Structured Data Capture
4.0.0-ci-build - STU 4 CI-build
Structured Data Capture
4.0.0-ci-build - STU 4 CI-build
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
| Page standards status: Informative |
{
"resourceType" : "QuestionnaireResponse",
"id" : "Cardiology-MariaSantos",
"language" : "en",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Patient Information<br/> Surname: Santos<br/>First Name: Maria<br/>DOB: 1948-05-19<br/>Gender: Female<br/>HN PC: ON<br/>Address (Line 1): 85 King St S<br/>Mobile #: 519-555-0362<br/>Home #: 519-555-0198<br/>Email: maria.santos@example.com<br/>[Optional]\u00a0Additional\u00a0Patient\u00a0Information<br/><br/> Sex assigned at birth: Female<br/>Pronouns: She/HerThey/Them<br/>Preferred language: English<br/>Best method of contact: Home<br/><span style=\"display:none;\"><br/></span> Accessibility concerns or disability<br/><br/>Wheelchair; Hearing impaired<br/><br/>Referral Details<br/> Triage Considerations Requested Priority: <br/><span style=\"font-weight:bold;color:#EE6B00;\">Routine<br/></span><br/>Service(s) Requested <span style=\"display:none;\"><br/></span> Cardiology Consultation<br/><b>Concern(s)\u00a0/\u00a0Indication(s)\u00a0Triggering\u00a0Referral</b><br/><i>Select\u00a0all\u00a0that\u00a0apply:</i><br/><br/> <span style=\"display:none;\"><br/></span> Congestive Heart Failure<br/><span style=\"font-weight:bold;\">Clinical\u00a0Question\u00a0/\u00a0Goal(s)\u00a0of\u00a0Referral\u00a0with\u00a0Relevant\u00a0History,\u00a0Management\u00a0and\u00a0Investigations<br/></span> 77F, progressive exertional dyspnea and bilateral ankle edema x 2 months. BNP elevated at 480. CXR shows mild cardiomegaly. On furosemide 20mg with partial response. Please assess and advise on HF management.<br/>Cumulative Patient Profile<br/><br/><i>Please delete any sensitive information you do not intend to share from the CPP</i><br/> Current Problem List: Suspected CHF (onset Jan 2026)\nHypertension\nType 2 diabetes<br/>Past Medical History: Left hip replacement (2020)\nType 2 diabetes (2012)<br/>Current Medications : Furosemide 20 mg PO daily\nPerindopril 4 mg PO daily\nMetformin 500 mg PO BID\nEmpagliflozin 10 mg PO daily<br/>Family History: Mother: CHF, deceased age 80<br/>Allergies: NKDA<br/>Referrer's Information<br/> Site Name: Amplify Primary Care<br/>Address (Line 1): 10248 Yonge St<br/>Phone #: \t416-555-5555<br/>Fax #: \t416-555-5555<br/>Billing Number: 55554<br/>Professional ID: 55555<br/>Signed: Dr. Sean Sender<br/>Role: Family Physician</div>"
},
"questionnaire" : "http://hl7.org/fhir/uv/sdc/Questionnaire/CardiologyForm",
"status" : "completed",
"subject" : {
"reference" : "Patient/pat-53234",
"display" : "MOMO ABBAS"
},
"authored" : "2026-03-12T22:51:31.735Z",
"author" : {
"reference" : "Practitioner/smart-Practitioner-71482713",
"type" : "Practitioner",
"display" : "Susan Clark"
},
"item" : [
{
"linkId" : "patient_header",
"text" : "Patient Information",
"item" : [
{
"linkId" : "patient_surname",
"text" : "Surname:",
"answer" : [
{
"valueString" : "Santos"
}
]
},
{
"linkId" : "patient_firstname",
"text" : "First Name:",
"answer" : [
{
"valueString" : "Maria"
}
]
},
{
"linkId" : "patient_date_of_birth",
"text" : "DOB:",
"answer" : [
{
"valueDate" : "1948-05-19"
}
]
},
{
"linkId" : "patient_gender",
"text" : "Gender:",
"answer" : [
{
"valueCoding" : {
"system" : "http://hl7.org/fhir/administrative-gender",
"code" : "female",
"display" : "Female"
}
}
]
},
{
"linkId" : "patient_hc_pc",
"text" : "HN PC:",
"answer" : [
{
"valueString" : "ON",
"item" : [
{
"linkId" : "patient_hc_number",
"text" : "HN:",
"answer" : [
{
"valueString" : "7413582609"
}
]
},
{
"linkId" : "patient_hc_vc",
"text" : "HN VC:",
"answer" : [
{
"valueString" : "TC"
}
]
}
]
}
]
