| { | |
| "resourceType" : "CodeSystem", | |
| "id" : "onc-observation-codes", | |
| "text" : { | |
| "status" : "generated", | |
| "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CodeSystem onc-observation-codes</b></p><a name=\"onc-observation-codes\"> </a><a name=\"hconc-observation-codes\"> </a><p>This code system <code>https://clinyqai.github.io/open-nursing-core-ig/CodeSystem/onc-observation-codes</code> defines the following codes:</p><table class=\"codes\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style=\"white-space:nowrap\">mst-score<a name=\"onc-observation-codes-mst-score\"> </a></td><td>Monk Skin Tone Score</td><td>Assessment of skin tone using the Monk Skin Tone Scale</td></tr><tr><td style=\"white-space:nowrap\">waterlow-score<a name=\"onc-observation-codes-waterlow-score\"> </a></td><td>Waterlow Score</td><td>Total score for Waterlow pressure ulcer risk assessment</td></tr><tr><td style=\"white-space:nowrap\">must-score<a name=\"onc-observation-codes-must-score\"> </a></td><td>MUST Score</td><td>Malnutrition Universal Screening Tool total score</td></tr><tr><td style=\"white-space:nowrap\">must-bmi-score<a name=\"onc-observation-codes-must-bmi-score\"> </a></td><td>MUST BMI Score</td><td>Malnutrition Universal Screening Tool BMI score</td></tr><tr><td style=\"white-space:nowrap\">must-weight-loss-score<a name=\"onc-observation-codes-must-weight-loss-score\"> </a></td><td>MUST Weight Loss Score</td><td>Malnutrition Universal Screening Tool weight loss score</td></tr><tr><td style=\"white-space:nowrap\">must-acute-disease-score<a name=\"onc-observation-codes-must-acute-disease-score\"> </a></td><td>MUST Acute Disease Score</td><td>Malnutrition Universal Screening Tool acute disease effect score</td></tr><tr><td style=\"white-space:nowrap\">braden-total-score<a name=\"onc-observation-codes-braden-total-score\"> </a></td><td>Braden Total Score</td><td>Braden scale total score</td></tr><tr><td style=\"white-space:nowrap\">braden-sensory<a name=\"onc-observation-codes-braden-sensory\"> </a></td><td>Braden Sensory Perception</td><td>Sensory perception Braden scale</td></tr><tr><td style=\"white-space:nowrap\">braden-moisture<a name=\"onc-observation-codes-braden-moisture\"> </a></td><td>Braden Moisture</td><td>Moisture Braden scale</td></tr><tr><td style=\"white-space:nowrap\">braden-activity<a name=\"onc-observation-codes-braden-activity\"> </a></td><td>Braden Activity</td><td>Activity Braden scale</td></tr><tr><td style=\"white-space:nowrap\">braden-mobility<a name=\"onc-observation-codes-braden-mobility\"> </a></td><td>Braden Mobility</td><td>Mobility Braden scale</td></tr><tr><td style=\"white-space:nowrap\">braden-nutrition<a name=\"onc-observation-codes-braden-nutrition\"> </a></td><td>Braden Nutrition</td><td>Nutrition Braden scale</td></tr><tr><td style=\"white-space:nowrap\">braden-friction<a name=\"onc-observation-codes-braden-friction\"> </a></td><td>Braden Friction/Shear</td><td>Friction and shear Braden scale</td></tr><tr><td style=\"white-space:nowrap\">barthel-score<a name=\"onc-observation-codes-barthel-score\"> </a></td><td>Barthel Index Score</td><td>Total score for Barthel Index assessment</td></tr><tr><td style=\"white-space:nowrap\">news2-score<a name=\"onc-observation-codes-news2-score\"> </a></td><td>NEWS2 Score</td><td>National Early Warning Score 2 Total Score</td></tr><tr><td style=\"white-space:nowrap\">news2-subscore<a name=\"onc-observation-codes-news2-subscore\"> </a></td><td>NEWS2 Sub-score</td><td>Sub-score for NEWS2 parameter</td></tr><tr><td style=\"white-space:nowrap\">wound-stage<a name=\"onc-observation-codes-wound-stage\"> </a></td><td>Wound Stage</td><td>Stage of the wound</td></tr><tr><td style=\"white-space:nowrap\">stage-1<a name=\"onc-observation-codes-stage-1\"> </a></td><td>Stage 1</td><td>Stage 1 pressure ulcer</td></tr><tr><td style=\"white-space:nowrap\">stage-2<a name=\"onc-observation-codes-stage-2\"> </a></td><td>Stage 2</td><td>Stage 2 pressure ulcer</td></tr><tr><td style=\"white-space:nowrap\">stage-3<a name=\"onc-observation-codes-stage-3\"> </a></td><td>Stage 3</td><td>Stage 3 pressure ulcer</td></tr><tr><td style=\"white-space:nowrap\">stage-4<a name=\"onc-observation-codes-stage-4\"> </a></td><td>Stage 4</td><td>Stage 4 pressure ulcer</td></tr><tr><td style=\"white-space:nowrap\">unstageable<a name=\"onc-observation-codes-unstageable\"> </a></td><td>Unstageable</td><td>Unstageable pressure ulcer</td></tr><tr><td style=\"white-space:nowrap\">deep-tissue<a name=\"onc-observation-codes-deep-tissue\"> </a></td><td>Deep