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 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
Custom observation codes for Open Nursing Core
Assessment of skin tone using the Monk Skin Tone Scale
Total score for Waterlow pressure ulcer risk assessment
Malnutrition Universal Screening Tool total score
Malnutrition Universal Screening Tool BMI score
Malnutrition Universal Screening Tool weight loss score
Malnutrition Universal Screening Tool acute disease effect score
Total score for Barthel Index assessment
National Early Warning Score 2 Total Score
White; usually burns, tans with difficulty
Cream white; sometimes mild burn, gradually tans
Moderate brown; rarely burns, tans with ease
Dark brown; very rarely burns, tans very easily
Deeply pigmented dark brown to black; never burns, tans very easily
Patient-identified priorities and non-clinical goals
Narrative summary of patient background, preferences, and autobiography
Assessment of the quality of nurse-patient engagement (1-5)
Total score for Rockwood Clinical Frailty Scale
No active disease symptoms but less fit than category 1
Medical problems are well controlled, but not regularly active
Not dependent for daily help, but symptoms limit activities
Need help with high order IADLs (finances, transportation, heavy housework)
Need help with all outside activities and some housekeeping
Completely dependent, approaching end of life
Approaching the end of life (life expectancy <6 months)
4AT Item 3: Attention (Months Backwards)
4AT Item 4: Acute Change or Fluctuating Course
Requirement for adjustment to care delivery (Equality Act)
Assessment of capacity to make a specific decision
Patient lacks capacity for this decision
Decision made in patient's best interest
Separate hard lumps, like nuts (hard to pass)
Like a sausage but with cracks on its surface
Like a sausage or snake, smooth and soft
Soft blobs with clear-cut edges (passed easily)
Fluffy pieces with ragged edges, a mushy stool
Watery, no solid pieces. Entirely liquid
Total Abbey Pain Scale Score (0-100+ but usually 0-18+)
Looking tense, frowning, grimacing, looking frightened
Fidgeting, rocking, guarding part of body, withdrawn
Increased confusion, refusing to eat, alteration in usual pattern
Temperature, pulse, blood pressure changes, perspiration, pallor
Skin tears, pressure areas, arthritis, contractures, previous injuries
Total fluid input over specified period (e.g. 24h)
Total fluid output over specified period (e.g. 24h)
Antecedent-Behaviour-Consequence Chart for PBS
What happened immediately before the behaviour (triggers)
Description of the behaviour itself (observable actions)
What happened immediately after (response/outcome)
Hypothesized function (e.g. Sensory, Escape, Attention, Tangible)
Condition of lips (Pink/Moist vs Dry/Cracked)
Condition of tongue (Pink/Moist vs Coated/Red)
Condition of gums (Pink/Firm vs Bleeding/Receding)
Condition of teeth or dentures (Clean/Intact vs Decayed/Broken/Loose)
Saliva quality (Moist/Watery vs Thick/Sticky/Absent)
Type of seizure (Tonic-Clonic, Absence, Focal, etc)
Duration/Description of post-ictal recovery
Number or description of distinct awakenings
No indication of acute change or fluctuating course
Less than 7 months correctly recited backwards