Nuclear Medicine 0..* choice iconicon Value Set:
Options: 1 option
...... 222686221935 sub Nuclear Medicine 0..1 group Enable When: 918517139023 = Nuclear Medicine (standardized-referral-form-codes#20010)
Value Set:
....... 924189648184 MUGA - Resting 0..* choice iconicon Value Set:
Options: 1 option
....... 857163514910 Cardiac Pyrophosphate 0..* choice iconicon Value Set:
Options: 1 option
....... 892165959617 Myocardial perfusion scan 0..* choice iconicon Value Set:
Options: 1 option
....... 538288549138 sub MIBI 0..1 group Enable When: 892165959617 = MIBI Scans / Myocardial Perfusion Imaging (MPI): (standardized-referral-form-codes#20028)
Value Set:
........ 373435981917 MIBI Scan - Exercise Stress Test 0..* string Value Set:
Options: 1 option
........ 434394942688 MIBI Scan - Dobutamine/Persantine Stress Test 0..* string Value Set:
Options: 1 option
........ 913594478162 Thallium Viability Test 0..* string Value Set:
Options: 1 option
...... 992682216482 Tilt Table Testing 0..* choice iconicon Value Set:
Options: 1 option
...... cardiology_referral_services_cardiactesting_other Other 0..* choice iconicon Value Set:
Options: 1 option
...... cardiology_referral_services_cardiactesting_other_specify Specify 1..1 text Enable When: cardiology_referral_services_cardiactesting_other = other (v3 Code System NullFlavor#OTH)
Value Set:
..... 785727177547 Cardiology Consultation 0..* choice iconicon Value Set:
Options: 1 option
.... 186952778859 Concern(s) / Indication(s) Triggering Referral Select all that apply: 1..1 group Value Set:
..... 219569805461 Arrhythmias or Palpitations 0..* choice iconicon Value Set:
Options: 1 option
..... 571934328499 Cardiovascular Risk Assessment 0..* choice iconicon Value Set:
Options: 1 option
..... 459737733395 Chest Pain or Angina 0..* choice iconicon Value Set:
Options: 1 option
..... 929919815516 Congenital Heart Disease 0..* choice iconicon Value Set:
Options: 1 option
..... 832263816528 Congestive Heart Failure 0..* choice iconicon Value Set:
Options: 1 option
..... 803760213460 Coronary Artery Disease 0..* choice iconicon Value Set:
Options: 1 option
..... 129767162379 Dyspnea 0..* choice iconicon Value Set:
Options: 1 option
..... 116150628533 Hypertension 0..* choice iconicon Value Set:
Options: 1 option
..... 513825527027 Murmur 0..* choice iconicon Value Set:
Options: 1 option
..... 975075898688 Pericardial Disease 0..* choice iconicon Value Set:
Options: 1 option
..... 704148928571 Peripheral Edema 0..* choice iconicon Value Set:
Options: 1 option
..... 886489617115 Post-Myocardial Infarction 0..* choice iconicon Value Set:
Options: 1 option
..... 621745958993 Pre-operative Consultation 0..* choice iconicon Value Set:
Options: 1 option
..... 873024527134 Procedure Date (if known) 0..1 date Enable When: 621745958993 = Pre-operative Consultation (standardized-referral-form-codes#20044)
Value Set:
..... 197975129599 Syncope 0..* choice iconicon Value Set:
Options: 1 option
..... 675849150752 Valvular Heart Disease or Prosthetic Heart Valve 0..* choice iconicon Value Set:
Options: 1 option
..... 721982740516 Other 0..* choice iconicon Value Set:
Options: 1 option
..... 720594942482 Specify 1..1 text Enable When: 721982740516 = other (v3 Code System NullFlavor#OTH)
Value Set:
.... Descriptionofclinicalquestion Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations 1..1 text Value Set:
.... cpp_separate CPP attached separately (if not entered below) 0..* string Value Set:
Options: 1 option
.... cpp_currentprob Current Problem List: 0..1 text Enable When: cpp_separate exists false
Value Set:
.... cpp_pastmedicalhistory Past Medical History: 0..1 text Enable When: cpp_separate exists false
Value Set:
.... cpp_currentmedications Current Medications : 0..1 text Enable When: cpp_separate exists false
Value Set:
.... cpp_familyhistory Family History: 0..1 text Enable When: cpp_separate exists false
Value Set:
.... cpp_allergies Allergies: 0..1 text Enable When: cpp_separate exists false
Value Set:
... preferredconsultlocation_header Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered. 0..1 group Value Set:
.... preferredconsultlocation_selector Preferred consultant or location 0..* string Value Set:
Options: 1 option
.... preferredconsultlocation_specify Please specify either a preferred consultant or location 0..1 group Enable When: preferredconsultlocation_selector = Preferred consultant or location
Value Set:
..... preferredconsultlocation_consultant Consultant: 0..1 string Value Set:
..... preferredconsultlocation_location Location: 0..1 string Value Set:
.... preferredconsultlocation_willingtotravel Patient willing to travel for shorter wait time 0..* string Value Set:
Options: 1 option
.... preferredconsultlocation_otherconsiderations Other considerations: 0..1 string Value Set:
... supportingdocumentation_header Supporting Documentation Please attach all relevant laboratory and diagnostic investigations. 0..1 group Value Set:
.... supportingdocumentation_details Personal Health Information that is medically relevant has not been disclosed at the request of the patient. 0..* string Value Set:
Options: 1 option
... supportingdocumentation_attachment Add Attachments 0..1 attachment Value Set:
... feedbacksurvey_cardiology Click here to provide feedback on this form 0..1 display Value Set:
... referrer_header Referrer's Information 0..1 group Value Set:
.... referrer_sitename Site Name: 0..1 string Value Set:
.... referrer_address_line1 Address (Line 1): 1..1 string Value Set:
..... referrer_address_line2 Address (Line 2): 0..1 string Value Set:
..... referrer_address_city City: 1..1 string Value Set:
..... referrer_address_province Province: 1..1 string Max Length: 2
Value Set:
..... referrer_address_postalcode Postal Code: 1..1 string Value Set:
.... referrer_phone Phone #: 0..1 string Value Set:
.... referrer_fax Fax #: 0..1 string Value Set:
.... referrer_billing Billing Number: 0..1 integer Value Set:
.... referrer_professionalid Professional ID: 0..1 integer Value Set:
.... referrer_signature Signed: 1..1 text Value Set:
.... referrer_role Role: 0..1 choice Value Set:
Options: 9 options

