onc-observation-codes
type: CodeSystem
node role: treeRoot
id:
  v: onc-observation-codes
text:
  status:
    v: generated
  div:
    v: 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: 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 Typ…
url:
  v: https://clinyqai.github.io/open-nursing-core-ig/CodeSystem/onc-observation-codes
  l: onc-observation-codes
version:
  v: 0.1.0
name:
  v: ONCObservationCodes
title:
  v: ONC Observation Codes
status:
  v: draft
date:
  v: 2026-01-01T13:37:23+00:00
description:
  v: Custom observation codes for Open Nursing Core
content:
  v: complete
count:
  v: 108
concept:
  code:
    v: mst-score
  display:
    v: Monk Skin Tone Score
  definition:
    v: Assessment of skin tone using the Monk Skin Tone Scale
concept:
  code:
    v: waterlow-score
  display:
    v: Waterlow Score
  definition:
    v: Total score for Waterlow pressure ulcer risk assessment
concept:
  code:
    v: must-score
  display:
    v: MUST Score
  definition:
    v: Malnutrition Universal Screening Tool total score
concept:
  code:
    v: must-bmi-score
  display:
    v: MUST BMI Score
  definition:
    v: Malnutrition Universal Screening Tool BMI score
concept:
  code:
    v: must-weight-loss-score
  display:
    v: MUST Weight Loss Score
  definition:
    v: Malnutrition Universal Screening Tool weight loss score
concept:
  code:
    v: must-acute-disease-score
  display:
    v: MUST Acute Disease Score
  definition:
    v: Malnutrition Universal Screening Tool acute disease effect score
concept:
  code:
    v: braden-total-score
  display:
    v: Braden Total Score
  definition:
    v: Braden scale total score
concept:
  code:
    v: braden-sensory
  display:
    v: Braden Sensory Perception
  definition:
    v: Sensory perception Braden scale
concept:
  code:
    v: braden-moisture
  display:
    v: Braden Moisture
  definition:
    v: Moisture Braden scale
concept:
  code:
    v: braden-activity
  display:
    v: Braden Activity
  definition:
    v: Activity Braden scale
concept:
  code:
    v: braden-mobility
  display:
    v: Braden Mobility
  definition:
    v: Mobility Braden scale
concept:
  code:
    v: braden-nutrition
  display:
    v: Braden Nutrition
  definition:
    v: Nutrition Braden scale
concept:
  code:
    v: braden-friction
  display:
    v: Braden Friction/Shear
  definition:
    v: Friction and shear Braden scale
concept:
  code:
    v: barthel-score
  display:
    v: Barthel Index Score
  definition:
    v: Total score for Barthel Index assessment
concept:
  code:
    v: news2-score
  display:
    v: NEWS2 Score
  definition:
    v: National Early Warning Score 2 Total Score
concept:
  code:
    v: news2-subscore
  display:
    v: NEWS2 Sub-score
  definition:
    v: Sub-score for NEWS2 parameter
concept:
  code:
    v: wound-stage
  display:
    v: Wound Stage
  definition:
    v: Stage of the wound
concept:
  code:
    v: stage-1
  display:
    v: Stage 1
  definition:
    v: Stage 1 pressure ulcer
concept:
  code:
    v: stage-2
  display:
    v: Stage 2
  definition:
    v: Stage 2 pressure ulcer
concept:
  code:
    v: stage-3
  display:
    v: Stage 3
  definition:
    v: Stage 3 pressure ulcer
concept:
  code:
    v: stage-4
  display:
    v: Stage 4
  definition:
    v: Stage 4 pressure ulcer
concept:
  code:
    v: unstageable
  display:
    v: Unstageable
  definition:
    v: Unstageable pressure ulcer
concept:
  code:
    v: deep-tissue
  display:
    v: Deep Tissue Injury
  definition:
    v: Deep tissue injury
concept:
  code:
    v: risk-falls
  display:
    v: Risk of Falls
  definition:
    v: Risk of falls diagnosis
concept:
  code:
    v: fitzpatrick-1
  display:
    v: Type I

v: Pale white; always burns, never tans

code:
  v: fitzpatrick-2
display:
  v: Type II
definition:
  v: White; usually burns, tans with difficulty

code:
  v: fitzpatrick-3
display:
  v: Type III
definition:
  v: Cream white; sometimes mild burn, gradually tans

code:
  v: fitzpatrick-4
display:
  v: Type IV
definition:
  v: Moderate brown; rarely burns, tans with ease

code:
  v: fitzpatrick-5
display:
  v: Type V
definition:
  v: Dark brown; very rarely burns, tans very easily

code:
  v: fitzpatrick-6
display:
  v: Type VI
definition:
  v: Deeply pigmented dark brown to black; never burns, tans very easily

code:
  v: what-matters
display:
  v: What Matters to Me
definition:
  v: Patient-identified priorities and non-clinical goals

