<status value="draft"/> <date value="2026-01-01T13:37:23+00:00"/> <description value="Custom observation codes for Open Nursing Core"/> <content value="complete"/> <count value="108"/> <concept> <code value="mst-score"/> <display value="Monk Skin Tone Score"/> <definition value="Assessment of skin tone using the Monk Skin Tone Scale"/> </concept> <concept> <code value="waterlow-score"/> <display value="Waterlow Score"/> <definition value="Total score for Waterlow pressure ulcer risk assessment"/> </concept> <concept> <code value="must-score"/> <display value="MUST Score"/> <definition value="Malnutrition Universal Screening Tool total score"/> </concept> <concept> <code value="must-bmi-score"/> <display value="MUST BMI Score"/> <definition value="Malnutrition Universal Screening Tool BMI score"/> </concept> <concept> <code value="must-weight-loss-score"/> <display value="MUST Weight Loss Score"/> <definition value="Malnutrition Universal Screening Tool weight loss score"/> </concept> <concept> <code value="must-acute-disease-score"/> <display value="MUST Acute Disease Score"/> <definition value="Malnutrition Universal Screening Tool acute disease effect score"/> </concept> <concept> <code value="braden-total-score"/> <display value="Braden Total Score"/> <definition value="Braden scale total score"/> </concept> <concept> <code value="braden-sensory"/> <display value="Braden Sensory Perception"/> <definition value="Sensory perception Braden scale"/> </concept> <concept> <code value="braden-moisture"/> <display value="Braden Moisture"/> <definition value="Moisture Braden scale"/> </concept> <concept> <code value="braden-activity"/> <display value="Braden Activity"/> <definition value="Activity Braden scale"/> </concept> <concept> <code value="braden-mobility"/> <display value="Braden Mobility"/> <definition value="Mobility Braden scale"/> </concept> <concept> <code value="braden-nutrition"/> <display value="Braden Nutrition"/> <definition value="Nutrition Braden scale"/> </concept> <concept> <code value="braden-friction"/> <display value="Braden Friction/Shear"/> <definition value="Friction and shear Braden scale"/> </concept> <concept> <code value="barthel-score"/> <display value="Barthel Index Score"/> <definition value="Total score for Barthel Index assessment"/> </concept> <concept> <code value="news2-score"/> <display value="NEWS2 Score"/> <definition value="National Early Warning Score 2 Total Score"/> </concept> <concept> <code value="news2-subscore"/> <display value="NEWS2 Sub-score"/> <definition value="Sub-score for NEWS2 parameter"/> </concept> <concept> <code value="wound-stage"/> <display value="Wound Stage"/> <definition value="Stage of the wound"/> </concept> <concept> <code value="stage-1"/> <display value="Stage 1"/> <definition value="Stage 1 pressure ulcer"/> </concept> <concept> <code value="stage-2"/> <display value="Stage 2"/> <definition value="Stage 2 pressure ulcer"/> </concept> <concept> <code value="stage-3"/> <display value="Stage 3"/> <definition value="Stage 3 pressure ulcer"/> </concept> <concept> <code value="stage-4"/> <display value="Stage 4"/> <definition value="Stage 4 pressure ulcer"/> </concept> <concept> <code value="unstageable"/> <display value="Unstageable"/> <definition value="Unstageable pressure ulcer"/> </concept> <concept> <code value="deep-tissue"/> <display value="Deep Tissue Injury"/> <definition value="Deep tissue injury"/> </concept> <concept> <code value="risk-falls"/> <display value="Risk of Falls"/> <definition value="Risk of falls diagnosis"/> </concept> <concept> <code value="fitzpatrick-1"/> <display value="Type I"/> <definition value="Pale white; always burns, never tans"/> </concept> <concept> <code value="fitzpatrick-2"/> <display value="Type II"/> <definition value="White; usually burns, tans with difficulty"/> </concept> <concept> <code value="fitzpatrick-3"/> <display value="Type III"/> <definition value="Cream white; sometimes mild burn, gradually tans"/> </concept> <concept> <code