CMS ACCESS Model API
0.9.8 - draft US

This page is part of the ACCESS Model IG v0.9.8 DRAFT (v0.9.8: Releases Draft) based on FHIR (HL7® FHIR® Standard) R4. No current official version has been published yet. For a full list of available versions, see the Directory of published versions

Questionnaire:

Computable Name:

Profile: SDCBaseQuestionnaire version: 3.0.0

Structure
LinkIDTextCardinalityTypeFlagsDescription & Constraintsdoco
.. Questionnaire http://example.org/Questionnaire/OswestryDisabilityIndexQuestionnaire#0.9.7
... odi-1 Pain intensity 0..1 choice Value Set:
Options: 6 options
... odi-2 Personal care (washing, dressing, etc.) 0..1 choice Value Set:
Options: 6 options
... odi-3 Lifting 0..1 choice Value Set:
Options: 6 options
... odi-5 Sitting 0..1 choice Value Set:
Options: 6 options
... odi-6 Standing 0..1 choice Value Set:
Options: 6 options
... odi-7 Sleeping 0..1 choice Value Set:
Options: 6 options
... odi-8 Sex life (if applicable) 0..1 choice Value Set:
Options: 6 options
... odi-9 Social life 0..1 choice Value Set:
Options: 6 options
... odi-10 Traveling 0..1 choice Value Set:
Options: 6 options
... score Oswestry disability index score ODI 0..1 decimal iconicon Value Set:

doco Documentation for this format

Options Sets

Answer options for odi-1

  • I have no pain at the moment.
  • The pain is very mild at the moment.
  • The pain is moderate at the moment.
  • The pain is fairly severe at the moment.
  • The pain is very severe at the moment.
  • The pain is the worst imaginable at the moment.

Answer options for odi-2

  • I can look after myself normally without causing extra pain.
  • I can look after myself normally but it is very painful.
  • It is painful to look after myself and I am slow and careful.
  • I need some help but can manage most of my personal care.
  • I need help every day in most aspects of my personal care.
  • I do not get dressed, I wash with difficulty and stay in bed.

Answer options for odi-3

  • I can lift heavy weights without additional pain.
  • I can lift heavy weights but it gives additional pain.
  • Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed e.g. on a table.
  • Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.
  • I can lift very light weights.
  • I cannot lift or carry anything at all.

Answer options for odi-4

  • Pain does not prevent me walking any distance.
  • Pain prevents me from walking more than one mile.
  • Pain prevents me from walking more than a quarter of a mile.
  • Pain prevents me from walking more than 100 yards.
  • I can only walk using a stick or crutches.
  • I am in bed most of the time and have to crawl to the toilet.

Answer options for odi-5

  • I can sit in any chair as long as I like.
  • I can only sit in my favorite chair as long as I like.
  • Pain prevents me from sitting for more than one hour.
  • Pain prevents me from sitting for more than half an hour.
  • Pain prevents me from sitting for more than 10 minutes.
  • Pain prevents me from sitting at all.

Answer options for odi-6

  • I can stand as long as I want without additional pain.
  • I can stand as long as I want but it gives me additional pain.
  • Pain prevents me from standing for more than 1 hour.
  • Pain prevents me from standing for more than half an hour.
  • Pain prevents me from standing for more than 10 minutes.
  • Pain prevents me from standing at all.

Answer options for odi-7

  • My sleep is never interrupted by pain.
  • My sleep is occasionally interrupted by pain.
  • Because of pain I have less than 6 hours sleep.
  • Because of pain I have less than 4 hours sleep.
  • Because of pain I have less than 2 hours sleep.
  • Pain prevents me from sleeping at all.

Answer options for odi-8

  • My sex life is normal and causes no additional pain.
  • My sex life is normal but causes some additional pain.
  • My sex life is nearly normal but is very painful.
  • My sex life is severely restricted by pain.
  • My sex life is non existent because of pain.
  • Pain prevents me from having any sex life at all.

Answer options for odi-9

  • My social life is normal and causes me no additional pain.
  • My social life is normal but increases the degree of pain.
  • Pain has no significant effect on social life apart from limiting my more energetic interests e.g. sports, etc.
  • Pain has restricted my social life and I do not go out as often.
  • Pain has restricted social life to my home.
  • I have no social life because of pain.

Answer options for odi-10

  • I can travel anywhere without pain.
  • I can travel anywhere but it gives me additional pain.
  • Pain is bad but I am able to manage trips over two hours.
  • Pain restricts me to trips of less than one hour.
  • Pain restricts trips to short necessary journeys under 30 minutes.
  • Pain prevents traveling except to receive treatment.

Profile: SDCBaseQuestionnaire version: 3.0.0

Pain intensity

Personal care (washing, dressing, etc.)

Lifting

Walking

Sitting

Standing

Sleeping

Sex life (if applicable)

Social life

Traveling

Oswestry disability index score ODI

  • linkId: score
  • Answers:

Profile: SDCBaseQuestionnaire version: 3.0.0

LinkIDDescription & Constraintsdoco
.. odi-1 Value Set:
Options: 6 options
.. odi-2 Value Set:
Options: 6 options
.. odi-3 Value Set:
Options: 6 options
.. odi-4 Value Set:
Options: 6 options
.. odi-5 Value Set:
Options: 6 options
.. odi-6 Value Set:
Options: 6 options
.. odi-7 Value Set:
Options: 6 options
.. odi-8 Value Set:
Options: 6 options
.. odi-9 Value Set:
Options: 6 options
.. odi-10 Value Set:
Options: 6 options
.. score Value Set:

doco Documentation for this format

Test this Questionnaire

Try this questionnaire out:

Responses for this Questionnaire