code:
  v: patient-story
display:
  v: Patient Story
definition:
  v: Narrative summary of patient background, preferences, and autobiography

code:
  v: relational-engagement
display:
  v: Relational Engagement Score
definition:
  v: Assessment of the quality of nurse-patient engagement (1-5)

code:
  v: cfs-score
display:
  v: Clinical Frailty Scale Score
definition:
  v: Total score for Rockwood Clinical Frailty Scale

code:
  v: cfs-1
display:
  v: Very Fit
definition:
  v: Robus, active, energetic and motivated

code:
  v: cfs-2
display:
  v: Well
definition:
  v: No active disease symptoms but less fit than category 1

code:
  v: cfs-3
display:
  v: Managing Well
definition:
  v: Medical problems are well controlled, but not regularly active

code:
  v: cfs-4
display:
  v: Vulnerable
definition:
  v: Not dependent for daily help, but symptoms limit activities

code:
  v: cfs-5
display:
  v: Mildly Frail
definition:
  v: Need help with high order IADLs (finances, transportation, heavy housework)

code:
  v: cfs-6
display:
  v: Moderately Frail
definition:
  v: Need help with all outside activities and some housekeeping

code:
  v: cfs-7
display:
  v: Severely Frail
definition:
  v: Completely dependent for personal care

code:
  v: cfs-8
display:
  v: Very Severely Frail
definition:
  v: Completely dependent, approaching end of life

code:
  v: cfs-9
display:
  v: Terminally Ill
definition:
  v: Approaching the end of life (life expectancy <6 months)

code:
  v: 4at-score
display:
  v: 4AT Delirium Score
definition:
  v: Total score for 4AT assessment

code:
  v: 4at-alertness
display:
  v: Alertness
definition:
  v: 4AT Item 1: Alertness

code:
  v: 4at-amt4
display:
  v: AMT4 Score
definition:
  v: 4AT Item 2: Abbreviated Mental Test 4

code:
  v: 4at-attention
display:
  v: Attention
definition:
  v: 4AT Item 3: Attention (Months Backwards)

code:
  v: 4at-acute-change
display:
  v: Acute Change
definition:
  v: 4AT Item 4: Acute Change or Fluctuating Course

code:
  v: reasonable-adjustment
display:
  v: Reasonable Adjustment
definition:
  v: Requirement for adjustment to care delivery (Equality Act)

code:
  v: mca-assessment
display:
  v: Mental Capacity Assessment
definition:
  v: Assessment of capacity to make a specific decision

code:
  v: capacity-present
display:
  v: Capacity Present
definition:
  v: Patient has capacity for this decision

code:
  v: capacity-absent
display:
  v: Capacity Absent
definition:
  v: Patient lacks capacity for this decision

code:
  v: best-interest
display:
  v: Best Interest Decision
definition:
  v: Decision made in patient's best interest

code:
  v: bristol-score
display:
  v: Bristol Stool Score
definition:
  v: Bristol Stool Form Scale Score (1-7)

code:
  v: bristol-1
display:
  v: Type 1
definition:
  v: Separate hard lumps, like nuts (hard to pass)

code:
  v: bristol-2
display:
  v: Type 2
definition:
  v: Sausage-shaped but lumpy

code:
  v: bristol-3
display:
  v: Type 3
definition:
  v: Like a sausage but with cracks on its surface

code:
  v: bristol-4
display:
  v: Type 4
definition:
  v: Like a sausage or snake, smooth and soft

code:
  v: bristol-5
display:
  v: Type 5
definition:
  v: Soft blobs with clear-cut edges (passed easily)

code:
  v: bristol-6
display:
  v: Type 6
definition:
  v: Fluffy pieces with ragged edges, a mushy stool

code:
  v: bristol-7
display:
  v: Type 7
definition:
  v: Watery, no solid pieces. Entirely liquid

code:
  v: abbey-score
display:
  v: Abbey Pain Scale Score
definition:
  v: Total Abbey Pain Scale Score (0-100+ but usually 0-18+)

code:
  v: abbey-vocalization
display:
  v: Vocalization
definition:
  v: Whimpering, groaning, crying

code:
  v: abbey-facial-expression
display:
  v: Facial Expression
definition:
  v: Looking tense, frowning, grimacing, looking frightened

code:
  v: abbey-body-language
display:
  v: Body Language
definition:
  v: Fidgeting, rocking, guarding part of body, withdrawn

code:
  v: abbey-behavioral-change
display:
  v: Behavioral Change
definition:
  v: Increased confusion, refusing to eat, alteration in usual pattern

code:
  v: abbey-psychological-change
display:
  v: Psychological Change
definition:
  v: Temperature, pulse, blood pressure changes, perspiration, pallor

code:
  v: abbey-physical-changes
display:
  v: Physical Changes
definition:
  v: Skin tears, pressure areas, arthritis, contractures, previous injuries