Tissue Injury</td><td>Deep tissue injury</td></tr><tr><td style=\"white-space:nowrap\">risk-falls<a name=\"onc-observation-codes-risk-falls\"> </a></td><td>Risk of Falls</td><td>Risk of falls diagnosis</td></tr><tr><td style=\"white-space:nowrap\">fitzpatrick-1<a name=\"onc-observation-codes-fitzpatrick-1\"> </a></td><td>Type I</td><td>Pale white; always burns, never tans</td></tr><tr><td style=\"white-space:nowrap\">fitzpatrick-2<a name=\"onc-observation-codes-fitzpatrick-2\"> </a></td><td>Type II</td><td>White; usually burns, tans with difficulty</td></tr><tr><td style=\"white-space:nowrap\">fitzpatrick-3<a name=\"onc-observation-codes-fitzpatrick-3\"> </a></td><td>Type III</td><td>Cream white; sometimes mild burn, gradually tans</td></tr><tr><td style=\"white-space:nowrap\">fitzpatrick-4<a name=\"onc-observation-codes-fitzpatrick-4\"> </a></td><td>Type IV</td><td>Moderate brown; rarely burns, tans with ease</td></tr><tr><td style=\"white-space:nowrap\">fitzpatrick-5<a name=\"onc-observation-codes-fitzpatrick-5\"> </a></td><td>Type V</td><td>Dark brown; very rarely burns, tans very easily</td></tr><tr><td style=\"white-space:nowrap\">fitzpatrick-6<a name=\"onc-observation-codes-fitzpatrick-6\"> </a></td><td>Type VI</td><td>Deeply pigmented dark brown to black; never burns, tans very easily</td></tr><tr><td style=\"white-space:nowrap\">what-matters<a name=\"onc-observation-codes-what-matters\"> </a></td><td>What Matters to Me</td><td>Patient-identified priorities and non-clinical goals</td></tr><tr><td style=\"white-space:nowrap\">patient-story<a name=\"onc-observation-codes-patient-story\"> </a></td><td>Patient Story</td><td>Narrative summary of patient background, preferences, and autobiography</td></tr><tr><td style=\"white-space:nowrap\">relational-engagement<a name=\"onc-observation-codes-relational-engagement\"> </a></td><td>Relational Engagement Score</td><td>Assessment of the quality of nurse-patient engagement (1-5)</td></tr><tr><td style=\"white-space:nowrap\">cfs-score<a name=\"onc-observation-codes-cfs-score\"> </a></td><td>Clinical Frailty Scale Score</td><td>Total score for Rockwood Clinical Frailty Scale</td></tr><tr><td style=\"white-space:nowrap\">cfs-1<a name=\"onc-observation-codes-cfs-1\"> </a></td><td>Very Fit</td><td>Robus, active, energetic and motivated</td></tr><tr><td style=\"white-space:nowrap\">cfs-2<a name=\"onc-observation-codes-cfs-2\"> </a></td><td>Well</td><td>No active disease symptoms but less fit than category 1</td></tr><tr><td style=\"white-space:nowrap\">cfs-3<a name=\"onc-observation-codes-cfs-3\"> </a></td><td>Managing Well</td><td>Medical problems are well controlled, but not regularly active</td></tr><tr><td style=\"white-space:nowrap\">cfs-4<a name=\"onc-observation-codes-cfs-4\"> </a></td><td>Vulnerable</td><td>Not dependent for daily help, but symptoms limit activities</td></tr><tr><td style=\"white-space:nowrap\">cfs-5<a name=\"onc-observation-codes-cfs-5\"> </a></td><td>Mildly Frail</td><td>Need help with high order IADLs (finances, transportation, heavy housework)</td></tr><tr><td style=\"white-space:nowrap\">cfs-6<a name=\"onc-observation-codes-cfs-6\"> </a></td><td>Moderately Frail</td><td>Need help with all outside activities and some housekeeping</td></tr><tr><td style=\"white-space:nowrap\">cfs-7<a name=\"onc-observation-codes-cfs-7\"> </a></td><td>Severely Frail</td><td>Completely dependent for personal care</td></tr><tr><td style=\"white-space:nowrap\">cfs-8<a name=\"onc-observation-codes-cfs-8\"> </a></td><td>Very Severely Frail</td><td>Completely dependent, approaching end of life</td></tr><tr><td style=\"white-space:nowrap\">cfs-9<a name=\"onc-observation-codes-cfs-9\"> </a></td><td>Terminally Ill</td><td>Approaching the end of life (life expectancy <6 months)</td></tr><tr><td style=\"white-space:nowrap\">4at-score<a name=\"onc-observation-codes-4at-score\"> </a></td><td>4AT Delirium Score</td><td>Total score for 4AT assessment</td></tr><tr><td style=\"white-space:nowrap\">4at-alertness<a name=\"onc-observation-codes-4at-alertness\"> </a></td><td>Alertness</td><td>4AT Item 1: Alertness</td></tr><tr><td style=\"white-space:nowrap\">4at-amt4<a name=\"onc-observation-codes-4at-amt4\"> </a></td><td>AMT4 Score</td><td>4AT Item 2: Abbreviated Mental Test 4</td></tr><tr><td style=\"white-space:nowrap\">4at-attention<a name=\"onc-observation-codes-4at-attention\"> </a></td><td>Attention</td><td>4AT Item 3: Attention (Months Backwards)</td></tr><tr><td style=\"white-space:nowrap\">4at-acute-change<a name=\"onc-observation-codes-4at-acute-change\"> </a></td><td>Acute