doco Documentation for this format

Options Sets

Answer options for patient_gender

  • http://hl7.org/fhir/administrative-gender#male ("Male")
  • http://hl7.org/fhir/administrative-gender#female ("Female")
  • http://hl7.org/fhir/administrative-gender#other ("Other")

Answer options for additionalinfo_sexassignedatbirth

  • http://loinc.org#LA3-6 ("Female")
  • http://loinc.org#LA2-8 ("Male")
  • http://example.com/CodeSystem/exampleCS#Intersex ("Intersex")
  • http://loinc.org#LA4489-6 ("Unknown")

Answer options for additionalinfo_pronouns

  • http://loinc.org#LA29519-8 ("She/Her")
  • http://loinc.org#LA29518-0 ("He/Him")
  • http://loinc.org#LA29519-8 ("They/Them")
  • http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")

Answer options for additionalinfo_preferredlanguage

  • urn:ietf:bcp:47#en ("English")
  • urn:ietf:bcp:47#fr ("French")
  • http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")

Answer options for additionalinfo_preferredlanguage_translatorrequired

  • Translator Required

Answer options for additionalinfo_bestmethodofcontact

  • http://hl7.org/fhir/contact-point-use#mobile ("Mobile")
  • http://hl7.org/fhir/contact-point-use#home ("Home")
  • http://hl7.org/fhir/contact-point-use#work ("Work")
  • http://hl7.org/fhir/contact-point-system#email ("Email")

Answer options for additionalinfo_bestmethodofcontact_voicemails

  • Voicemails acceptable

Answer options for additionalinfo_preferredname_select

  • Preferred Name

Answer options for additionalinfo_alternatecontact_select

  • Alternate contact

Answer options for additionalinfo_alternatecontact_bookingcontact

  • http://terminology.hl7.org/CodeSystem/v2-0532#Y ("Yes")
  • http://terminology.hl7.org/CodeSystem/v2-0532#N ("No")

Answer options for additionalinfo_unsafecontacts_select

  • Unsafe contact persons (do not speak with)