code:
  v: fluid-input-total
display:
  v: Total Fluid Input
definition:
  v: Total fluid input over specified period (e.g. 24h)

code:
  v: fluid-output-total
display:
  v: Total Fluid Output
definition:
  v: Total fluid output over specified period (e.g. 24h)

code:
  v: fluid-balance
display:
  v: Fluid Balance
definition:
  v: Total Input minus Total Output

code:
  v: urine-output
display:
  v: Urine Output
definition:
  v: Volume of urine passed

code:
  v: abc-chart
display:
  v: ABC Chart
definition:
  v: Antecedent-Behaviour-Consequence Chart for PBS

code:
  v: abc-antecedent
display:
  v: Antecedent
definition:
  v: What happened immediately before the behaviour (triggers)

code:
  v: abc-behaviour
display:
  v: Behaviour
definition:
  v: Description of the behaviour itself (observable actions)

code:
  v: abc-consequence
display:
  v: Consequence
definition:
  v: What happened immediately after (response/outcome)

code:
  v: abc-function
display:
  v: Function of Behaviour
definition:
  v: Hypothesized function (e.g. Sensory, Escape, Attention, Tangible)

code:
  v: abc-duration
display:
  v: Duration
definition:
  v: Duration of the episode

code:
  v: abc-intensity
display:
  v: Intensity
definition:
  v: Intensity of the behaviour (1-10)

code:
  v: oral-health-score
display:
  v: Oral Health Score
definition:
  v: Total Oral Health Assessment Score

code:
  v: oral-lips
display:
  v: Lips
definition:
  v: Condition of lips (Pink/Moist vs Dry/Cracked)

code:
  v: oral-tongue
display:
  v: Tongue
definition:
  v: Condition of tongue (Pink/Moist vs Coated/Red)

code:
  v: oral-gums
display:
  v: Gums
definition:
  v: Condition of gums (Pink/Firm vs Bleeding/Receding)

code:
  v: oral-teeth
display:
  v: Teeth/Dentures
definition:
  v: Condition of teeth or dentures (Clean/Intact vs Decayed/Broken/Loose)

code:
  v: oral-saliva
display:
  v: Saliva
definition:
  v: Saliva quality (Moist/Watery vs Thick/Sticky/Absent)

code:
  v: seizure-record
display:
  v: Seizure Record
definition:
  v: Record of a seizure event

code:
  v: seizure-type
display:
  v: Seizure Type
definition:
  v: Type of seizure (Tonic-Clonic, Absence, Focal, etc)

code:
  v: seizure-duration
display:
  v: Seizure Duration
definition:
  v: Duration of the active seizure phase

code:
  v: seizure-recovery
display:
  v: Recovery Phase
definition:
  v: Duration/Description of post-ictal recovery

code:
  v: seizure-trigger
display:
  v: Trigger
definition:
  v: Suspected trigger for the seizure

code:
  v: sleep-record
display:
  v: Sleep Record
definition:
  v: Record of a sleep period

code:
  v: sleep-quality
display:
  v: Sleep Quality
definition:
  v: Subjective or observed quality of sleep

code:
  v: sleep-hours
display:
  v: Hours Slept
definition:
  v: Total hours of sleep achieved

code:
  v: sleep-disturbances
display:
  v: Disturbances
definition:
  v: Number or description of distinct awakenings

code:
  v: urinalysis-panel
display:
  v: Urinalysis Panel
definition:
  v: Urine Dipstick Test Panel

code:
  v: ua-leukocytes
display:
  v: Leukocytes
definition:
  v: Leukocytes (WBCs) in urine

code:
  v: ua-nitrites
display:
  v: Nitrites
definition:
  v: Nitrites in urine

code:
  v: ua-protein
display:
  v: Protein
definition:
  v: Protein in urine

code:
  v: ua-blood
display:
  v: Blood
definition:
  v: Blood (Hemoglobin) in urine

code:
  v: ua-glucose
display:
  v: Glucose
definition:
  v: Glucose in urine

code:
  v: ua-ketones
display:
  v: Ketones
definition:
  v: Ketones in urine

code:
  v: ua-ph
display:
  v: pH
definition:
  v: Urine pH Level

code:
  v: ua-sg
display:
  v: Specific Gravity
definition:
  v: Urine Specific Gravity

code:
  v: mca-present
display:
  v: Capacity Present
definition:
  v: Patient has capacity for this decision

code:
  v: 4at-change-no
display:
  v: No Acute Change
definition:
  v: No indication of acute change or fluctuating course

code:
  v: 4at-amt4-1error
display:
  v: 1 Error
definition:
  v: 1 error in AMT4 test

code:
  v: 4at-attention-gt7
display:
  v: Months Backwards < 7 months
definition:
  v: Less than 7 months correctly recited backwards

code:
  v: 4at-alert-normal
display:
  v: Normal Alertness
definition:
  v: Patient is fully alert