{ "resourceType" : "CodeSystem", "id" : "onc-observation-codes", "text" : { "status" : "generated", "div" : "

Generated Narrative: CodeSystem onc-observation-codes

This code system https://clinyqai.github.io/open-nursing-core-ig/CodeSystem/onc-observation-codes defines the following codes:

CodeDisplayDefinition
mst-score Monk Skin Tone ScoreAssessment of skin tone using the Monk Skin Tone Scale
waterlow-score Waterlow ScoreTotal score for Waterlow pressure ulcer risk assessment
must-score MUST ScoreMalnutrition Universal Screening Tool total score
must-bmi-score MUST BMI ScoreMalnutrition Universal Screening Tool BMI score
must-weight-loss-score MUST Weight Loss ScoreMalnutrition Universal Screening Tool weight loss score
must-acute-disease-score MUST Acute Disease ScoreMalnutrition Universal Screening Tool acute disease effect score
braden-total-score Braden Total ScoreBraden scale total score
braden-sensory Braden Sensory PerceptionSensory perception Braden scale
braden-moisture Braden MoistureMoisture Braden scale
braden-activity Braden ActivityActivity Braden scale
braden-mobility Braden MobilityMobility Braden scale
braden-nutrition Braden NutritionNutrition Braden scale
braden-friction Braden Friction/ShearFriction and shear Braden scale
barthel-score Barthel Index ScoreTotal score for Barthel Index assessment
news2-score NEWS2 ScoreNational Early Warning Score 2 Total Score
news2-subscore NEWS2 Sub-scoreSub-score for NEWS2 parameter
wound-stage Wound StageStage of the wound
stage-1 Stage 1Stage 1 pressure ulcer
stage-2 Stage 2Stage 2 pressure ulcer
stage-3 Stage 3Stage 3 pressure ulcer
stage-4 Stage 4Stage 4 pressure ulcer
unstageable UnstageableUnstageable pressure ulcer
deep-tissue Deep Tissue InjuryDeep tissue injury
risk-falls Risk of FallsRisk of falls diagnosis
fitzpatrick-1 Type IPale white; always burns, never tans
fitzpatrick-2 Type IIWhite; usually burns, tans with difficulty
fitzpatrick-3 Type IIICream white; sometimes mild burn, gradually tans
fitzpatrick-4 Type IVModerate brown; rarely burns, tans with ease
fitzpatrick-5 Type VDark brown; very rarely burns, tans very easily
fitzpatrick-6 Type VIDeeply pigmented dark brown to black; never burns, tans very easily
what-matters What Matters to MePatient-identified priorities and non-clinical goals
patient-story Patient StoryNarrative summary of patient background, preferences, and autobiography
relational-engagement Relational Engagement ScoreAssessment of the quality of nurse-patient engagement (1-5)
cfs-score Clinical Frailty Scale ScoreTotal score for Rockwood Clinical Frailty Scale
cfs-1 Very FitRobus, active, energetic and motivated
cfs-2 WellNo active disease symptoms but less fit than category 1
cfs-3 Managing WellMedical problems are well controlled, but not regularly active
cfs-4 VulnerableNot dependent for daily help, but symptoms limit activities
cfs-5 Mildly FrailNeed help with high order IADLs (finances, transportation, heavy housework)
cfs-6 Moderately FrailNeed help with all outside activities and some housekeeping
cfs-7 Severely FrailCompletely dependent for personal care
cfs-8 Very Severely FrailCompletely dependent, approaching end of life
cfs-9 Terminally IllApproaching the end of life (life expectancy <6 months)
4at-score 4AT Delirium ScoreTotal score for 4AT assessment
4at-alertness Alertness4AT Item 1: Alertness
4at-amt4 AMT4 Score4AT Item 2: Abbreviated Mental Test 4
4at-attention Attention4AT Item 3: Attention (Months Backwards)
4at-acute-change Acute Change4AT Item 4: Acute Change or Fluctuating Course
reasonable-adjustment Reasonable AdjustmentRequirement for adjustment to care delivery (Equality Act)
mca-assessment Mental Capacity AssessmentAssessment of capacity to make a specific decision
capacity-present Capacity PresentPatient has capacity for this decision