Change</td><td>4AT Item 4: Acute Change or Fluctuating Course</td></tr><tr><td style=\"white-space:nowrap\">reasonable-adjustment<a name=\"onc-observation-codes-reasonable-adjustment\"> </a></td><td>Reasonable Adjustment</td><td>Requirement for adjustment to care delivery (Equality Act)</td></tr><tr><td style=\"white-space:nowrap\">mca-assessment<a name=\"onc-observation-codes-mca-assessment\"> </a></td><td>Mental Capacity Assessment</td><td>Assessment of capacity to make a specific decision</td></tr><tr><td style=\"white-space:nowrap\">capacity-present<a name=\"onc-observation-codes-capacity-present\"> </a></td><td>Capacity Present</td><td>Patient has capacity for this decision</td></tr><tr><td style=\"white-space:nowrap\">capacity-absent<a name=\"onc-observation-codes-capacity-absent\"> </a></td><td>Capacity Absent</td><td>Patient lacks capacity for this decision</td></tr><tr><td style=\"white-space:nowrap\">best-interest<a name=\"onc-observation-codes-best-interest\"> </a></td><td>Best Interest Decision</td><td>Decision made in patient's best interest</td></tr><tr><td style=\"white-space:nowrap\">bristol-score<a name=\"onc-observation-codes-bristol-score\"> </a></td><td>Bristol Stool Score</td><td>Bristol Stool Form Scale Score (1-7)</td></tr><tr><td style=\"white-space:nowrap\">bristol-1<a name=\"onc-observation-codes-bristol-1\"> </a></td><td>Type 1</td><td>Separate hard lumps, like nuts (hard to pass)</td></tr><tr><td style=\"white-space:nowrap\">bristol-2<a name=\"onc-observation-codes-bristol-2\"> </a></td><td>Type 2</td><td>Sausage-shaped but lumpy</td></tr><tr><td style=\"white-space:nowrap\">bristol-3<a name=\"onc-observation-codes-bristol-3\"> </a></td><td>Type 3</td><td>Like a sausage but with cracks on its surface</td></tr><tr><td style=\"white-space:nowrap\">bristol-4<a name=\"onc-observation-codes-bristol-4\"> </a></td><td>Type 4</td><td>Like a sausage or snake, smooth and soft</td></tr><tr><td style=\"white-space:nowrap\">bristol-5<a name=\"onc-observation-codes-bristol-5\"> </a></td><td>Type 5</td><td>Soft blobs with clear-cut edges (passed easily)</td></tr><tr><td style=\"white-space:nowrap\">bristol-6<a name=\"onc-observation-codes-bristol-6\"> </a></td><td>Type 6</td><td>Fluffy pieces with ragged edges, a mushy stool</td></tr><tr><td style=\"white-space:nowrap\">bristol-7<a name=\"onc-observation-codes-bristol-7\"> </a></td><td>Type 7</td><td>Watery, no solid pieces. Entirely liquid</td></tr><tr><td style=\"white-space:nowrap\">abbey-score<a name=\"onc-observation-codes-abbey-score\"> </a></td><td>Abbey Pain Scale Score</td><td>Total Abbey Pain Scale Score (0-100+ but usually 0-18+)</td></tr><tr><td style=\"white-space:nowrap\">abbey-vocalization<a name=\"onc-observation-codes-abbey-vocalization\"> </a></td><td>Vocalization</td><td>Whimpering, groaning, crying</td></tr><tr><td style=\"white-space:nowrap\">abbey-facial-expression<a name=\"onc-observation-codes-abbey-facial-expression\"> </a></td><td>Facial Expression</td><td>Looking tense, frowning, grimacing, looking frightened</td></tr><tr><td style=\"white-space:nowrap\">abbey-body-language<a name=\"onc-observation-codes-abbey-body-language\"> </a></td><td>Body Language</td><td>Fidgeting, rocking, guarding part of body, withdrawn</td></tr><tr><td style=\"white-space:nowrap\">abbey-behavioral-change<a name=\"onc-observation-codes-abbey-behavioral-change\"> </a></td><td>Behavioral Change</td><td>Increased confusion, refusing to eat, alteration in usual pattern</td></tr><tr><td style=\"white-space:nowrap\">abbey-psychological-change<a name=\"onc-observation-codes-abbey-psychological-change\"> </a></td><td>Psychological Change</td><td>Temperature, pulse, blood pressure changes, perspiration, pallor</td></tr><tr><td style=\"white-space:nowrap\">abbey-physical-changes<a name=\"onc-observation-codes-abbey-physical-changes\"> </a></td><td>Physical Changes</td><td>Skin tears, pressure areas, arthritis, contractures, previous injuries</td></tr><tr><td style=\"white-space:nowrap\">fluid-input-total<a name=\"onc-observation-codes-fluid-input-total\"> </a></td><td>Total Fluid Input</td><td>Total fluid input over specified period (e.g. 24h)</td></tr><tr><td style=\"white-space:nowrap\">fluid-output-total<a name=\"onc-observation-codes-fluid-output-total\"> </a></td><td>Total Fluid Output</td><td>Total fluid output over specified period (e.g. 24h)</td></tr><tr><td style=\"white-space:nowrap\">fluid-balance<a name=\"onc-observation-codes-fluid-balance\"> </a></td><td>Fluid Balance</td><td>Total Input minus Total