value="fitzpatrick-4"/> <display value="Type IV"/> <definition value="Moderate brown; rarely burns, tans with ease"/> </concept> <concept> <code value="fitzpatrick-5"/> <display value="Type V"/> <definition value="Dark brown; very rarely burns, tans very easily"/> </concept> <concept> <code value="fitzpatrick-6"/> <display value="Type VI"/> <definition value="Deeply pigmented dark brown to black; never burns, tans very easily"/> </concept> <concept> <code value="what-matters"/> <display value="What Matters to Me"/> <definition value="Patient-identified priorities and non-clinical goals"/> </concept> <concept> <code value="patient-story"/> <display value="Patient Story"/> <definition value="Narrative summary of patient background, preferences, and autobiography"/> </concept> <concept> <code value="relational-engagement"/> <display value="Relational Engagement Score"/> <definition value="Assessment of the quality of nurse-patient engagement (1-5)"/> </concept> <concept> <code value="cfs-score"/> <display value="Clinical Frailty Scale Score"/> <definition value="Total score for Rockwood Clinical Frailty Scale"/> </concept> <concept> <code value="cfs-1"/> <display value="Very Fit"/> <definition value="Robus, active, energetic and motivated"/> </concept> <concept> <code value="cfs-2"/> <display value="Well"/> <definition value="No active disease symptoms but less fit than category 1"/> </concept> <concept> <code value="cfs-3"/> <display value="Managing Well"/> <definition value="Medical problems are well controlled, but not regularly active"/> </concept> <concept> <code value="cfs-4"/> <display value="Vulnerable"/> <definition value="Not dependent for daily help, but symptoms limit activities"/> </concept> <concept> <code value="cfs-5"/> <display value="Mildly Frail"/> <definition value="Need help with high order IADLs (finances, transportation, heavy housework)"/> </concept> <concept> <code value="cfs-6"/> <display value="Moderately Frail"/> <definition value="Need help with all outside activities and some housekeeping"/> </concept> <concept> <code value="cfs-7"/> <display value="Severely Frail"/> <definition value="Completely dependent for personal care"/> </concept> <concept> <code value="cfs-8"/> <display value="Very Severely Frail"/> <definition value="Completely dependent, approaching end of life"/> </concept> <concept> <code value="cfs-9"/> <display value="Terminally Ill"/> <definition value="Approaching the end of life (life expectancy <6 months)"/> </concept> <concept> <code value="4at-score"/> <display value="4AT Delirium Score"/> <definition value="Total score for 4AT assessment"/> </concept> <concept> <code value="4at-alertness"/> <display value="Alertness"/> <definition value="4AT Item 1: Alertness"/> </concept> <concept> <code value="4at-amt4"/> <display value="AMT4 Score"/> <definition value="4AT Item 2: Abbreviated Mental Test 4"/> </concept> <concept> <code value="4at-attention"/> <display value="Attention"/> <definition value="4AT Item 3: Attention (Months Backwards)"/> </concept> <concept> <code value="4at-acute-change"/> <display value="Acute Change"/> <definition value="4AT Item 4: Acute Change or Fluctuating Course"/> </concept> <concept> <code value="reasonable-adjustment"/> <display value="Reasonable Adjustment"/> <definition value="Requirement for adjustment to care delivery (Equality Act)"/> </concept> <concept> <code value="mca-assessment"/> <display value="Mental Capacity Assessment"/> <definition value="Assessment of capacity to make a specific decision"/> </concept> <concept> <code value="capacity-present"/> <display value="Capacity Present"/> <definition value="Patient has capacity for this decision"/> </concept> <concept> <code value="capacity-absent"/> <display value="Capacity Absent"/> <definition value="Patient lacks capacity for this decision"/> </concept> <concept> <code value="best-interest"/> <display value="Best Interest Decision"/> <definition value="Decision made in patient's best interest"/> </concept> <concept> <code