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