Output</td></tr><tr><td style=\"white-space:nowrap\">urine-output<a name=\"onc-observation-codes-urine-output\"> </a></td><td>Urine Output</td><td>Volume of urine passed</td></tr><tr><td style=\"white-space:nowrap\">abc-chart<a name=\"onc-observation-codes-abc-chart\"> </a></td><td>ABC Chart</td><td>Antecedent-Behaviour-Consequence Chart for PBS</td></tr><tr><td style=\"white-space:nowrap\">abc-antecedent<a name=\"onc-observation-codes-abc-antecedent\"> </a></td><td>Antecedent</td><td>What happened immediately before the behaviour (triggers)</td></tr><tr><td style=\"white-space:nowrap\">abc-behaviour<a name=\"onc-observation-codes-abc-behaviour\"> </a></td><td>Behaviour</td><td>Description of the behaviour itself (observable actions)</td></tr><tr><td style=\"white-space:nowrap\">abc-consequence<a name=\"onc-observation-codes-abc-consequence\"> </a></td><td>Consequence</td><td>What happened immediately after (response/outcome)</td></tr><tr><td style=\"white-space:nowrap\">abc-function<a name=\"onc-observation-codes-abc-function\"> </a></td><td>Function of Behaviour</td><td>Hypothesized function (e.g. Sensory, Escape, Attention, Tangible)</td></tr><tr><td style=\"white-space:nowrap\">abc-duration<a name=\"onc-observation-codes-abc-duration\"> </a></td><td>Duration</td><td>Duration of the episode</td></tr><tr><td style=\"white-space:nowrap\">abc-intensity<a name=\"onc-observation-codes-abc-intensity\"> </a></td><td>Intensity</td><td>Intensity of the behaviour (1-10)</td></tr><tr><td style=\"white-space:nowrap\">oral-health-score<a name=\"onc-observation-codes-oral-health-score\"> </a></td><td>Oral Health Score</td><td>Total Oral Health Assessment Score</td></tr><tr><td style=\"white-space:nowrap\">oral-lips<a name=\"onc-observation-codes-oral-lips\"> </a></td><td>Lips</td><td>Condition of lips (Pink/Moist vs Dry/Cracked)</td></tr><tr><td style=\"white-space:nowrap\">oral-tongue<a name=\"onc-observation-codes-oral-tongue\"> </a></td><td>Tongue</td><td>Condition of tongue (Pink/Moist vs Coated/Red)</td></tr><tr><td style=\"white-space:nowrap\">oral-gums<a name=\"onc-observation-codes-oral-gums\"> </a></td><td>Gums</td><td>Condition of gums (Pink/Firm vs Bleeding/Receding)</td></tr><tr><td style=\"white-space:nowrap\">oral-teeth<a name=\"onc-observation-codes-oral-teeth\"> </a></td><td>Teeth/Dentures</td><td>Condition of teeth or dentures (Clean/Intact vs Decayed/Broken/Loose)</td></tr><tr><td style=\"white-space:nowrap\">oral-saliva<a name=\"onc-observation-codes-oral-saliva\"> </a></td><td>Saliva</td><td>Saliva quality (Moist/Watery vs Thick/Sticky/Absent)</td></tr><tr><td style=\"white-space:nowrap\">seizure-record<a name=\"onc-observation-codes-seizure-record\"> </a></td><td>Seizure Record</td><td>Record of a seizure event</td></tr><tr><td style=\"white-space:nowrap\">seizure-type<a name=\"onc-observation-codes-seizure-type\"> </a></td><td>Seizure Type</td><td>Type of seizure (Tonic-Clonic, Absence, Focal, etc)</td></tr><tr><td style=\"white-space:nowrap\">seizure-duration<a name=\"onc-observation-codes-seizure-duration\"> </a></td><td>Seizure Duration</td><td>Duration of the active seizure phase</td></tr><tr><td style=\"white-space:nowrap\">seizure-recovery<a name=\"onc-observation-codes-seizure-recovery\"> </a></td><td>Recovery Phase</td><td>Duration/Description of post-ictal recovery</td></tr><tr><td style=\"white-space:nowrap\">seizure-trigger<a name=\"onc-observation-codes-seizure-trigger\"> </a></td><td>Trigger</td><td>Suspected trigger for the seizure</td></tr><tr><td style=\"white-space:nowrap\">sleep-record<a name=\"onc-observation-codes-sleep-record\"> </a></td><td>Sleep Record</td><td>Record of a sleep period</td></tr><tr><td style=\"white-space:nowrap\">sleep-quality<a name=\"onc-observation-codes-sleep-quality\"> </a></td><td>Sleep Quality</td><td>Subjective or observed quality of sleep</td></tr><tr><td style=\"white-space:nowrap\">sleep-hours<a name=\"onc-observation-codes-sleep-hours\"> </a></td><td>Hours Slept</td><td>Total hours of sleep achieved</td></tr><tr><td style=\"white-space:nowrap\">sleep-disturbances<a name=\"onc-observation-codes-sleep-disturbances\"> </a></td><td>Disturbances</td><td>Number or description of distinct awakenings</td></tr><tr><td style=\"white-space:nowrap\">urinalysis-panel<a name=\"onc-observation-codes-urinalysis-panel\"> </a></td><td>Urinalysis Panel</td><td>Urine Dipstick Test Panel</td></tr><tr><td style=\"white-space:nowrap\">ua-leukocytes<a name=\"onc-observation-codes-ua-leukocytes\"> </a></td><td>Leukocytes</td><td>Leukocytes (WBCs) in urine</td></tr><tr><td