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 |
@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:QuestionnaireResponse ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "Cardiology-MariaSantos"] ; #
fhir:language [ fhir:v "en"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<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] Additional Patient Information<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) / Indication(s) Triggering Referral</b><br/><i>Select all that apply:</i><br/><br/> <span style=\"display:none;\"><br/></span> Congestive Heart Failure<br/><span style=\"font-weight:bold;\">Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations<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 #: 416-555-5555<br/>Fax #: 416-555-5555<br/>Billing Number: 55554<br/>Professional ID: 55555<br/>Signed: Dr. Sean Sender<br/>Role: Family Physician</div>"^^rdf:XMLLiteral ]
] ; #
fhir:questionnaire [
fhir:v "http://hl7.org/fhir/uv/sdc/Questionnaire/CardiologyForm"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/uv/sdc/Questionnaire/CardiologyForm>
] ; #
fhir:status [ fhir:v "completed"] ; #
fhir:subject [
fhir:l fhir:Patient/pat-53234 ;
fhir:reference [ fhir:v "Patient/pat-53234" ] ;
fhir:display [ fhir:v "MOMO ABBAS" ]
] ; #
fhir:authored [ fhir:v "2026-03-12T22:51:31.735Z"^^xsd:dateTime] ; #
fhir:author [
fhir:l fhir:Practitioner/smart-Practitioner-71482713 ;
fhir:reference [ fhir:v "Practitioner/smart-Practitioner-71482713" ] ;
fhir:type [
fhir:v "Practitioner"^^xsd:anyURI ;
fhir:l fhir:Practitioner ] ;
fhir:display [ fhir:v "Susan Clark" ]
] ; #
fhir:item ( [
fhir:linkId [ fhir:v "patient_header" ] ;
fhir:text [ fhir:v "Patient Information" ] ;
( fhir:item [
fhir:linkId [ fhir:v "patient_surname" ] ;
fhir:text [ fhir:v "Surname:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Santos" ] ] ) ] [
fhir:linkId [ fhir:v "patient_firstname" ] ;
fhir:text [ fhir:v "First Name:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Maria" ] ] ) ] [
fhir:linkId [ fhir:v "patient_date_of_birth" ] ;
fhir:text [ fhir:v "DOB:" ] ;
( fhir:answer [
fhir:value [
a fhir:Date ;
fhir:v "1948-05-19"^^xsd:date ] ] ) ] [
fhir:linkId [ fhir:v "patient_gender" ] ;
fhir:text [ fhir:v "Gender:" ] ;
( fhir:answer [
fhir:value [
a fhir:Coding ;
fhir:system [
fhir:v "http://hl7.org/fhir/administrative-gender"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/administrative-gender> ] ;
fhir:code [ fhir:v "female" ] ;
fhir:display [ fhir:v "Female" ] ] ] ) ] [
fhir:linkId [ fhir:v "patient_hc_pc" ] ;
fhir:text [ fhir:v "HN PC:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "ON" ] ;
( fhir:item [
fhir:linkId [ fhir:v "patient_hc_number" ] ;
fhir:text [ fhir:v "HN:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "7413582609" ] ] ) ] [
fhir:linkId [ fhir:v "patient_hc_vc" ] ;
fhir:text [ fhir:v "HN VC:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "TC" ] ] ) ] ) ] ) ] [
fhir:linkId [ fhir:v "patient_address_line1" ] ;
fhir:text [ fhir:v "Address (Line 1):" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "85 King St S" ] ;
( fhir:item [
fhir:linkId [ fhir:v "patient_address_line2" ] ;
fhir:text [ fhir:v "Address (Line 2):" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Unit 302" ] ] ) ] [
fhir:linkId [ fhir:v "patient_address_city" ] ;
fhir:text [ fhir:v "City:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Waterloo" ] ] ) ] [
fhir:linkId [ fhir:v "patient_address_province" ] ;
fhir:text [ fhir:v "Province:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "ON" ] ] ) ] [
fhir:linkId [ fhir:v "patient_address_postalcode" ] ;
fhir:text [ fhir:v "Postal Code:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "N2J 1P2" ] ] ) ] ) ] ) ] [
fhir:linkId [ fhir:v "patient_phone_mobile" ] ;
fhir:text [ fhir:v "Mobile #:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "519-555-0362" ] ] ) ] [
