FHIR Implementation Guide for NJSAMS


1.0.0 - release

NJSAMS - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Questionnaire: BioPsychoSocial Questionnaire

Official URL: https://fhir.njsams.rutgers.edu/NJSAMS-fhir/Questionnaire/BioPsychoQuestionnaire Version: 1.0.0
Draft as of 2022-08-31 Computable Name:

Generated Narrative: Questionnaire BioPsychoQuestionnaire

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. Questionnairehttps://fhir.njsams.rutgers.edu/NJSAMS-fhir/Questionnaire/BioPsychoQuestionnaire#1.0.0
... ClientIdentificationInformationnull0..1group
.... ClientIdentificationInformation.NickNameNickName0..1text
.... ClientIdentificationInformation.GenderAtBirthIs identified gender different from gender at birth? :0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... ClientIdentificationInformation.GenderOtherIf other Specify0..1text
.... ClientIdentificationInformation.IsPermAddressIs this a permanent address?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... ClientIdentificationInformation.CommentsClientInfoComments0..1text
... RaceEthnicityReligionSpiritualitynull0..1group
.... RaceEthnicityReligionSpirituality.RaceRace0..1text
.... RaceEthnicityReligionSpirituality.EthnicityEthnicity0..1text
.... RaceEthnicityReligionSpirituality.NationalOriginNationalOrigin:0..1text
.... RaceEthnicityReligionSpirituality.ImmigrationStatusImmigrationStatus:0..1text
.... RaceEthnicityReligionSpirituality.ExpRaceEthnicityDescribe if/how any of the above have impacted your identity or experience0..1text
.... RaceEthnicityReligionSpirituality.CommentsRaceEthnicityAdditional Comments:0..1text
.... RaceEthnicityReligionSpirituality.ReligionReligion0..1text
.... RaceEthnicityReligionSpirituality.IsSpritualAre you spiritual?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... RaceEthnicityReligionSpirituality.SpritualRoleIf Y, please describe how spirituality plays a role in your life0..1text
.... RaceEthnicityReligionSpirituality.AttendReligiousServicesDo you regularly attend a religious institution/religious or spiritual services?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... RaceEthnicityReligionSpirituality.ExpReligionDescribe if/how any of the above have impacted your identity or experience :0..1text
.... RaceEthnicityReligionSpirituality.CommentsReligionAdditional Comments:0..1text
... BioFamilyofOriginnull0..1group
.... BioFamilyofOrigin.TotalSiblingsHow many siblings do you have?0..1text
.... BioFamilyofOrigin.BirthOrderWhat is your birth order?0..1text
.... BioFamilyofOrigin.IsConflictWas/is there conflict in your family of origin?0..1text
.... BioFamilyofOrigin.IsCutOffAre you cut-off from any family members (ex. not talking to someone in the immediate family or members in your family not talking to each other?)0..1text
.... BioFamilyofOrigin.ACEScoreThis is your ACE Score Note: If YES the ACE score is 10..1integer
.... BioFamilyofOrigin.ACEQue1While you were growing up, during your first 18 years of life 1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioFamilyofOrigin.ACEQue22. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioFamilyofOrigin.BFOQue33. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Touch or fondle you or have you touch their body in a sexual way?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioFamilyofOrigin.BFOQue44. Did you often or very often feel That... No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioFamilyofOrigin.BFOQue55. Did you often or very often feel That... You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioFamilyofOrigin.BFOQue66. Were your parents ever separated or divorced?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioFamilyofOrigin.BFOQue77. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioFamilyofOrigin.BFOQue88. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioFamilyofOrigin.BFOQue99. Was a household member depressed or mentally ill, or did a household member attempt suicide?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioFamilyofOrigin.BFOQue1010. Did a household member go to prison?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioFamilyofOrigin.CommentsFamilyOriginAdditional Comments:0..1text
... EducationEmploymentnull0..1group
.... EducationEmployment.HighLevelEducationWhat is the highest level of education completed?0..1text
.... EducationEmployment.CurrentlySchoolAre you currently in school?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... EducationEmployment.AnySchoolPlanDo you plan to continue your education at some time in the future?0..1text