style=\"white-space:nowrap\">ua-nitrites<a name=\"onc-observation-codes-ua-nitrites\"> </a></td><td>Nitrites</td><td>Nitrites in urine</td></tr><tr><td style=\"white-space:nowrap\">ua-protein<a name=\"onc-observation-codes-ua-protein\"> </a></td><td>Protein</td><td>Protein in urine</td></tr><tr><td style=\"white-space:nowrap\">ua-blood<a name=\"onc-observation-codes-ua-blood\"> </a></td><td>Blood</td><td>Blood (Hemoglobin) in urine</td></tr><tr><td style=\"white-space:nowrap\">ua-glucose<a name=\"onc-observation-codes-ua-glucose\"> </a></td><td>Glucose</td><td>Glucose in urine</td></tr><tr><td style=\"white-space:nowrap\">ua-ketones<a name=\"onc-observation-codes-ua-ketones\"> </a></td><td>Ketones</td><td>Ketones in urine</td></tr><tr><td style=\"white-space:nowrap\">ua-ph<a name=\"onc-observation-codes-ua-ph\"> </a></td><td>pH</td><td>Urine pH Level</td></tr><tr><td style=\"white-space:nowrap\">ua-sg<a name=\"onc-observation-codes-ua-sg\"> </a></td><td>Specific Gravity</td><td>Urine Specific Gravity</td></tr><tr><td style=\"white-space:nowrap\">mca-present<a name=\"onc-observation-codes-mca-present\"> </a></td><td>Capacity Present</td><td>Patient has capacity for this decision</td></tr><tr><td style=\"white-space:nowrap\">4at-change-no<a name=\"onc-observation-codes-4at-change-no\"> </a></td><td>No Acute Change</td><td>No indication of acute change or fluctuating course</td></tr><tr><td style=\"white-space:nowrap\">4at-amt4-1error<a name=\"onc-observation-codes-4at-amt4-1error\"> </a></td><td>1 Error</td><td>1 error in AMT4 test</td></tr><tr><td style=\"white-space:nowrap\">4at-attention-gt7<a name=\"onc-observation-codes-4at-attention-gt7\"> </a></td><td>Months Backwards < 7 months</td><td>Less than 7 months correctly recited backwards</td></tr><tr><td style=\"white-space:nowrap\">4at-alert-normal<a name=\"onc-observation-codes-4at-alert-normal\"> </a></td><td>Normal Alertness</td><td>Patient is fully alert</td></tr></table></div>" | |
| }, | |
| "url" : "https://clinyqai.github.io/open-nursing-core-ig/CodeSystem/onc-observation-codes", | |
| "version" : "0.1.0", | |
| "name" : "ONCObservationCodes", | |
| "title" : "ONC Observation Codes", | |
| "status" : "draft", | |
| "date" : "2026-01-01T13:37:23+00:00", | |
| "description" : "Custom observation codes for Open Nursing Core", | |
| "content" : "complete", | |
| "count" : 108, | |
| "concept" : [{ | |
| "code" : "mst-score", | |
| "display" : "Monk Skin Tone Score", | |
| "definition" : "Assessment of skin tone using the Monk Skin Tone Scale" | |
| }, | |
| { | |
| "code" : "waterlow-score", | |
| "display" : "Waterlow Score", | |
| "definition" : "Total score for Waterlow pressure ulcer risk assessment" | |
| }, | |
| { | |
| "code" : "must-score", | |
| "display" : "MUST Score", | |
| "definition" : "Malnutrition Universal Screening Tool total score" | |
| }, | |
| { | |
| "code" : "must-bmi-score", | |
| "display" : "MUST BMI Score", | |
| "definition" : "Malnutrition Universal Screening Tool BMI score" | |
| }, | |
| { | |
| "code" : "must-weight-loss-score", | |
| "display" : "MUST Weight Loss Score", | |
| "definition" : "Malnutrition Universal Screening Tool weight loss score" | |
| }, | |
| { | |
| "code" : "must-acute-disease-score", | |
| "display" : "MUST Acute Disease Score", | |
| "definition" : "Malnutrition Universal Screening Tool acute disease effect score" | |
| }, | |
| { | |
| "code" : "braden-total-score", | |
| "display" : "Braden Total Score", | |
| "definition" : "Braden scale total score" | |
| }, | |
| { | |
| "code" : "braden-sensory", | |
| "display" : "Braden Sensory Perception", | |
| "definition" : "Sensory perception Braden scale" | |
| }, | |
| { | |
| "code" : "braden-moisture", | |
| "display" : "Braden Moisture", | |
| "definition" : "Moisture Braden scale" | |
| }, | |
| { | |
| "code" : "braden-activity", | |
| "display" : "Braden Activity", | |
| "definition" : "Activity Braden scale" | |
| }, | |
| { | |
| "code" : "braden-mobility", | |
| "display" : "Braden Mobility", | |
| "definition" : "Mobility Braden scale" | |
| }, | |
| { | |
| "code" : "braden-nutrition", | |
| "display" : "Braden Nutrition", | |
| "definition" : "Nutrition Braden scale" | |
| }, | |
| { | |
| "code" : "braden-friction", | |
| "display" : "Braden Friction/Shear", | |
| "definition" : "Friction and shear Braden scale" | |
| }, | |
| { | |
| "code" : "barthel-score", | |
| "display" : "Barthel Index Score", | |
| "definition" : "Total score for Barthel Index assessment" | |
| }, | |
| { | |
| "code" : "news2-score", | |
