1_Questionnaire-MINICOG.json

{
  "resourceType": "Questionnaire",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-render"
    ]
  },
  "id": "CIRG-MINICOG",
  "url": "http://www.cdc.gov/ncbddd/fasd/minicog",
  "name": "MINICOG",
  "identifier": [
    {
      "system": "http://hl7.org/fhir/uv/sdc/NamingSystem/questionnaire-ids",
      "value": "MINICOG"
    }
  ],
  "status": "draft",
  "title": "Mini Cognitive Assessment",
  "subjectType": [
    "Patient"
  ],
  "extension": [
    {
      "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-entryMode/",
      "valueCanonical": "#MiniCogLogicLibrary|1.0",
      "valueCode": "random"
    }
  ],
  "item": [
    {
      "linkId": "introduction",
      "type": "display",
      "_text": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
            "valueString": "<p style='font-size:1.3em'>The <b>Mini-Cog©</b> is a fast and simple screening test to help detect dementia in its early stages.<br/><br/>Please administer the Mini-Cog© questionnaire on paper to the patient and enter the results on the following page.<br/>These questions are to be answered by the <b>patient</b>.<br/>Link to the paper assessment is <a href='https://mini-cog.com/download-the-mini-cog-instrument/' target='_blank'>here</a>.</p>"
          }
        ]
      }
    },
    {
      "linkId": "minicog-question1",
      "type": "decimal",
      "text": "Word Recall (0-3 points)",
      "required": true
    },
    {
      "linkId": "minicog-question1-instruction",
      "type": "display",
      "readOnly": true,
      "_text": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
            "valueString": "<div class=\"instruction\">1 point for each word spontaneously recalled without cueing.</div><br/>"
          }
        ]
      }
    },
    {
      "linkId": "minicog-question2",
      "type": "decimal",
      "text": "Clock Draw (0 or 2 points)",
      "required": true
    },
    {
      "linkId": "minicog-question2-instruction",
      "type": "display",
      "readOnly": true,
      "_text": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
            "valueString": "<div class=\"instruction\">Normal clock = 2 points. A normal clock has all numbers placed in the correct sequence and approximately correct position (e.g., 12, 3, 6 and 9 are in anchor positions) with no missing or duplicate numbers. Hands are pointing to the 11 and 2 (11:10). Hand length is not scored. Inability or refusal to draw a clock (abnormal) = 0 points.</div><br/>"
          }
        ]
      }
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
          "valueExpression": {
            "language": "text/cql",
            "expression": "DisplayScoreFullMiniCog",
            "reference": "#MinicogLogicLibrary|1.0"
          }
        },
        {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression",
          "valueExpression": {
            "language": "text/cql",
            "expression": "ScoreFullMiniCog",
            "reference": "#MinicogLogicLibrary|1.0"
          }
        }
      ],
      "linkId": "minicog-total-score",
      "text": "Total Score (0 - 5 points)",
      "type": "decimal",
      "required": false
    },
    {
      "linkId": "minicog-total-score-explanation",
      "type": "display",
      "extension": [
        {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
          "valueExpression": {
            "language": "text/cql",
            "expression": "DisplayScoreFullMiniCog",
            "reference": "#MinicogLogicLibrary|1.0"
          }
        }
      ],
      "readOnly": true,
      "_text": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
            "valueString": "<div class=\"instruction\">Word Recall score + Clock Draw score</div>"
          }
        ]
      }
    },
    {
      "linkId": "minicog-questionnaire-footnote",
      "type": "display",
      "readOnly":true,
      "_text": {
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
            "valueString": "<div class=\"info\">A cut point of <3 on the Mini-Cog™ has been validated for dementia screening, but many individuals with clinically meaningful cognitive impairment will score higher. When greater sensitivity is desired, a cut point of <4 is recommended as it may indicate a need for further evaluation of cognitive status.</div>"
          }
        ]
      }
    }
  ]
}