| 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 |