Answer options for additionalinfo_unsafecontacts_speakwithpatientdirectly

  • Only speak with patient directly

Answer options for additionalinfo_accessibilityconcernsordisability_selectt

  • Accessibility concerns or disability

Answer options for additionalinfo_accessibilityconcernsordisability

  • http://snomed.info/sct#129839007 ("Falls risk")
  • http://snomed.info/sct#301621006 ("Patient requires lift")
  • http://snomed.info/sct#105503008 ("Wheelchair")
  • http://snomed.info/sct#15188001 ("Hearing impaired")

Answer options for additionalinfo_specialconsiderations_select

  • Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)

Answer options for additionalinfo_sendcopiestoadditionalproviders

  • Send copies of reports to additional providers

Answer options for additionalinfo_sendcopiestoadditionalproviders_ispcp

  • This is the Primary Care Provider

Answer options for referral_requestedpriority

  • http://hl7.org/fhir/request-priority#routine ("Routine")
  • http://hl7.org/fhir/request-priority#urgent ("Urgent")

Answer options for referral_secondopinion

  • http://snomed.info/sct#77406008 ("Second or third medical opinion")

Answer options for 223886162384

  • http://example.com/CodeSystem/standardized-referral-form-codes#20001 ("Cardiac Testing")

Answer options for 720409326878

  • http://example.com/CodeSystem/standardized-referral-form-codes#20003 ("24 Hour Ambulatory Blood Pressure Monitoring")

Answer options for 960455115596

  • http://example.com/CodeSystem/standardized-referral-form-codes#20004 ("Coronary Angiogram")

Answer options for 297634898828

  • http://example.com/CodeSystem/standardized-referral-form-codes#20005 ("Echocardiogram - Resting")

Answer options for 165530569567

  • http://example.com/CodeSystem/standardized-referral-form-codes#20012 ("Echocardiogram (2D)")

Answer options for 286552421895

  • http://example.com/CodeSystem/standardized-referral-form-codes#20013 ("Echocardiogram with Contrast")

Answer options for 910527687300

  • http://example.com/CodeSystem/standardized-referral-form-codes#20014 ("Echocardiogram with Saline (Bubble)")

Answer options for 657824763133

  • http://example.com/CodeSystem/standardized-referral-form-codes#20015 ("Pediatric Echocardiogram")

Answer options for 992743200182

  • http://example.com/CodeSystem/standardized-referral-form-codes#20016 ("Transesophageal Echocardiogram (TEE)")

Answer options for 894277763438

  • http://example.com/CodeSystem/standardized-referral-form-codes#20006 ("Electrocardiogram (ECG)")

Answer options for 279226023495

  • http://example.com/CodeSystem/standardized-referral-form-codes#20007 ("Holter Monitoring")

Answer options for 671328703851

  • http://example.com/CodeSystem/standardized-referral-form-codes#20017 ("24 Hours")

Answer options for 423992261841

  • http://example.com/CodeSystem/standardized-referral-form-codes#20018 ("48 Hours")

Answer options for 419924239187

  • http://example.com/CodeSystem/standardized-referral-form-codes#20019 ("72 Hours")

Answer options for 731054417270

  • http://example.com/CodeSystem/standardized-referral-form-codes#20020 ("7 Days")

Answer options for 235876421044

  • http://example.com/CodeSystem/standardized-referral-form-codes#20021 ("14 Days")

Answer options for 374742834400

  • http://example.com/CodeSystem/standardized-referral-form-codes#20008 ("Loop / Event Monitor")

Answer options for 159161544747

  • http://example.com/CodeSystem/standardized-referral-form-codes#20009 ("Stress Testing")

Answer options for 814218498309

  • http://example.com/CodeSystem/standardized-referral-form-codes#20022 ("ECG - Exercise Stress Test")

Answer options for 307107493993

  • http://example.com/CodeSystem/standardized-referral-form-codes#20023 ("ECG - Dobutamine/Persantine Stress Test")

Answer options for 805303414102

  • http://example.com/CodeSystem/standardized-referral-form-codes#20024 ("Echocardiogram - Exercise Stress Test")

Answer options for 193586908489

  • http://example.com/CodeSystem/standardized-referral-form-codes#20025 ("Echocardiogram - Dobutamine/Persantine Stress Test")

Answer options for 918517139023

  • http://example.com/CodeSystem/standardized-referral-form-codes#20010 ("Nuclear Medicine")

Answer options for 924189648184

  • http://example.com/CodeSystem/standardized-referral-form-codes#20026 ("MUGA - Resting")