fhir:linkId [ fhir:v "patient_phone_home" ] ;
fhir:text [ fhir:v "Home #:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "519-555-0198" ] ] ) ] [
fhir:linkId [ fhir:v "patient_email" ] ;
fhir:text [ fhir:v "Email:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "maria.santos@example.com" ] ] ) ] )
] [
fhir:linkId [ fhir:v "additionalinfo_header" ] ;
fhir:text [ fhir:v "[Optional] Additional Patient Information" ] ;
( fhir:item [
fhir:linkId [ fhir:v "additionalinfo_sexassignedatbirth" ] ;
fhir:text [ fhir:v "Sex assigned at birth:" ] ;
( fhir:answer [
fhir:value [
a fhir:Coding, loinc:LA3-6 ;
fhir:system [
fhir:v "http://loinc.org"^^xsd:anyURI ;
fhir:l <http://loinc.org> ] ;
fhir:code [ fhir:v "LA3-6" ] ;
fhir:display [ fhir:v "Female" ] ] ] ) ] [
fhir:linkId [ fhir:v "additionalinfo_pronouns" ] ;
fhir:text [ fhir:v "Pronouns:" ] ;
( fhir:answer [
fhir:value [
a fhir:Coding, loinc:LA29519-8 ;
fhir:system [
fhir:v "http://loinc.org"^^xsd:anyURI ;
fhir:l <http://loinc.org> ] ;
fhir:code [ fhir:v "LA29519-8" ] ;
fhir:display [ fhir:v "She/Her" ] ] ] ) ] [
fhir:linkId [ fhir:v "additionalinfo_preferredlanguage" ] ;
fhir:text [ fhir:v "Preferred language:" ] ;
( fhir:answer [
fhir:value [
a fhir:Coding ;
fhir:system [
fhir:v "urn:ietf:bcp:47"^^xsd:anyURI ;
fhir:l <urn:ietf:bcp:47> ] ;
fhir:code [ fhir:v "en" ] ;
fhir:display [ fhir:v "English" ] ] ] ) ] [
fhir:linkId [ fhir:v "additionalinfo_bestmethodofcontact" ] ;
fhir:text [ fhir:v "Best method of contact:" ] ;
( fhir:answer [
fhir:value [
a fhir:Coding ;
fhir:system [
fhir:v "http://hl7.org/fhir/contact-point-use"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/contact-point-use> ] ;
fhir:code [ fhir:v "home" ] ;
fhir:display [ fhir:v "Home" ] ] ] ) ] [
fhir:linkId [ fhir:v "additionalinfo_accessibilityconcernsordisability_selectt" ] ;
fhir:text [ fhir:v "Accessibility concerns or disability" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Accessibility concerns or disability" ] ] ) ] [
fhir:linkId [ fhir:v "additionalinfo_accessibilityconcernsordisability" ] ;
fhir:text [ fhir:v "Accessibility concerns Options" ] ;
( fhir:answer [
fhir:value [
a fhir:Coding, sct:105503008 ;
fhir:system [
fhir:v "http://snomed.info/sct"^^xsd:anyURI ;
fhir:l <http://snomed.info/sct> ] ;
fhir:code [ fhir:v "105503008" ] ;
fhir:display [ fhir:v "Wheelchair" ] ] ] [
fhir:value [
a fhir:Coding, sct:15188001 ;
fhir:system [
fhir:v "http://snomed.info/sct"^^xsd:anyURI ;
fhir:l <http://snomed.info/sct> ] ;
fhir:code [ fhir:v "15188001" ] ;
fhir:display [ fhir:v "Hearing impaired" ] ] ] ) ] )
] [
fhir:linkId [ fhir:v "102173268919" ] ;
fhir:text [ fhir:v "Referral Details" ] ;
( fhir:item [
fhir:linkId [ fhir:v "cardio_triagecons" ] ;
fhir:text [ fhir:v "Triage Considerations" ] ;
( fhir:item [
fhir:linkId [ fhir:v "referral_requestedpriority" ] ;
fhir:text [ fhir:v "Requested Priority:" ] ;
( fhir:answer [
fhir:value [
a fhir:Coding ;
fhir:system [
fhir:v "http://hl7.org/fhir/request-priority"^^xsd:anyURI ;
fhir:l <http://hl7.org/fhir/request-priority> ] ;
fhir:code [ fhir:v "routine" ] ;
fhir:display [ fhir:v "Routine" ] ] ] ) ] ) ] [
fhir:linkId [ fhir:v "695991571585" ] ;
fhir:text [ fhir:v "Service(s) Requested Select all that apply:" ] ;
( fhir:item [
fhir:linkId [ fhir:v "785727177547" ] ;
fhir:text [ fhir:v "Cardiology Consultation" ] ;
( fhir:answer [
fhir:value [
a fhir:Coding ;
fhir:system [
fhir:v "http://example.com/CodeSystem/standardized-referral-form-codes"^^xsd:anyURI ;
fhir:l <http://example.com/CodeSystem/standardized-referral-form-codes> ] ;
fhir:code [ fhir:v "20002" ] ;
fhir:display [ fhir:v "Cardiology Consultation" ] ] ] ) ] ) ] [
fhir:linkId [ fhir:v "186952778859" ] ;
fhir:text [ fhir:v "Concern(s) / Indication(s) Triggering Referral Select all that apply:" ] ;
( fhir:item [
fhir:linkId [ fhir:v "832263816528" ] ;
fhir:text [ fhir:v "Congestive Heart Failure" ] ;