value="bristol-score"/> <display value="Bristol Stool Score"/> <definition value="Bristol Stool Form Scale Score (1-7)"/> </concept> <concept> <code value="bristol-1"/> <display value="Type 1"/> <definition value="Separate hard lumps, like nuts (hard to pass)"/> </concept> <concept> <code value="bristol-2"/> <display value="Type 2"/> <definition value="Sausage-shaped but lumpy"/> </concept> <concept> <code value="bristol-3"/> <display value="Type 3"/> <definition value="Like a sausage but with cracks on its surface"/> </concept> <concept> <code value="bristol-4"/> <display value="Type 4"/> <definition value="Like a sausage or snake, smooth and soft"/> </concept> <concept> <code value="bristol-5"/> <display value="Type 5"/> <definition value="Soft blobs with clear-cut edges (passed easily)"/> </concept> <concept> <code value="bristol-6"/> <display value="Type 6"/> <definition value="Fluffy pieces with ragged edges, a mushy stool"/> </concept> <concept> <code value="bristol-7"/> <display value="Type 7"/> <definition value="Watery, no solid pieces. Entirely liquid"/> </concept> <concept> <code value="abbey-score"/> <display value="Abbey Pain Scale Score"/> <definition value="Total Abbey Pain Scale Score (0-100+ but usually 0-18+)"/> </concept> <concept> <code value="abbey-vocalization"/> <display value="Vocalization"/> <definition value="Whimpering, groaning, crying"/> </concept> <concept> <code value="abbey-facial-expression"/> <display value="Facial Expression"/> <definition value="Looking tense, frowning, grimacing, looking frightened"/> </concept> <concept> <code value="abbey-body-language"/> <display value="Body Language"/> <definition value="Fidgeting, rocking, guarding part of body, withdrawn"/> </concept> <concept> <code value="abbey-behavioral-change"/> <display value="Behavioral Change"/> <definition value="Increased confusion, refusing to eat, alteration in usual pattern"/> </concept> <concept> <code value="abbey-psychological-change"/> <display value="Psychological Change"/> <definition value="Temperature, pulse, blood pressure changes, perspiration, pallor"/> </concept> <concept> <code value="abbey-physical-changes"/> <display value="Physical Changes"/> <definition value="Skin tears, pressure areas, arthritis, contractures, previous injuries"/> </concept> <concept> <code value="fluid-input-total"/> <display value="Total Fluid Input"/> <definition value="Total fluid input over specified period (e.g. 24h)"/> </concept> <concept> <code value="fluid-output-total"/> <display value="Total Fluid Output"/> <definition value="Total fluid output over specified period (e.g. 24h)"/> </concept> <concept> <code value="fluid-balance"/> <display value="Fluid Balance"/> <definition value="Total Input minus Total Output"/> </concept> <concept> <code value="urine-output"/> <display value="Urine Output"/> <definition value="Volume of urine passed"/> </concept> <concept> <code value="abc-chart"/> <display value="ABC Chart"/> <definition value="Antecedent-Behaviour-Consequence Chart for PBS"/> </concept> <concept> <code value="abc-antecedent"/> <display value="Antecedent"/> <definition value="What happened immediately before the behaviour (triggers)"/> </concept> <concept> <code value="abc-behaviour"/> <display value="Behaviour"/> <definition value="Description of the behaviour itself (observable actions)"/> </concept> <concept> <code value="abc-consequence"/> <display value="Consequence"/> <definition value="What happened immediately after (response/outcome)"/> </concept> <concept> <code value="abc-function"/> <display value="Function of Behaviour"/> <definition value="Hypothesized function (e.g. Sensory, Escape, Attention, Tangible)"/> </concept> <concept> <code value="abc-duration"/> <display value="Duration"/> <definition value="Duration of the episode"/> </concept> <concept> <code value="abc-intensity"/> <display value="Intensity"/> <definition value="Intensity of the behaviour (1-10)"/> </concept> <concept> <code value="oral-health-score"/> <display