capacity-absent Capacity AbsentPatient lacks capacity for this decision
best-interest Best Interest DecisionDecision made in patient's best interest
bristol-score Bristol Stool ScoreBristol Stool Form Scale Score (1-7)
bristol-1 Type 1Separate hard lumps, like nuts (hard to pass)
bristol-2 Type 2Sausage-shaped but lumpy
bristol-3 Type 3Like a sausage but with cracks on its surface
bristol-4 Type 4Like a sausage or snake, smooth and soft
bristol-5 Type 5Soft blobs with clear-cut edges (passed easily)
bristol-6 Type 6Fluffy pieces with ragged edges, a mushy stool
bristol-7 Type 7Watery, no solid pieces. Entirely liquid
abbey-score Abbey Pain Scale ScoreTotal Abbey Pain Scale Score (0-100+ but usually 0-18+)
abbey-vocalization VocalizationWhimpering, groaning, crying
abbey-facial-expression Facial ExpressionLooking tense, frowning, grimacing, looking frightened
abbey-body-language Body LanguageFidgeting, rocking, guarding part of body, withdrawn
abbey-behavioral-change Behavioral ChangeIncreased confusion, refusing to eat, alteration in usual pattern
abbey-psychological-change Psychological ChangeTemperature, pulse, blood pressure changes, perspiration, pallor
abbey-physical-changes Physical ChangesSkin tears, pressure areas, arthritis, contractures, previous injuries
fluid-input-total Total Fluid InputTotal fluid input over specified period (e.g. 24h)
fluid-output-total Total Fluid OutputTotal fluid output over specified period (e.g. 24h)
fluid-balance Fluid BalanceTotal Input minus Total Output
urine-output Urine OutputVolume of urine passed
abc-chart ABC ChartAntecedent-Behaviour-Consequence Chart for PBS
abc-antecedent AntecedentWhat happened immediately before the behaviour (triggers)
abc-behaviour BehaviourDescription of the behaviour itself (observable actions)
abc-consequence ConsequenceWhat happened immediately after (response/outcome)
abc-function Function of BehaviourHypothesized function (e.g. Sensory, Escape, Attention, Tangible)
abc-duration DurationDuration of the episode
abc-intensity IntensityIntensity of the behaviour (1-10)
oral-health-score Oral Health ScoreTotal Oral Health Assessment Score
oral-lips LipsCondition of lips (Pink/Moist vs Dry/Cracked)
oral-tongue TongueCondition of tongue (Pink/Moist vs Coated/Red)
oral-gums GumsCondition of gums (Pink/Firm vs Bleeding/Receding)
oral-teeth Teeth/DenturesCondition of teeth or dentures (Clean/Intact vs Decayed/Broken/Loose)
oral-saliva SalivaSaliva quality (Moist/Watery vs Thick/Sticky/Absent)
seizure-record Seizure RecordRecord of a seizure event
seizure-type Seizure TypeType of seizure (Tonic-Clonic, Absence, Focal, etc)
seizure-duration Seizure DurationDuration of the active seizure phase
seizure-recovery Recovery PhaseDuration/Description of post-ictal recovery
seizure-trigger TriggerSuspected trigger for the seizure
sleep-record Sleep RecordRecord of a sleep period
sleep-quality Sleep QualitySubjective or observed quality of sleep
sleep-hours Hours SleptTotal hours of sleep achieved
sleep-disturbances DisturbancesNumber or description of distinct awakenings
urinalysis-panel Urinalysis PanelUrine Dipstick Test Panel
ua-leukocytes LeukocytesLeukocytes (WBCs) in urine
ua-nitrites NitritesNitrites in urine
ua-protein ProteinProtein in urine
ua-blood BloodBlood (Hemoglobin) in urine
ua-glucose GlucoseGlucose in urine
ua-ketones KetonesKetones in urine
ua-ph pHUrine pH Level
ua-sg Specific GravityUrine Specific Gravity
mca-present Capacity PresentPatient has capacity for this decision
4at-change-no No Acute ChangeNo indication of acute change or fluctuating course
4at-amt4-1error 1 Error1 error in AMT4 test
4at-attention-gt7 Months Backwards < 7 monthsLess than 7 months correctly recited backwards
4at-alert-normal Normal AlertnessPatient is fully alert
" }, "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" }] }