.... EducationEmployment.CurSchoolStoppingIf so, what are the circumstances that are stopping you from doing so at this time?0..1text
.... EducationEmployment.SchoolBehaviorWhen you were at school, did you have any difficulty learning/paying attention, behavior?0..1text
.... EducationEmployment.ExpSchoolHas anything related to school/education been a positive experience in the past or currently? Has it been a negative experience?0..1text
.... EducationEmployment.CommentsEducationAdditional Comments:0..1text
.... EducationEmployment.IsEmployedAre you currently employed?0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... EducationEmployment.TotalEmployedIf Y,how long0..1text
.... EducationEmployment.WhereEmployedIf Y,Where0..1text
.... EducationEmployment.EmpHistoryHistory of employment0..1text
.... EducationEmployment.EmpBarriersDescribe any current or past barriers to working0..1text
.... EducationEmployment.ExpEmployedDescribe if/how working has been positive/a support in the past or currently? Has it been a negative experience?0..1text
.... EducationEmployment.CommentsEmploymentAdditional Comments:0..1text
... BioMentalStatusnull0..1group
.... BioMentalStatus.AppearanceAppearance0..1open-choiceValue Set: NJSAMS BioPsycho appearance type
.... BioMentalStatus.AppearanceOtherIf Other, describe0..1text
.... BioMentalStatus.AttitudeAttitude0..1open-choiceValue Set: NJSAMS BioPsycho attitude type
.... BioMentalStatus.AttitudeOtherdescribe0..1text
.... BioMentalStatus.BehaviorBehavior0..1open-choiceValue Set: NJSAMS BioPsycho behavior type
.... BioMentalStatus.BehaviorOtherdescribe0..1text
.... BioMentalStatus.SpeechSpeech0..1open-choiceValue Set: NJSAMS BioPsycho speech type
.... BioMentalStatus.SpeechOtherdescribe0..1text
.... BioMentalStatus.AffectAffect0..*open-choiceValue Set: NJSAMS BioPsycho affect type
.... BioMentalStatus.AffectOtherIf Other, describe0..1text
.... BioMentalStatus.MoodMood0..*open-choiceValue Set: NJSAMS BioPsycho mood type
.... BioMentalStatus.MoodOtherIf Other, describe0..1text
.... BioMentalStatus.ThoughtProcessThought Process0..*open-choiceValue Set: NJSAMS BioPsycho thought process
.... BioMentalStatus.ThoughtProcOtherIf Other, describe0..1text
.... BioMentalStatus.ThoughtContentThought Content0..*open-choiceValue Set: NJSAMS BioPsycho thought content
.... BioMentalStatus.ThoughtContOtherIf Other, describe0..1text
.... BioMentalStatus.TC_SIdeationIf Suicidal ideation0..1choiceValue Set: NJSAMS BioPsycho Thought Content suicidal ideation
.... BioMentalStatus.TC_SIdeationAPIf Suicidal ideation is Active0..1choiceValue Set: NJSAMS BioPsycho Thought Content ideation active/passive
.... BioMentalStatus.TC_SIdeationA_PlanPlan:0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioMentalStatus.TC_SIdeationA_IntendIntent0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioMentalStatus.TC_SIdeationA_MeansMeans0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioMentalStatus.TC_HIdeationif Homicidal ideation0..1choiceValue Set: NJSAMS BioPsycho Thought Content homicidal ideation
.... BioMentalStatus.TC_HIdeationAPIf Homicidal ideation is Active0..1choiceValue Set: NJSAMS BioPsycho Thought Content ideation active/passive
.... BioMentalStatus.TC_HIdeationA_PlanPlan:0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioMentalStatus.TC_HIdeationA_IntendIntent0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioMentalStatus.TC_HIdeationA_MeansMeans0..1choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioMentalStatus.PerceptionPerception0..1open-choiceValue Set: NJSAMS BioPsycho perception type
.... BioMentalStatus.PerceptionOtherdescribe0..1text
.... BioMentalStatus.OrientationOrientation0..1open-choiceValue Set: NJSAMS BioPsycho orientation type
.... BioMentalStatus.OrientationOtherdescribe0..1text
.... BioMentalStatus.MemoryConcentrationMemory/Concentration0..1open-choiceValue Set: NJSAMS BioPsycho memory/concentration type
.... BioMentalStatus.MemoryConOtherIf Other, describe0..1text
.... BioMentalStatus.InsightJudgmentInsight/Judgment0..1open-choiceValue Set: NJSAMS BioPsycho insight/judgment type
.... BioMentalStatus.InsightJudgOtherdescribe0..1text
.... BioMentalStatus.CommentsMentalStatusAdditional Comments0..1text
... PhysicalHealthDiagnosisTreatmentHistorynull0..1group
