Integreo_FAITH.be_Patient_Questionnaire (Integreo_FAITH.be_Patient_Questionnaire)
- Status: inactive
- How to create a CSV file for this data collection?
- Start date: 11/10/2019
- End date creation: 12/08/2024
- End date submission: 12/08/2024
- End date comments: 12/08/2024
1 Patient identification
Section help
Dear patient Thank you for taking the time to respond to this questionnaire. You are part of an integrated care project and have given permission to be contacted for a few questions regarding your health and the care you received. These questions will allow us to get to know how you experience your health and the care you receive. Your answers will be processed in a coded way. This means we will link your answers with other health data we have about you, without being able to identify you. Your care givers are not able to see your individual answers. We ask you to answer all questions truthfully. There are no right or wrong answers. The survey takes about 5 minutes to complete. Thank you again for your cooperation!
National registry ID of the patient
Help
Please encode a social security identification number (SSIN). Please note that the patient ID is always pseudonymised before being transferred to Healthdata.
Technical specs
CSV column name:
patient_id
Required:
true
Mapping of the clinical building blocks (indicative only)
Concept:
be.en.hd.Patient
Data element:
PatientIdentificationNumber
Validation
The validity of the national register number is checked with the mod97 check.
Fields
Section help
Please encode a social security identification number (SSIN). Please note that the patient ID is always pseudonymised before being transferred to Healthdata.
Internal patient ID
Help
This field can be used to enter an internal ID or reference number. It is available for internal use only and is not transferred to Healthdata. If there is an integration between HD4DP and your organisation's patient administration system, additional patient identification information such as date of birth, sex and SSIN can be automatically enriched based on this internal patient ID. Please do not encode the social security identification number (SSIN) in this field. The SSIN must be encoded in the field 'National registry ID of the patient'.
Technical specs
CSV column name:
patient_id|internal_patient_id
Only when:
Required:
false
Generated
Help
The patient_id|generated column can be set to 'TRUE' for an automatically generated patient_id.This column should only be added in case the patient_id is empty. If the column is set to 'TRUE', a patient_id is automatically generated based on the name, first name, date of birth and sex of the patient.
Technical specs
CSV column name:
patient_id|generated
Required:
false
Options
| Label | Value |
| Yes | TRUE |
| No | FALSE |
Name
Help
The name of the patient is never transferred to Healthdata and is available for your information only.
Technical specs
CSV column name:
patient_id|name
Length:
50
Only when:
Required:
false
Mapping of the clinical building blocks (indicative only)
Concept:
be.en.hd.Patient
Data element:
LastName
First name
Help
The first name of the patient is never transferred and is available for your information only.
Technical specs
CSV column name:
patient_id|first_name
Length:
50
Only when:
Required:
false
Mapping of the clinical building blocks (indicative only)
Concept:
be.en.hd.Patient
Data element:
FirstNames
Date of birth
Technical specs
Format:
DD/MM/YYYY
CSV column name:
patient_id|date_of_birth
Only when:
Required:
false
Mapping of the clinical building blocks (indicative only)
Concept:
be.en.hd.Patient
Data element:
DateOfBirth
Sex
Technical specs
CSV column name:
patient_id|sex
Only when:
Required:
false
Options
| Label | Value |
| Female | F |
| Male | M |
| Unkown | U |
Mapping of the clinical building blocks (indicative only)
Concept:
be.en.hd.Patient
Data element:
Gender
Place of residence
Technical specs
CSV column name:
patient_id|place_of_residence
Length:
5
Reference list:
POSTAL_CODE
Only when:
Required:
false
Mapping of the clinical building blocks (indicative only)
Concept:
be.en.hd.Patient
Data element:
Postcode
Deceased?
Technical specs
CSV column name:
patient_id|deceased
Only when:
Required:
false
Mapping of the clinical building blocks (indicative only)
Concept:
be.en.hd.Patient
Data element:
DeathIndicator
Options
| Label | Value |
| Yes | TRUE |
| No | FALSE |
Date of death
Technical specs
Format:
DD/MM/YYYY
CSV column name:
patient_id|date_of_death
Only when:
Required:
false
Mapping of the clinical building blocks (indicative only)
Concept:
be.en.hd.Patient
Data element:
DateOfDeath
2 Health
Section help
The next questions discuss how you experience your health, specifically mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. For each theme, select the position that describes your state of health best.
