US Core Implementation Guide
7.0.0-ballot - Ballot United States of America flag

This page is part of the US Core (v7.0.0-ballot: STU7 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 6.1.0. For a full list of available versions, see the Directory of published versions

Questionnaire: Questionnaire PRAPARE Example (Experimental)

Official URL: http://hl7.org/fhir/us/core/Questionnaire/prapare-example Version: 7.0.0-ballot
Standards status: Informative Computable Name: PRAPAREExample

Usage:Clinical Focus: SDOH

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License
Structure
LinkIdTextCardinalityTypeDescription & Constraintsdoco
.. PRAPAREExampleQuestionnairehttp://hl7.org/fhir/us/core/Questionnaire/prapare-example#7.0.0-ballot
... /93025-5Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]0..1group
.... /93043-8Personal characteristics0..1group
..... /93043-8/56051-6Do you consider yourself Hispanic/Latino?0..1choiceOptions: 3 options
..... /93043-8/32624-9Race0..*choiceOptions: 8 options
..... /93043-8/93035-4At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?0..1choiceOptions: 3 options
..... /93043-8/93034-7Have you been discharged from the armed forces of the United States?0..1choiceOptions: 3 options
..... /93043-8/54899-0Preferred language0..1choiceOptions: 3 options
.... /93042-0Family and home0..1group
..... /93042-0/63512-8How many people are living or staying at this address?0..1integer
..... /93042-0/71802-3Housing status0..1choiceOptions: 3 options
...... /93042-0/71802-3-helpDescribes patients living arrangement0..1display
..... /93042-0/93033-9Are you worried about losing your housing?0..1choiceOptions: 3 options
..... /93042-0/56799-0Address0..1string
.... /93041-2Money and resources0..1group
..... /93041-2/82589-3Highest level of educ0..1choiceOptions: 4 options
..... /93041-2/67875-5Employment status current0..1choiceOptions: 5 options
..... /93041-2/76437-3Primary insurance0..1choiceOptions: 7 options
..... /93041-2/63586-2What was your best estimate of the total income of all family members from all sources, before taxes, in last year?0..1decimal
..... /93041-2/93031-3In 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..*choiceOptions: 8 options
..... /93041-2/93030-5Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?0..*choiceOptions: 4 options
.... /93040-4Social and emotional health0..1group
..... /93040-4/93029-7How 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..1choiceOptions: 5 options
..... /93040-4/93038-8Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you?0..1choiceOptions: 6 options
.... /93039-6Optional additional questions0..1group
..... /93039-6/93028-9In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?0..1choiceOptions: 3 options
..... /93039-6/93027-1Are you a refugee?0..1choiceOptions: 3 options
..... /93039-6/93026-3Do you feel physically and emotionally safe where you currently live?0..1choiceOptions: 4 options
..... /93039-6/76501-6Within the last year, have you been afraid of your partner or ex-partner?0..1choiceOptions: 2 options

doco Documentation for this format

Option 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")