.... PhysicalHealthDiagnosisTreatmentHistory.IsDiagnosisMentalSUD1. Have you been diagnosed with a mental health or substance use disorder?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... PhysicalHealthDiagnosisTreatmentHistory.DescDiagnosisMentalSUDIf yes please list/describe d/x:0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.IsTreatmentMentalSUD2. Have you been in treatment for a substance use or mental health disorder?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... PhysicalHealthDiagnosisTreatmentHistory.DescTreatmentMentalSUDIf yes please describe when and where if known and outcome0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.IsMedicationMentalSUD3. Have you been prescribed medication for SUD or mental health diagnosis?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... PhysicalHealthDiagnosisTreatmentHistory.DescMedicationMentalSUDIf yes, have you taken medication as prescribed and has it been helpful:0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.IsHospializedtMentalSUD4. Have you been hospitalized due to your SUD or mental health diagnosis?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... PhysicalHealthDiagnosisTreatmentHistory.ExpMentalSUD5. Have your experiences with treatment been helpful?0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.ExpNegativeMentalSUD6. Have you had negative experiences in treatment in the past?0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.CommentsDiagnosisTxHistoryAdditional Comments:0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.IsFamilyDiagnosisMentalSUD1. Has any one in your family been diagnosed with a SUD or mental health d/o?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... PhysicalHealthDiagnosisTreatmentHistory.DescFamilyDiagnosisMentalSUDIf yes, who and what was their diagnosis [if known]:0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.OutcomeFamilyDiagnosisMentalSUDWas this individual treated and what was the outcome:0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.CommentsFamilyDiagnosisTxHistoryAdditional Comments:0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.IsProbPhysicalHealth1. Do you have any problems with your health [diognoses or undiagnosed]?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... PhysicalHealthDiagnosisTreatmentHistory.DescProbPhysicalHealthIf yes, please list/describe:0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.IsInjury2. Have you ever had an injury?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... PhysicalHealthDiagnosisTreatmentHistory.DescInjuryIf yes, please list/describe:0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.DescMedicalIssue3. Has your substance use prevented you from seeking medical attention or otherwise addressing your medical issues?0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.IsMedMedicalIssue4. Have you been prescribed any medications for your medical issues?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... PhysicalHealthDiagnosisTreatmentHistory.DescMedMedicalIssueIf yes, are you taking these medications regularly/as prescribed?0..1text
.... PhysicalHealthDiagnosisTreatmentHistory.CommentsPhysicalHealthAdditional Comments:0..1text
... SocialRecreationalnull0..1group
.... SocialRecreational.IsSocialActivity1. Are you currently involved in any social/recreational activities, such as hobbies, sports, clubs, etc.?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... SocialRecreational.IssueSocialActivity2. Have you had difficulties participating in these activities due to your substance use?0..1text
.... SocialRecreational.DescSocialActivityIf yes, please list/describe your interests/activities0..1text
.... SocialRecreational.SupportSocialActivity3. Has your involvement in these activities been a support in your life in any way?0..1text
.... SocialRecreational.CommentsSocialAdditional Comments:0..1text
... BioPsychoSocialLegalnull0..1group
.... BioPsychoSocialLegal.IsLegalInvolveCurr1. Do you currently have any involvement with the legal system (charges pending, probation, parole, etc.)?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioPsychoSocialLegal.DescLegalInvolveCurrIf yes, please describe0..1text
.... BioPsychoSocialLegal.IsLegalInvolvePast2. Have you even been involved in the legal system in the past?0..1open-choiceValue Set: https://hl7.org/fhir/R4/valueset-example-yesnodontknow.html
.... BioPsychoSocialLegal.DescLegalInvolvePastIf yes, please describe0..1text
.... BioPsychoSocialLegal.BarrierLegalInvolve3. Has your involvement with the legal system been a barrier in your life in any way?0..1text
.... BioPsychoSocialLegal.SupportLegalInvolve4. Has your involvement been a support in your life in any way?0..1text
.... BioPsychoSocialLegal.CommentsLegalAdditional Comments:0..1text

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