| "display" : "NEWS2 Score", | |
| "definition" : "National Early Warning Score 2 Total Score" | |
| }, | |
| { | |
| "code" : "news2-subscore", | |
| "display" : "NEWS2 Sub-score", | |
| "definition" : "Sub-score for NEWS2 parameter" | |
| }, | |
| { | |
| "code" : "wound-stage", | |
| "display" : "Wound Stage", | |
| "definition" : "Stage of the wound" | |
| }, | |
| { | |
| "code" : "stage-1", | |
| "display" : "Stage 1", | |
| "definition" : "Stage 1 pressure ulcer" | |
| }, | |
| { | |
| "code" : "stage-2", | |
| "display" : "Stage 2", | |
| "definition" : "Stage 2 pressure ulcer" | |
| }, | |
| { | |
| "code" : "stage-3", | |
| "display" : "Stage 3", | |
| "definition" : "Stage 3 pressure ulcer" | |
| }, | |
| { | |
| "code" : "stage-4", | |
| "display" : "Stage 4", | |
| "definition" : "Stage 4 pressure ulcer" | |
| }, | |
| { | |
| "code" : "unstageable", | |
| "display" : "Unstageable", | |
| "definition" : "Unstageable pressure ulcer" | |
| }, | |
| { | |
| "code" : "deep-tissue", | |
| "display" : "Deep Tissue Injury", | |
| "definition" : "Deep tissue injury" | |
| }, | |
| { | |
| "code" : "risk-falls", | |
| "display" : "Risk of Falls", | |
| "definition" : "Risk of falls diagnosis" | |
| }, | |
| { | |
| "code" : "fitzpatrick-1", | |
| "display" : "Type I", | |
| "definition" : "Pale white; always burns, never tans" | |
| }, | |
| { | |
| "code" : "fitzpatrick-2", | |
| "display" : "Type II", | |
| "definition" : "White; usually burns, tans with difficulty" | |
| }, | |
| { | |
| "code" : "fitzpatrick-3", | |
| "display" : "Type III", | |
| "definition" : "Cream white; sometimes mild burn, gradually tans" | |
| }, | |
| { | |
| "code" : "fitzpatrick-4", | |
| "display" : "Type IV", | |
| "definition" : "Moderate brown; rarely burns, tans with ease" | |
| }, | |
| { | |
| "code" : "fitzpatrick-5", | |
| "display" : "Type V", | |
| "definition" : "Dark brown; very rarely burns, tans very easily" | |
| }, | |
| { | |
| "code" : "fitzpatrick-6", | |
| "display" : "Type VI", | |
| "definition" : "Deeply pigmented dark brown to black; never burns, tans very easily" | |
| }, | |
| { | |
| "code" : "what-matters", | |
| "display" : "What Matters to Me", | |
| "definition" : "Patient-identified priorities and non-clinical goals" | |
| }, | |
| { | |
| "code" : "patient-story", | |
| "display" : "Patient Story", | |
| "definition" : "Narrative summary of patient background, preferences, and autobiography" | |
| }, | |
| { | |
| "code" : "relational-engagement", | |
| "display" : "Relational Engagement Score", | |
| "definition" : "Assessment of the quality of nurse-patient engagement (1-5)" | |
| }, | |
| { | |
| "code" : "cfs-score", | |
| "display" : "Clinical Frailty Scale Score", | |
| "definition" : "Total score for Rockwood Clinical Frailty Scale" | |
| }, | |
| { | |
| "code" : "cfs-1", | |
| "display" : "Very Fit", | |
| "definition" : "Robus, active, energetic and motivated" | |
| }, | |
| { | |
| "code" : "cfs-2", | |
| "display" : "Well", | |
| "definition" : "No active disease symptoms but less fit than category 1" | |
| }, | |
| { | |
| "code" : "cfs-3", | |
| "display" : "Managing Well", | |
| "definition" : "Medical problems are well controlled, but not regularly active" | |
| }, | |
| { | |
| "code" : "cfs-4", | |
| "display" : "Vulnerable", | |
| "definition" : "Not dependent for daily help, but symptoms limit activities" | |
| }, | |
| { | |
| "code" : "cfs-5", | |
| "display" : "Mildly Frail", | |
| "definition" : "Need help with high order IADLs (finances, transportation, heavy housework)" | |
| }, | |
| { | |
| "code" : "cfs-6", | |
| "display" : "Moderately Frail", | |
| "definition" : "Need help with all outside activities and some housekeeping" | |
| }, | |
| { | |
| "code" : "cfs-7", | |
| "display" : "Severely Frail", | |
| "definition" : "Completely dependent for personal care" | |
| }, | |
| { | |
| "code" : "cfs-8", | |
| "display" : "Very Severely Frail", | |
| "definition" : "Completely dependent, approaching end of life" | |
| }, | |
| { | |
| "code" : "cfs-9", | |
| "display" : "Terminally Ill", | |
| "definition" : "Approaching the end of life (life expectancy <6 months)" | |
| }, | |
| { | |
| "code" : "4at-score", | |
| "display" : "4AT Delirium Score", | |
| "definition" : "Total score for 4AT assessment" | |
| }, | |
| { | |
| "code" : "4at-alertness", | |
| "display" : "Alertness", | |
| "definition" : "4AT Item 1: Alertness" | |
| }, | |
| { | |
| "code" : "4at-amt4", | |
| "display" : "AMT4 Score", | |
| "definition" : "4AT Item 2: Abbreviated Mental Test 4" | |
