| # ONC Observation Codes - Open Nursing Core FHIR Implementation Guide (ONC-IG) v0.1.0 | |
| * [**Table of Contents**](toc.md) | |
| * [**Artifacts Summary**](artifacts.md) | |
| * **ONC Observation Codes** | |
| ## CodeSystem: ONC Observation Codes | |
| | | | | |
| | :--- | :--- | | |
| | *Official URL*:https://clinyqai.github.io/open-nursing-core-ig/CodeSystem/onc-observation-codes | *Version*:0.1.0 | | |
| | Draft as of 2026-01-01 | *Computable Name*:ONCObservationCodes | | |
| Custom observation codes for Open Nursing Core | |
| This Code system is referenced in the content logical definition of the following value sets: | |
| * [NEWS2CodeValueSet](ValueSet-news2-code-vs.md) | |
| * [NEWS2SubscoreCodeValueSet](ValueSet-news2-subscore-code-vs.md) | |
| * [NursingProblemValueSet](ValueSet-nursing-problem-valueset.md) | |
| * [AlertnessVS](ValueSet-onc-4at-alertness-vs.md) | |
| * [ClinicalFrailtyScaleVS](ValueSet-onc-cfs-vs.md) | |
| * [MentalCapacityVS](ValueSet-onc-mca-vs.md) | |
| * [PBSFunctionVS](ValueSet-onc-pbs-function-vs.md) | |
| * [SkinToneVS](ValueSet-skintone-vs.md) | |
| * [WoundStageValueSet](ValueSet-wound-stage-vs.md) | |
| ## Resource Content | |
| ```json | |
| { | |
| "resourceType" : "CodeSystem", | |
| "id" : "onc-observation-codes", | |
| "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" | |
| } | |
| ] | |
| } | |
| ``` | |