},
{
"linkId" : "patient_address_line1",
"text" : "Address (Line 1):",
"answer" : [
{
"valueString" : "85 King St S",
"item" : [
{
"linkId" : "patient_address_line2",
"text" : "Address (Line 2):",
"answer" : [
{
"valueString" : "Unit 302"
}
]
},
{
"linkId" : "patient_address_city",
"text" : "City:",
"answer" : [
{
"valueString" : "Waterloo"
}
]
},
{
"linkId" : "patient_address_province",
"text" : "Province:",
"answer" : [
{
"valueString" : "ON"
}
]
},
{
"linkId" : "patient_address_postalcode",
"text" : "Postal Code:",
"answer" : [
{
"valueString" : "N2J 1P2"
}
]
}
]
}
]
},
{
"linkId" : "patient_phone_mobile",
"text" : "Mobile #:",
"answer" : [
{
"valueString" : "519-555-0362"
}
]
},
{
"linkId" : "patient_phone_home",
"text" : "Home #:",
"answer" : [
{
"valueString" : "519-555-0198"
}
]
},
{
"linkId" : "patient_email",
"text" : "Email:",
"answer" : [
{
"valueString" : "maria.santos@example.com"
}
]
}
]
},
{
"linkId" : "additionalinfo_header",
"text" : "[Optional] Additional Patient Information",
"item" : [
{
"linkId" : "additionalinfo_sexassignedatbirth",
"text" : "Sex assigned at birth:",
"answer" : [
{
"valueCoding" : {
"system" : "http://loinc.org",
"code" : "LA3-6",
"display" : "Female"
}
}
]
},
{
"linkId" : "additionalinfo_pronouns",
"text" : "Pronouns:",
"answer" : [
{
"valueCoding" : {
"system" : "http://loinc.org",
"code" : "LA29519-8",
"display" : "She/Her"
}
}
]
},
{
"linkId" : "additionalinfo_preferredlanguage",
"text" : "Preferred language:",
"answer" : [
{
"valueCoding" : {
"system" : "urn:ietf:bcp:47",
"code" : "en",
"display" : "English"
}
}
]
},
{
"linkId" : "additionalinfo_bestmethodofcontact",
"text" : "Best method of contact:",
"answer" : [
{
"valueCoding" : {
"system" : "http://hl7.org/fhir/contact-point-use",
"code" : "home",
"display" : "Home"
}
}
]
},
{
"linkId" : "additionalinfo_accessibilityconcernsordisability_selectt",
"text" : "Accessibility concerns or disability",
"answer" : [
{
"valueString" : "Accessibility concerns or disability"
}
]
},
{
"linkId" : "additionalinfo_accessibilityconcernsordisability",
"text" : "Accessibility concerns Options",
"answer" : [
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "105503008",
"display" : "Wheelchair"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "15188001",
"display" : "Hearing impaired"
}
}
]
}
]
},
{
"linkId" : "102173268919",
"text" : "Referral Details",
"item" : [
{
"linkId" : "cardio_triagecons",
"text" : "Triage Considerations",
"item" : [
{
"linkId" : "referral_requestedpriority",
"text" : "Requested Priority:",
"answer" : [
{
"valueCoding" : {
"system" : "http://hl7.org/fhir/request-priority",
"code" : "routine",
"display" : "Routine"
}
}
]
}
]
},
{
"linkId" : "695991571585",
"text" : "Service(s) Requested Select all that apply:",
"item" : [
{
"linkId" : "785727177547",
"text" : "Cardiology Consultation",
"answer" : [
{
"valueCoding" : {
"system" : "http://example.com/CodeSystem/standardized-referral-form-codes",
"code" : "20002",
"display" : "Cardiology Consultation"
}
}
]
}
]
},
{
"linkId" : "186952778859",
"text" : "Concern(s) / Indication(s) Triggering Referral Select all that apply:",
"item" : [
{
"linkId" : "832263816528",
"text" : "Congestive Heart Failure",
"answer" : [
{
"valueCoding" : {
"system" : "http://example.com/CodeSystem/standardized-referral-form-codes",
"code" : "20036",
"display" : "Congestive Heart Failure"
}
}
]
}
]
},
{
"linkId" : "Descriptionofclinicalquestion",
"text" : "Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations",
"answer" : [
{
"valueString" : "77F, progressive exertional dyspnea and bilateral ankle edema x 2 months. BNP elevated at 480. CXR shows mild cardiomegaly. On furosemide 20mg with partial response. Please assess and advise on HF management."