| }, | |
| { | |
| "code" : "4at-attention", | |
| "display" : "Attention", | |
| "definition" : "4AT Item 3: Attention (Months Backwards)" | |
| }, | |
| { | |
| "code" : "4at-acute-change", | |
| "display" : "Acute Change", | |
| "definition" : "4AT Item 4: Acute Change or Fluctuating Course" | |
| }, | |
| { | |
| "code" : "reasonable-adjustment", | |
| "display" : "Reasonable Adjustment", | |
| "definition" : "Requirement for adjustment to care delivery (Equality Act)" | |
| }, | |
| { | |
| "code" : "mca-assessment", | |
| "display" : "Mental Capacity Assessment", | |
| "definition" : "Assessment of capacity to make a specific decision" | |
| }, | |
| { | |
| "code" : "capacity-present", | |
| "display" : "Capacity Present", | |
| "definition" : "Patient has capacity for this decision" | |
| }, | |
| { | |
| "code" : "capacity-absent", | |
| "display" : "Capacity Absent", | |
| "definition" : "Patient lacks capacity for this decision" | |
| }, | |
| { | |
| "code" : "best-interest", | |
| "display" : "Best Interest Decision", | |
| "definition" : "Decision made in patient's best interest" | |
| }, | |
| { | |
| "code" : "bristol-score", | |
| "display" : "Bristol Stool Score", | |
| "definition" : "Bristol Stool Form Scale Score (1-7)" | |
| }, | |
| { | |
| "code" : "bristol-1", | |
| "display" : "Type 1", | |
| "definition" : "Separate hard lumps, like nuts (hard to pass)" | |
| }, | |
| { | |
| "code" : "bristol-2", | |
| "display" : "Type 2", | |
| "definition" : "Sausage-shaped but lumpy" | |
| }, | |
| { | |
| "code" : "bristol-3", | |
| "display" : "Type 3", | |
| "definition" : "Like a sausage but with cracks on its surface" | |
| }, | |
| { | |
| "code" : "bristol-4", | |
| "display" : "Type 4", | |
| "definition" : "Like a sausage or snake, smooth and soft" | |
| }, | |
| { | |
| "code" : "bristol-5", | |
| "display" : "Type 5", | |
| "definition" : "Soft blobs with clear-cut edges (passed easily)" | |
| }, | |
| { | |
| "code" : "bristol-6", | |
| "display" : "Type 6", | |
| "definition" : "Fluffy pieces with ragged edges, a mushy stool" | |
| }, | |
| { | |
| "code" : "bristol-7", | |
| "display" : "Type 7", | |
| "definition" : "Watery, no solid pieces. Entirely liquid" | |
| }, | |
| { | |
| "code" : "abbey-score", | |
| "display" : "Abbey Pain Scale Score", | |
| "definition" : "Total Abbey Pain Scale Score (0-100+ but usually 0-18+)" | |
| }, | |
| { | |
| "code" : "abbey-vocalization", | |
| "display" : "Vocalization", | |
| "definition" : "Whimpering, groaning, crying" | |
| }, | |
| { | |
| "code" : "abbey-facial-expression", | |
| "display" : "Facial Expression", | |
| "definition" : "Looking tense, frowning, grimacing, looking frightened" | |
| }, | |
| { | |
| "code" : "abbey-body-language", | |
| "display" : "Body Language", | |
| "definition" : "Fidgeting, rocking, guarding part of body, withdrawn" | |
| }, | |
| { | |
| "code" : "abbey-behavioral-change", | |
| "display" : "Behavioral Change", | |
| "definition" : "Increased confusion, refusing to eat, alteration in usual pattern" | |
| }, | |
| { | |
| "code" : "abbey-psychological-change", | |
| "display" : "Psychological Change", | |
| "definition" : "Temperature, pulse, blood pressure changes, perspiration, pallor" | |
| }, | |
| { | |
| "code" : "abbey-physical-changes", | |
| "display" : "Physical Changes", | |
| "definition" : "Skin tears, pressure areas, arthritis, contractures, previous injuries" | |
| }, | |
| { | |
| "code" : "fluid-input-total", | |
| "display" : "Total Fluid Input", | |
| "definition" : "Total fluid input over specified period (e.g. 24h)" | |
| }, | |
| { | |
| "code" : "fluid-output-total", | |
| "display" : "Total Fluid Output", | |
| "definition" : "Total fluid output over specified period (e.g. 24h)" | |
| }, | |
| { | |
| "code" : "fluid-balance", | |
| "display" : "Fluid Balance", | |
| "definition" : "Total Input minus Total Output" | |
| }, | |
| { | |
| "code" : "urine-output", | |
| "display" : "Urine Output", | |
| "definition" : "Volume of urine passed" | |
| }, | |
| { | |
| "code" : "abc-chart", | |
| "display" : "ABC Chart", | |
| "definition" : "Antecedent-Behaviour-Consequence Chart for PBS" | |
| }, | |
| { | |
| "code" : "abc-antecedent", | |
| "display" : "Antecedent", | |
| "definition" : "What happened immediately before the behaviour (triggers)" | |
| }, | |
| { | |
| "code" : "abc-behaviour", | |
| "display" : "Behaviour", | |
| "definition" : "Description of the behaviour itself (observable actions)" | |
| }, | |
| { | |
| "code" : "abc-consequence", | |