( fhir:answer [
fhir:value [
a fhir:Coding ;
fhir:system [
fhir:v "http://example.com/CodeSystem/standardized-referral-form-codes"^^xsd:anyURI ;
fhir:l <http://example.com/CodeSystem/standardized-referral-form-codes> ] ;
fhir:code [ fhir:v "20036" ] ;
fhir:display [ fhir:v "Congestive Heart Failure" ] ] ] ) ] ) ] [
fhir:linkId [ fhir:v "Descriptionofclinicalquestion" ] ;
fhir:text [ fhir:v "Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "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." ] ] ) ] )
] [
fhir:linkId [ fhir:v "cpp_header" ] ;
fhir:text [ fhir:v "Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP" ] ;
( fhir:item [
fhir:linkId [ fhir:v "cpp_currentprob" ] ;
fhir:text [ fhir:v "Current Problem List:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Suspected CHF (onset Jan 2026)\nHypertension\nType 2 diabetes" ] ] ) ] [
fhir:linkId [ fhir:v "cpp_pastmedicalhistory" ] ;
fhir:text [ fhir:v "Past Medical History:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Left hip replacement (2020)\nType 2 diabetes (2012)" ] ] ) ] [
fhir:linkId [ fhir:v "cpp_currentmedications" ] ;
fhir:text [ fhir:v "Current Medications :" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Furosemide 20 mg PO daily\nPerindopril 4 mg PO daily\nMetformin 500 mg PO BID\nEmpagliflozin 10 mg PO daily" ] ] ) ] [
fhir:linkId [ fhir:v "cpp_familyhistory" ] ;
fhir:text [ fhir:v "Family History:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Mother: CHF, deceased age 80" ] ] ) ] [
fhir:linkId [ fhir:v "cpp_allergies" ] ;
fhir:text [ fhir:v "Allergies:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "NKDA" ] ] ) ] )
] [
fhir:linkId [ fhir:v "referrer_header" ] ;
fhir:text [ fhir:v "Referrer's Information" ] ;
( fhir:item [
fhir:linkId [ fhir:v "referrer_sitename" ] ;
fhir:text [ fhir:v "Site Name:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Amplify Primary Care" ] ] ) ] [
fhir:linkId [ fhir:v "referrer_address_line1" ] ;
fhir:text [ fhir:v "Address (Line 1):" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "10248 Yonge St" ] ;
( fhir:item [
fhir:linkId [ fhir:v "referrer_address_line2" ] ;
fhir:text [ fhir:v "Address (Line 2):" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Suite 515" ] ] ) ] [
fhir:linkId [ fhir:v "referrer_address_city" ] ;
fhir:text [ fhir:v "City:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Richmond Hill" ] ] ) ] [
fhir:linkId [ fhir:v "referrer_address_province" ] ;
fhir:text [ fhir:v "Province:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "ON" ] ] ) ] [
fhir:linkId [ fhir:v "referrer_address_postalcode" ] ;
fhir:text [ fhir:v "Postal Code:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "L4C 5K9" ] ] ) ] ) ] ) ] [
fhir:linkId [ fhir:v "referrer_phone" ] ;
fhir:text [ fhir:v "Phone #:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v " 416-555-5555" ] ] ) ] [
fhir:linkId [ fhir:v "referrer_fax" ] ;
fhir:text [ fhir:v "Fax #:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v " 416-555-5555" ] ] ) ] [
fhir:linkId [ fhir:v "referrer_billing" ] ;
fhir:text [ fhir:v "Billing Number:" ] ;
( fhir:answer [
fhir:value [
a fhir:Integer ;
fhir:v 55554 ] ] ) ] [
fhir:linkId [ fhir:v "referrer_professionalid" ] ;
fhir:text [ fhir:v "Professional ID:" ] ;
( fhir:answer [
fhir:value [
a fhir:Integer ;
fhir:v 55555 ] ] ) ] [
fhir:linkId [ fhir:v "referrer_signature" ] ;
fhir:text [ fhir:v "Signed:" ] ;
( fhir:answer [
fhir:value [
a fhir:String ;
fhir:v "Dr. Sean Sender" ] ] ) ] [
fhir:linkId [ fhir:v "referrer_role" ] ;
fhir:text [ fhir:v "Role:" ] ;
( fhir:answer [
fhir:value [
a fhir:Coding, sct:62247001 ;
fhir:system [
fhir:v "http://snomed.info/sct"^^xsd:anyURI ;
fhir:l <http://snomed.info/sct> ] ;
fhir:code [ fhir:v "62247001" ] ;
fhir:display [ fhir:v "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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