}
]
}
]
},
{
"linkId" : "cpp_header",
"text" : "Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP",
"item" : [
{
"linkId" : "cpp_currentprob",
"text" : "Current Problem List:",
"answer" : [
{
"valueString" : "Suspected CHF (onset Jan 2026)\nHypertension\nType 2 diabetes"
}
]
},
{
"linkId" : "cpp_pastmedicalhistory",
"text" : "Past Medical History:",
"answer" : [
{
"valueString" : "Left hip replacement (2020)\nType 2 diabetes (2012)"
}
]
},
{
"linkId" : "cpp_currentmedications",
"text" : "Current Medications :",
"answer" : [
{
"valueString" : "Furosemide 20 mg PO daily\nPerindopril 4 mg PO daily\nMetformin 500 mg PO BID\nEmpagliflozin 10 mg PO daily"
}
]
},
{
"linkId" : "cpp_familyhistory",
"text" : "Family History:",
"answer" : [
{
"valueString" : "Mother: CHF, deceased age 80"
}
]
},
{
"linkId" : "cpp_allergies",
"text" : "Allergies:",
"answer" : [
{
"valueString" : "NKDA"
}
]
}
]
},
{
"linkId" : "referrer_header",
"text" : "Referrer's Information",
"item" : [
{
"linkId" : "referrer_sitename",
"text" : "Site Name:",
"answer" : [
{
"valueString" : "Amplify Primary Care"
}
]
},
{
"linkId" : "referrer_address_line1",
"text" : "Address (Line 1):",
"answer" : [
{
"valueString" : "10248 Yonge St",
"item" : [
{
"linkId" : "referrer_address_line2",
"text" : "Address (Line 2):",
"answer" : [
{
"valueString" : "Suite 515"
}
]
},
{
"linkId" : "referrer_address_city",
"text" : "City:",
"answer" : [
{
"valueString" : "Richmond Hill"
}
]
},
{
"linkId" : "referrer_address_province",
"text" : "Province:",
"answer" : [
{
"valueString" : "ON"
}
]
},
{
"linkId" : "referrer_address_postalcode",
"text" : "Postal Code:",
"answer" : [
{
"valueString" : "L4C 5K9"
}
]
}
]
}
]
},
{
"linkId" : "referrer_phone",
"text" : "Phone #:",
"answer" : [
{
"valueString" : "\t416-555-5555"
}
]
},
{
"linkId" : "referrer_fax",
"text" : "Fax #:",
"answer" : [
{
"valueString" : "\t416-555-5555"
}
]
},
{
"linkId" : "referrer_billing",
"text" : "Billing Number:",
"answer" : [
{
"valueInteger" : 55554
}
]
},
{
"linkId" : "referrer_professionalid",
"text" : "Professional ID:",
"answer" : [
{
"valueInteger" : 55555
}
]
},
{
"linkId" : "referrer_signature",
"text" : "Signed:",
"answer" : [
{
"valueString" : "Dr. Sean Sender"
}
]
},
{
"linkId" : "referrer_role",
"text" : "Role:",
"answer" : [
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "62247001",
"display" : "Family Physician"
}
}
]
}
]
}
]
}
IG © 2022+ HL7 International / FHIR Infrastructure.
Package hl7.fhir.uv.sdc#4.0.0-ci-build based on FHIR 4.0.1.
Generated
2026-06-11
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