| "display" : "Consequence", | |
| "definition" : "What happened immediately after (response/outcome)" | |
| }, | |
| { | |
| "code" : "abc-function", | |
| "display" : "Function of Behaviour", | |
| "definition" : "Hypothesized function (e.g. Sensory, Escape, Attention, Tangible)" | |
| }, | |
| { | |
| "code" : "abc-duration", | |
| "display" : "Duration", | |
| "definition" : "Duration of the episode" | |
| }, | |
| { | |
| "code" : "abc-intensity", | |
| "display" : "Intensity", | |
| "definition" : "Intensity of the behaviour (1-10)" | |
| }, | |
| { | |
| "code" : "oral-health-score", | |
| "display" : "Oral Health Score", | |
| "definition" : "Total Oral Health Assessment Score" | |
| }, | |
| { | |
| "code" : "oral-lips", | |
| "display" : "Lips", | |
| "definition" : "Condition of lips (Pink/Moist vs Dry/Cracked)" | |
| }, | |
| { | |
| "code" : "oral-tongue", | |
| "display" : "Tongue", | |
| "definition" : "Condition of tongue (Pink/Moist vs Coated/Red)" | |
| }, | |
| { | |
| "code" : "oral-gums", | |
| "display" : "Gums", | |
| "definition" : "Condition of gums (Pink/Firm vs Bleeding/Receding)" | |
| }, | |
| { | |
| "code" : "oral-teeth", | |
| "display" : "Teeth/Dentures", | |
| "definition" : "Condition of teeth or dentures (Clean/Intact vs Decayed/Broken/Loose)" | |
| }, | |
| { | |
| "code" : "oral-saliva", | |
| "display" : "Saliva", | |
| "definition" : "Saliva quality (Moist/Watery vs Thick/Sticky/Absent)" | |
| }, | |
| { | |
| "code" : "seizure-record", | |
| "display" : "Seizure Record", | |
| "definition" : "Record of a seizure event" | |
| }, | |
| { | |
| "code" : "seizure-type", | |
| "display" : "Seizure Type", | |
| "definition" : "Type of seizure (Tonic-Clonic, Absence, Focal, etc)" | |
| }, | |
| { | |
| "code" : "seizure-duration", | |
| "display" : "Seizure Duration", | |
| "definition" : "Duration of the active seizure phase" | |
| }, | |
| { | |
| "code" : "seizure-recovery", | |
| "display" : "Recovery Phase", | |
| "definition" : "Duration/Description of post-ictal recovery" | |
| }, | |
| { | |
| "code" : "seizure-trigger", | |
| "display" : "Trigger", | |
| "definition" : "Suspected trigger for the seizure" | |
| }, | |
| { | |
| "code" : "sleep-record", | |
| "display" : "Sleep Record", | |
| "definition" : "Record of a sleep period" | |
| }, | |
| { | |
| "code" : "sleep-quality", | |
| "display" : "Sleep Quality", | |
| "definition" : "Subjective or observed quality of sleep" | |
| }, | |
| { | |
| "code" : "sleep-hours", | |
| "display" : "Hours Slept", | |
| "definition" : "Total hours of sleep achieved" | |
| }, | |
| { | |
| "code" : "sleep-disturbances", | |
| "display" : "Disturbances", | |
| "definition" : "Number or description of distinct awakenings" | |
| }, | |
| { | |
| "code" : "urinalysis-panel", | |
| "display" : "Urinalysis Panel", | |
| "definition" : "Urine Dipstick Test Panel" | |
| }, | |
| { | |
| "code" : "ua-leukocytes", | |
| "display" : "Leukocytes", | |
| "definition" : "Leukocytes (WBCs) in urine" | |
| }, | |
| { | |
| "code" : "ua-nitrites", | |
| "display" : "Nitrites", | |
| "definition" : "Nitrites in urine" | |
| }, | |
| { | |
| "code" : "ua-protein", | |
| "display" : "Protein", | |
| "definition" : "Protein in urine" | |
| }, | |
| { | |
| "code" : "ua-blood", | |
| "display" : "Blood", | |
| "definition" : "Blood (Hemoglobin) in urine" | |
| }, | |
| { | |
| "code" : "ua-glucose", | |
| "display" : "Glucose", | |
| "definition" : "Glucose in urine" | |
| }, | |
| { | |
| "code" : "ua-ketones", | |
| "display" : "Ketones", | |
| "definition" : "Ketones in urine" | |
| }, | |
| { | |
| "code" : "ua-ph", | |
| "display" : "pH", | |
| "definition" : "Urine pH Level" | |
| }, | |
| { | |
| "code" : "ua-sg", | |
| "display" : "Specific Gravity", | |
| "definition" : "Urine Specific Gravity" | |
| }, | |
| { | |
| "code" : "mca-present", | |
| "display" : "Capacity Present", | |
| "definition" : "Patient has capacity for this decision" | |
| }, | |
| { | |
| "code" : "4at-change-no", | |
| "display" : "No Acute Change", | |
| "definition" : "No indication of acute change or fluctuating course" | |
| }, | |
| { | |
| "code" : "4at-amt4-1error", | |
| "display" : "1 Error", | |
| "definition" : "1 error in AMT4 test" | |
| }, | |
| { | |
| "code" : "4at-attention-gt7", | |
| "display" : "Months Backwards < 7 months", | |
| "definition" : "Less than 7 months correctly recited backwards" | |
| }, | |
| { | |
| "code" : "4at-alert-normal", | |
| "display" : "Normal Alertness", | |
| "definition" : "Patient is fully alert" | |
| }] | |
| } |