Answer options for 857163514910

  • http://example.com/CodeSystem/standardized-referral-form-codes#20027 ("Cardiac Pyrophosphate")

Answer options for 892165959617

  • http://example.com/CodeSystem/standardized-referral-form-codes#20028 ("MIBI Scans / Myocardial Perfusion Imaging (MPI):")

Answer options for 373435981917

  • MIBI Scan - Exercise Stress Test

Answer options for 434394942688

  • MIBI Scan - Dobutamine/Persantine Stress Test

Answer options for 913594478162

  • Thallium Viability Test

Answer options for 992682216482

  • http://example.com/CodeSystem/standardized-referral-form-codes#20011 ("Tilt Table Testing")

Answer options for cardiology_referral_services_cardiactesting_other

  • http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")

Answer options for 785727177547

  • http://example.com/CodeSystem/standardized-referral-form-codes#20002 ("Cardiology Consultation")

Answer options for 219569805461

  • http://snomed.info/sct#698247007 ("Arrhythmias or Palpitations")

Answer options for 571934328499

  • http://example.com/CodeSystem/standardized-referral-form-codes#20033 ("Cardiovascular Risk Assessment")

Answer options for 459737733395

  • http://example.com/CodeSystem/standardized-referral-form-codes#20034 ("Chest Pain or Angina")

Answer options for 929919815516

  • http://example.com/CodeSystem/standardized-referral-form-codes#20035 ("Congenital Heart Disease")

Answer options for 832263816528

  • http://example.com/CodeSystem/standardized-referral-form-codes#20036 ("Congestive Heart Failure")

Answer options for 803760213460

  • http://example.com/CodeSystem/standardized-referral-form-codes#20037 ("Coronary Artery Disease")

Answer options for 129767162379

  • http://example.com/CodeSystem/standardized-referral-form-codes#20038 ("Dyspnea")

Answer options for 116150628533

  • http://example.com/CodeSystem/standardized-referral-form-codes#20039 ("Hypertension")

Answer options for 513825527027

  • http://example.com/CodeSystem/standardized-referral-form-codes#20040 ("Murmur")

Answer options for 975075898688

  • http://example.com/CodeSystem/standardized-referral-form-codes#20041 ("Pericardial Disease")

Answer options for 704148928571

  • http://example.com/CodeSystem/standardized-referral-form-codes#20042 ("Peripheral Edema")

Answer options for 886489617115

  • http://example.com/CodeSystem/standardized-referral-form-codes#20043 ("Post-Myocardial Infarction")

Answer options for 621745958993

  • http://example.com/CodeSystem/standardized-referral-form-codes#20044 ("Pre-operative Consultation")

Answer options for 197975129599

  • http://example.com/CodeSystem/standardized-referral-form-codes#20045 ("Syncope")

Answer options for 675849150752

  • http://snomed.info/sct#368009 ("Valvular Heart Disease or Prosthetic Heart Valve")

Answer options for 721982740516

  • http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")

Answer options for cpp_separate

  • CPP attached separately (if not entered below)

Answer options for preferredconsultlocation_selector

  • Preferred consultant or location

Answer options for preferredconsultlocation_willingtotravel

  • Patient willing to travel for shorter wait time

Answer options for supportingdocumentation_details

  • Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

Answer options for referrer_role

  • http://snomed.info/sct#309398001 ("Allied Health Professional")
  • http://snomed.info/sct#62247001 ("Family Physician")
  • http://snomed.info/sct#449161006 ("Physician Assistant")
  • http://snomed.info/sct#398130009 ("Medical Student")
  • http://snomed.info/sct#106292003 ("Nurse")
  • http://snomed.info/sct#224571005 ("Nurse Practitioner")
  • http://snomed.info/sct#405277009 ("Resident")
  • http://snomed.info/sct#69280009 ("Specialist")
  • http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")

Language: en

Patient Information

  • linkId: patient_header
  • Answers:

Surname:*

  • linkId: patient_surname
  • Answers:

First Name:*

  • linkId: patient_firstname
  • Answers:

DOB:*

  • linkId: patient_date_of_birth
  • Answers:

Gender:*

HN PC:

  • linkId: patient_hc_pc
  • Max Length:: 2
  • Answers:

HN:

  • linkId: patient_hc_number
  • Max Length:: 10
  • Answers:

HN VC:

  • linkId: patient_hc_vc
  • Answers:

Address (Line 1):*

  • linkId: patient_address_line1
  • Answers:

Address (Line 2):

  • linkId: patient_address_line2
  • Answers:

City:*

  • linkId: patient_address_city
  • Answers:

Province:*

  • linkId: patient_address_province
  • Max Length:: 2
  • Answers:

Postal Code:*

  • linkId: patient_address_postalcode
  • Answers:

Mobile #:

  • linkId: patient_phone_mobile
  • Answers:

Home #:

  • linkId: patient_phone_home
  • Answers:

Business #:

  • linkId: patient_phone_business
  • Answers:

Email:

  • linkId: patient_email
  • Answers:

[Optional] Additional Patient Information

  • linkId: additionalinfo_header
  • Answers:

Sex assigned at birth:

Pronouns:

Other pronouns:*

  • linkId: additionalinfo_pronouns_other
  • Enable When: todo
  • Answers:

Preferred language:

Specify:*

  • linkId: additionalinfo_preferredlanguage_specify
  • Enable When: todo
  • Answers:

Translator required

  • linkId: additionalinfo_preferredlanguage_translatorrequired
  • Enable When: todo
  • Answers:
  • Answers: 1 option

Best method of contact:

Voicemails acceptable

  • linkId: additionalinfo_bestmethodofcontact_voicemails
  • Enable When: todo
  • Answers:
  • Answers: 1 option

Preferred name

Prefered name String

  • linkId: additionalinfo_preferredname
  • Enable When: todo
  • Answers:

Alternate contact

Name:*

  • linkId: additionalinfo_alternatecontact_name
  • Enable When: todo
  • Answers:

Alternate contact phone #:

  • linkId: additionalinfo_alternatecontact_phone
  • Enable When: todo
  • Answers:

Relationship:

  • linkId: additionalinfo_alternatecontact_relationship
  • Enable When: todo
  • Answers:

Is Alternate contact the appointment booking contact?:

  • linkId: additionalinfo_alternatecontact_bookingcontact
  • Enable When: todo
  • Answers:
  • Answers: 2 options

Unsafe contact persons (do not speak with)

Only speak with patient directly

  • linkId: additionalinfo_unsafecontacts_speakwithpatientdirectly
  • Enable When: todo
  • Answers:
  • Answers: 1 option

Do not speak with:

  • linkId: additionalinfo_unsafecontacts_donotspeakwith
  • Enable When: todo
  • Answers:

Accessibility concerns or disability

  • linkId: additionalinfo_accessibilityconcernsordisability_selectt
  • Answers:
  • Answers: 1 option

Accessibility concerns Options

  • linkId: additionalinfo_accessibilityconcernsordisability
  • Enable When: todo
  • Answers:
  • Answers: 4 options

Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)

Details of special considerations:*

  • linkId: additionalinfo_specialconsiderations
  • Enable When: todo
  • Answers:

Send copies of reports to additional providers

Name(s):*

  • linkId: additionalinfo_sendcopiestoadditionalproviders_names
  • Enable When: todo
  • Answers:

Contact information:*

  • linkId: additionalinfo_sendcopiestoadditionalproviders_contactinfo
  • Enable When: todo
  • Answers:

This is the Primary Care Provider

  • linkId: additionalinfo_sendcopiestoadditionalproviders_ispcp
  • Enable When: todo
  • Answers:
  • Answers: 1 option

Referral Details

  • linkId: 102173268919
  • Answers:

Triage Considerations

  • linkId: cardio_triagecons
  • Answers:

Requested Priority:*

Reason for urgent triage*

  • linkId: referral_requestedpriority_urgentreason
  • Enable When: todo
  • Answers:

Second Opinion

Reason for second opinion:

  • linkId: referral_secondopinion_reason
  • Enable When: todo
  • Answers:

Service(s) Requested Select all that apply:*

  • linkId: 695991571585
  • Answers:

HSCs Assigned:

  • Flags: icon
  • linkId: referralService
  • Answers:

Cardiac Testing

Exam(s) Requested

  • linkId: 660331267409
  • Enable When: todo
  • Answers:

24 Hour Ambulatory Blood Pressure Monitoring

Coronary Angiogram

Echocardiogram - Resting

sub Echocardiogram - Resting

  • linkId: 443484577720
  • Enable When: todo
  • Answers:

Echocardiogram (2D)

Echocardiogram with Contrast

Echocardiogram with Saline (Bubble)

Pediatric Echocardiogram

Transesophageal Echocardiogram (TEE)

Electrocardiogram (ECG)

Holter Monitoring

sub holter monitoring

  • linkId: 440449731882
  • Enable When: todo
  • Answers:

24 Hours

48 Hours

72 Hours

7 Days

14 Days

Loop / Event Monitor

Cardiovascular stress testing

Sub Stress Testing

  • linkId: 370275060390
  • Enable When: todo
  • Answers:

ECG - Exercise Stress Test

ECG - Dobutamine/Persantine Stress Test

Echocardiogram - Exercise Stress Test

Echocardiogram - Dobutamine/Persantine Stress Test

Nuclear Medicine

sub Nuclear Medicine

  • linkId: 222686221935
  • Enable When: todo
  • Answers:

MUGA - Resting

Cardiac Pyrophosphate

Myocardial perfusion scan

sub MIBI

  • linkId: 538288549138
  • Enable When: todo
  • Answers:

MIBI Scan - Exercise Stress Test

MIBI Scan - Dobutamine/Persantine Stress Test

Thallium Viability Test

Tilt Table Testing

Other

Specify*

  • linkId: cardiology_referral_services_cardiactesting_other_specify
  • Enable When: todo
  • Answers:

Cardiology Consultation

Concern(s) / Indication(s) Triggering Referral Select all that apply:*

  • linkId: 186952778859
  • Answers:

Arrhythmias or Palpitations

Cardiovascular Risk Assessment

Chest Pain or Angina

Congenital Heart Disease

Congestive Heart Failure

Coronary Artery Disease

Dyspnea

Hypertension

Murmur

Pericardial Disease

Peripheral Edema

Post-Myocardial Infarction

Pre-operative Consultation

Procedure Date (if known)

  • linkId: 873024527134
  • Enable When: todo
  • Answers:

Syncope

Valvular Heart Disease or Prosthetic Heart Valve

Other

Specify*

  • linkId: 720594942482
  • Enable When: todo
  • Answers:

Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations*

  • linkId: Descriptionofclinicalquestion
  • Answers:

Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP

  • linkId: cpp_header
  • Answers:

CPP attached separately (if not entered below)

Current Problem List:

  • linkId: cpp_currentprob
  • Enable When: todo
  • Answers:

Past Medical History:

  • linkId: cpp_pastmedicalhistory
  • Enable When: todo
  • Answers:

Current Medications :

  • linkId: cpp_currentmedications
  • Enable When: todo
  • Answers:

Family History:

  • linkId: cpp_familyhistory
  • Enable When: todo
  • Answers:

Allergies:

  • linkId: cpp_allergies
  • Enable When: todo
  • Answers:

Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.

  • linkId: preferredconsultlocation_header
  • Answers:

Preferred consultant or location

Please specify either a preferred consultant or location

  • linkId: preferredconsultlocation_specify
  • Enable When: todo
  • Answers:

Consultant:

  • linkId: preferredconsultlocation_consultant
  • Answers:

Location:

  • linkId: preferredconsultlocation_location
  • Answers:

Patient willing to travel for shorter wait time

Other considerations:

  • linkId: preferredconsultlocation_otherconsiderations
  • Answers:

Supporting Documentation Please attach all relevant laboratory and diagnostic investigations.

  • linkId: supportingdocumentation_header
  • Answers:

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

Add Attachments

  • linkId: supportingdocumentation_attachment
  • Answers:

Click here to provide feedback on this form

  • linkId: feedbacksurvey_cardiology
  • Answers:

Referrer's Information

  • linkId: referrer_header
  • Answers:

Site Name:

  • linkId: referrer_sitename
  • Answers:

Address (Line 1):*

  • linkId: referrer_address_line1
  • Answers:

Address (Line 2):

  • linkId: referrer_address_line2
  • Answers:

City:*

  • linkId: referrer_address_city
  • Answers:

Province:*

  • linkId: referrer_address_province
  • Max Length:: 2
  • Answers:

Postal Code:*

  • linkId: referrer_address_postalcode
  • Answers:

Phone #:

  • linkId: referrer_phone
  • Answers:

Fax #:

  • linkId: referrer_fax
  • Answers:

Billing Number:

  • linkId: referrer_billing
  • Answers:

Professional ID:

  • linkId: referrer_professionalid
  • Answers:

Signed:*

  • linkId: referrer_signature
  • Answers:

Role:

Language: en

LinkIDDescription & Constraintsdoco
.. patient_header Value Set:
... patient_surname Value Set:
... patient_firstname Value Set:
... patient_date_of_birth Value Set:
... patient_hc_pc Max Length: 2
Value Set:
.... patient_hc_number Max Length: 10
Value Set:
.... patient_hc_vc Value Set:
... patient_address_line1 Value Set:
.... patient_address_line2 Value Set:
.... patient_address_city Value Set:
.... patient_address_province Max Length: 2
Value Set:
.... patient_address_postalcode Value Set:
... patient_phone_mobile Value Set:
... patient_phone_home Value Set:
... patient_phone_business Value Set:
... patient_email Value Set:
.. additionalinfo_header Value Set:
... additionalinfo_sexassignedatbirth Value Set:
Options: 4 options
... additionalinfo_pronouns Value Set:
Options: 4 options
.... additionalinfo_pronouns_other Enable When: Not done yet
Value Set:
... additionalinfo_preferredlanguage Value Set:
Options: 3 options
.... additionalinfo_preferredlanguage_specify Enable When: Not done yet
Value Set:
.... additionalinfo_preferredlanguage_translatorrequired Enable When: Not done yet
Value Set:
Options: 1 option
... additionalinfo_bestmethodofcontact Value Set:
Options: 4 options
.... additionalinfo_bestmethodofcontact_voicemails Enable When: Not done yet
Value Set:
Options: 1 option
... additionalinfo_preferredname_select Value Set:
Options: 1 option
... additionalinfo_preferredname Enable When: Not done yet
Value Set:
... additionalinfo_alternatecontact_select Value Set:
Options: 1 option
... additionalinfo_alternatecontact_name Enable When: Not done yet
Value Set:
... additionalinfo_alternatecontact_phone Enable When: Not done yet
Value Set:
... additionalinfo_alternatecontact_relationship Enable When: Not done yet
Value Set:
... additionalinfo_alternatecontact_bookingcontact Enable When: Not done yet
Value Set:
Options: 2 options
... additionalinfo_unsafecontacts_select Value Set:
Options: 1 option
... additionalinfo_unsafecontacts_speakwithpatientdirectly Enable When: Not done yet
Value Set:
Options: 1 option
... additionalinfo_unsafecontacts_donotspeakwith Enable When: Not done yet
Value Set:
... additionalinfo_accessibilityconcernsordisability_selectt Value Set:
Options: 1 option
... additionalinfo_accessibilityconcernsordisability Enable When: Not done yet
Value Set:
Options: 4 options
... additionalinfo_specialconsiderations_select Value Set:
Options: 1 option
... additionalinfo_specialconsiderations Enable When: Not done yet
Value Set:
... additionalinfo_sendcopiestoadditionalproviders Value Set:
Options: 1 option
... additionalinfo_sendcopiestoadditionalproviders_names Enable When: Not done yet
Value Set:
.... additionalinfo_sendcopiestoadditionalproviders_contactinfo Enable When: Not done yet
Value Set:
.... additionalinfo_sendcopiestoadditionalproviders_ispcp Enable When: Not done yet
Value Set:
Options: 1 option
.. 102173268919 Value Set:
... cardio_triagecons Value Set:
.... referral_requestedpriority Value Set:
Options: 2 options
..... referral_requestedpriority_urgentreason Enable When: Not done yet
Value Set:
.... referral_secondopinion Value Set:
Options: 1 option
.... referral_secondopinion_reason Enable When: Not done yet
Value Set:
... 695991571585 Value Set:
.... referralService Value Set:
.... 223886162384 Value Set:
Options: 1 option
.... 660331267409 Enable When: Not done yet
Value Set:
..... 720409326878 Value Set:
Options: 1 option
..... 960455115596 Value Set:
Options: 1 option
..... 297634898828 Value Set:
Options: 1 option
..... 443484577720 Enable When: Not done yet
Value Set:
...... 165530569567 Value Set:
Options: 1 option
...... 286552421895 Value Set:
Options: 1 option
...... 910527687300 Value Set:
Options: 1 option
...... 657824763133 Value Set:
Options: 1 option
...... 992743200182 Value Set:
Options: 1 option
..... 894277763438 Value Set:
Options: 1 option