value="Oral Health Score"/> <definition value="Total Oral Health Assessment Score"/> </concept> <concept> <code value="oral-lips"/> <display value="Lips"/> <definition value="Condition of lips (Pink/Moist vs Dry/Cracked)"/> </concept> <concept> <code value="oral-tongue"/> <display value="Tongue"/> <definition value="Condition of tongue (Pink/Moist vs Coated/Red)"/> </concept> <concept> <code value="oral-gums"/> <display value="Gums"/> <definition value="Condition of gums (Pink/Firm vs Bleeding/Receding)"/> </concept> <concept> <code value="oral-teeth"/> <display value="Teeth/Dentures"/> <definition value="Condition of teeth or dentures (Clean/Intact vs Decayed/Broken/Loose)"/> </concept> <concept> <code value="oral-saliva"/> <display value="Saliva"/> <definition value="Saliva quality (Moist/Watery vs Thick/Sticky/Absent)"/> </concept> <concept> <code value="seizure-record"/> <display value="Seizure Record"/> <definition value="Record of a seizure event"/> </concept> <concept> <code value="seizure-type"/> <display value="Seizure Type"/> <definition value="Type of seizure (Tonic-Clonic, Absence, Focal, etc)"/> </concept> <concept> <code value="seizure-duration"/> <display value="Seizure Duration"/> <definition value="Duration of the active seizure phase"/> </concept> <concept> <code value="seizure-recovery"/> <display value="Recovery Phase"/> <definition value="Duration/Description of post-ictal recovery"/> </concept> <concept> <code value="seizure-trigger"/> <display value="Trigger"/> <definition value="Suspected trigger for the seizure"/> </concept> <concept> <code value="sleep-record"/> <display value="Sleep Record"/> <definition value="Record of a sleep period"/> </concept> <concept> <code value="sleep-quality"/> <display value="Sleep Quality"/> <definition value="Subjective or observed quality of sleep"/> </concept> <concept> <code value="sleep-hours"/> <display value="Hours Slept"/> <definition value="Total hours of sleep achieved"/> </concept> <concept> <code value="sleep-disturbances"/> <display value="Disturbances"/> <definition value="Number or description of distinct awakenings"/> </concept> <concept> <code value="urinalysis-panel"/> <display value="Urinalysis Panel"/> <definition value="Urine Dipstick Test Panel"/> </concept> <concept> <code value="ua-leukocytes"/> <display value="Leukocytes"/> <definition value="Leukocytes (WBCs) in urine"/> </concept> <concept> <code value="ua-nitrites"/> <display value="Nitrites"/> <definition value="Nitrites in urine"/> </concept> <concept> <code value="ua-protein"/> <display value="Protein"/> <definition value="Protein in urine"/> </concept> <concept> <code value="ua-blood"/> <display value="Blood"/> <definition value="Blood (Hemoglobin) in urine"/> </concept> <concept> <code value="ua-glucose"/> <display value="Glucose"/> <definition value="Glucose in urine"/> </concept> <concept> <code value="ua-ketones"/> <display value="Ketones"/> <definition value="Ketones in urine"/> </concept> <concept> <code value="ua-ph"/> <display value="pH"/> <definition value="Urine pH Level"/> </concept> <concept> <code value="ua-sg"/> <display value="Specific Gravity"/> <definition value="Urine Specific Gravity"/> </concept> <concept> <code value="mca-present"/> <display value="Capacity Present"/> <definition value="Patient has capacity for this decision"/> </concept> <concept> <code value="4at-change-no"/> <display value="No Acute Change"/> <definition value="No indication of acute change or fluctuating course"/> </concept> <concept> <code value="4at-amt4-1error"/> <display value="1 Error"/> <definition value="1 error in AMT4 test"/> </concept> <concept> <code value="4at-attention-gt7"/> <display value="Months Backwards < 7 months"/> <definition value="Less than 7 months correctly recited backwards"/> </concept> <concept> <code value="4at-alert-normal"/> <display value="Normal Alertness"/> <definition value="Patient is fully alert"/> </concept> </CodeSystem>

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