Mobility
Technical specs
CSV column name:
CD_MOBLTY
Required:
true
Options
| Label | Value |
| I have no problems in walking about | 1 |
| I have slight problems in walking about | 2 |
| I have moderate problems in walking about | 3 |
| I have severe problems in walking about | 4 |
| I am unable to walk about | 5 |
Self-Care
Technical specs
CSV column name:
CD_SC
Required:
true
Options
| Label | Value |
| I have no problems washing or dressing myself | 1 |
| I have slight problems washing or dressing myself | 2 |
| I have moderate problems washing or dressing myself | 3 |
| I have severe problems washing or dressing myself | 4 |
| I am unable to wash or dress myself | 5 |
Usual activities (e.g. work, study, housework, family or leisure activities)
Technical specs
CSV column name:
CD_USUAL_ACTVTS
Required:
true
Options
| Label | Value |
| I have no problems doing my usual activities | 1 |
| I have slight problems doing my usual activities | 2 |
| I have moderate problems doing my usual activities | 3 |
| I have severe problems doing my usual activities | 4 |
| I am unable to do my usual activities | 5 |
Pain / Discomfort
Technical specs
CSV column name:
CD_PAIN_DISCMFRT
Required:
true
Options
| Label | Value |
| I have no pain or discomfort | 1 |
| I have slight pain or discomfort | 2 |
| I have moderate pain or discomfort | 3 |
| I have severe pain or discomfort | 4 |
| I have extreme pain or discomfort | 5 |
Anxiety / Depression
Technical specs
CSV column name:
CD_ANXTY_DEPR
Required:
true
Options
| Label | Value |
| I am not anxious or depressed | 1 |
| I am slightly anxious or depressed | 2 |
| I am moderately anxious or depressed | 3 |
| I am severely anxious or depressed | 4 |
| I am extremely anxious or depressed | 5 |
Visual analog scale (VAS) regarding health
Help
Please indicate on this scale (from 0 to 10) how good or bad your own health is today, in your opinion. 0 = Worst imaginable 10 = Best imaginable
Technical specs
Required:
false
Questions
| Label | CSV column name |
| How good is your health today? | CD_VAS_HLTH |
Answers
| Label | Value |
| 0 | 0 |
| 1 | 1 |
| 2 | 2 |
| 3 | 3 |
| 4 | 4 |
| 5 | 5 |
| 6 | 6 |
| 7 | 7 |
| 8 | 8 |
| 9 | 9 |
| 10 | 10 |
3 Care experience
Section help
The next questions discuss how you experience the care you receive. Answer every position on a scale from "Almost never" until "Almost always".
Date of survey
Technical specs
Format:
DD/MM/YYYY
CSV column name:
DT_SURVEY
Required:
true
Over the last six months, when I received care for my chronic conditions, I was:
Technical specs
Required:
false
Questions
| Label | CSV column name |
| Asked for my ideas when we made a treatment plan | CD_PACIC_IDEA_TREATPL |
| Given choices about treatment to think about | CD_PACIC_CHOICE_TREAT |
| Asked to talk about any problems with my medicines or their effects | CD_PACIC_PROB_MEDICN |
| Given a written list of things I should do to improve my health | CD_PACIC_LIST_HLTH |
| Satisfied that my care was well organized | CD_PACIC_SAT_ORG |
| Shown how what I did to take care of myself influenced my condition | CD_PACIC_MYSELF_COND |
| Asked to talk about my goals in caring for my condition | CD_PACIC_GOA_COND |
| Helped to set specific goals to improve my eating or exercise | CD_PACIC_EAT_EXRCSE |
| Given a copy of my treatment plan | CD_PACIC_CPY_TREATPL |
| Encouraged to go to a specific group or class to help me cope with my chronic condition | CD_PACIC_CHRON_COND |
| Asked questions, either directly or on a survey, about my health habits | CD_PACIC_HLTH_HABIT |
| Sure that my doctor or nurse thought about my values, beliefs, and traditions when they recommended treatments to me | CD_PACIC_DOCTOR_NURSE_TREAT |
| Helped to make a treatment plan that I could carry out in my daily life | CD_PACIC_TREATPL_LIFE |
| Helped to plan ahead so I could take care of my condition even in hard times | CD_PACIC_PLN_COND |
| Asked how my chronic condition affects my life | CD_PACIC_CHRON_COND_LIFE |
| Contacted after a visit to see how things were going | CD_PACIC_CONT_VISIT |
| Encouraged to attend programs in the community that could help me | CD_PACIC_PROG_COMMUN |
| Referred to a dietician, health educator or counsellor | CD_PACIC_REFR |
| Told how visits with other types of doctors, like an eye doctor or other specialist, helped my treatment | CD_PACIC_VISIT_DOCTOR_TREAT |
| Asked how my visits with doctors were going | CD_PACIC_VISIT_DOCTOR |
Answers
| Label | Value |
| None of the time | 1 |
| A little of the time | 2 |
| Some of the time | 3 |
| Most of the time | 4 |
| Always | 5 |