..... 279226023495 Value Set:
Options: 1 option
..... 440449731882 Enable When: Not done yet
Value Set:
...... 671328703851 Value Set:
Options: 1 option
...... 423992261841 Value Set:
Options: 1 option
...... 419924239187 Value Set:
Options: 1 option
...... 731054417270 Value Set:
Options: 1 option
...... 235876421044 Value Set:
Options: 1 option
..... 374742834400 Value Set:
Options: 1 option
..... 159161544747 Value Set:
Options: 1 option
..... 370275060390 Enable When: Not done yet
Value Set:
...... 814218498309 Value Set:
Options: 1 option
...... 307107493993 Value Set:
Options: 1 option
...... 805303414102 Value Set:
Options: 1 option
...... 193586908489 Value Set:
Options: 1 option
..... 918517139023 Value Set:
Options: 1 option
..... 222686221935 Enable When: Not done yet
Value Set:
...... 924189648184 Value Set:
Options: 1 option
...... 857163514910 Value Set:
Options: 1 option
...... 892165959617 Value Set:
Options: 1 option
...... 538288549138 Enable When: Not done yet
Value Set:
....... 373435981917 Value Set:
Options: 1 option
....... 434394942688 Value Set:
Options: 1 option
....... 913594478162 Value Set:
Options: 1 option
..... 992682216482 Value Set:
Options: 1 option
..... cardiology_referral_services_cardiactesting_other Value Set:
Options: 1 option
..... cardiology_referral_services_cardiactesting_other_specify Enable When: Not done yet
Value Set:
.... 785727177547 Value Set:
Options: 1 option
... 186952778859 Value Set:
.... 219569805461 Value Set:
Options: 1 option
.... 571934328499 Value Set:
Options: 1 option
.... 459737733395 Value Set:
Options: 1 option
.... 929919815516 Value Set:
Options: 1 option
.... 832263816528 Value Set:
Options: 1 option
.... 803760213460 Value Set:
Options: 1 option
.... 129767162379 Value Set:
Options: 1 option
.... 116150628533 Value Set:
Options: 1 option
.... 513825527027 Value Set:
Options: 1 option
.... 975075898688 Value Set:
Options: 1 option
.... 704148928571 Value Set:
Options: 1 option
.... 886489617115 Value Set:
Options: 1 option
.... 621745958993 Value Set:
Options: 1 option
.... 873024527134 Enable When: Not done yet
Value Set:
.... 197975129599 Value Set:
Options: 1 option
.... 675849150752 Value Set:
Options: 1 option
.... 721982740516 Value Set:
Options: 1 option
.... 720594942482 Enable When: Not done yet
Value Set:
... Descriptionofclinicalquestion Value Set:
.. cpp_header Value Set:
... cpp_separate Value Set:
Options: 1 option
... cpp_currentprob Enable When: Not done yet
Value Set:
... cpp_pastmedicalhistory Enable When: Not done yet
Value Set:
... cpp_currentmedications Enable When: Not done yet
Value Set:
... cpp_familyhistory Enable When: Not done yet
Value Set:
... cpp_allergies Enable When: Not done yet
Value Set:
.. preferredconsultlocation_header Value Set:
... preferredconsultlocation_selector Value Set:
Options: 1 option
... preferredconsultlocation_specify Enable When: Not done yet
Value Set:
.... preferredconsultlocation_consultant Value Set:
.... preferredconsultlocation_location Value Set:
... preferredconsultlocation_willingtotravel Value Set:
Options: 1 option
... preferredconsultlocation_otherconsiderations Value Set:
.. supportingdocumentation_header Value Set:
... supportingdocumentation_details Value Set:
Options: 1 option
.. supportingdocumentation_attachment Value Set:
.. feedbacksurvey_cardiology Value Set:
.. referrer_header Value Set:
... referrer_sitename Value Set:
... referrer_address_line1 Value Set:
.... referrer_address_line2 Value Set:
.... referrer_address_city Value Set:
.... referrer_address_province Max Length: 2
Value Set:
.... referrer_address_postalcode Value Set:
... referrer_phone Value Set:
... referrer_fax Value Set:
... referrer_billing Value Set:
... referrer_professionalid Value Set:
... referrer_signature Value Set:
... referrer_role Value Set:
Options: 9 options

doco Documentation for this format

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Try this questionnaire out:

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