Open Nursing Core FHIR Implementation Guide (ONC-IG)
0.1.0 - draft
Open Nursing Core FHIR Implementation Guide (ONC-IG) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Draft as of 2026-01-01 |
<CodeSystem xmlns="http://hl7.org/fhir">
<id value="onc-observation-codes"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CodeSystem onc-observation-codes</b></p><a name="onc-observation-codes"> </a><a name="hconc-observation-codes"> </a><p>This code system <code>https://clinyqai.github.io/open-nursing-core-ig/CodeSystem/onc-observation-codes</code> defines the following codes:</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap">mst-score<a name="onc-observation-codes-mst-score"> </a></td><td>Monk Skin Tone Score</td><td>Assessment of skin tone using the Monk Skin Tone Scale</td></tr><tr><td style="white-space:nowrap">waterlow-score<a name="onc-observation-codes-waterlow-score"> </a></td><td>Waterlow Score</td><td>Total score for Waterlow pressure ulcer risk assessment</td></tr><tr><td style="white-space:nowrap">must-score<a name="onc-observation-codes-must-score"> </a></td><td>MUST Score</td><td>Malnutrition Universal Screening Tool total score</td></tr><tr><td style="white-space:nowrap">must-bmi-score<a name="onc-observation-codes-must-bmi-score"> </a></td><td>MUST BMI Score</td><td>Malnutrition Universal Screening Tool BMI score</td></tr><tr><td style="white-space:nowrap">must-weight-loss-score<a name="onc-observation-codes-must-weight-loss-score"> </a></td><td>MUST Weight Loss Score</td><td>Malnutrition Universal Screening Tool weight loss score</td></tr><tr><td style="white-space:nowrap">must-acute-disease-score<a name="onc-observation-codes-must-acute-disease-score"> </a></td><td>MUST Acute Disease Score</td><td>Malnutrition Universal Screening Tool acute disease effect score</td></tr><tr><td style="white-space:nowrap">braden-total-score<a name="onc-observation-codes-braden-total-score"> </a></td><td>Braden Total Score</td><td>Braden scale total score</td></tr><tr><td style="white-space:nowrap">braden-sensory<a name="onc-observation-codes-braden-sensory"> </a></td><td>Braden Sensory Perception</td><td>Sensory perception Braden scale</td></tr><tr><td style="white-space:nowrap">braden-moisture<a name="onc-observation-codes-braden-moisture"> </a></td><td>Braden Moisture</td><td>Moisture Braden scale</td></tr><tr><td style="white-space:nowrap">braden-activity<a name="onc-observation-codes-braden-activity"> </a></td><td>Braden Activity</td><td>Activity Braden scale</td></tr><tr><td style="white-space:nowrap">braden-mobility<a name="onc-observation-codes-braden-mobility"> </a></td><td>Braden Mobility</td><td>Mobility Braden scale</td></tr><tr><td style="white-space:nowrap">braden-nutrition<a name="onc-observation-codes-braden-nutrition"> </a></td><td>Braden Nutrition</td><td>Nutrition Braden scale</td></tr><tr><td style="white-space:nowrap">braden-friction<a name="onc-observation-codes-braden-friction"> </a></td><td>Braden Friction/Shear</td><td>Friction and shear Braden scale</td></tr><tr><td style="white-space:nowrap">barthel-score<a name="onc-observation-codes-barthel-score"> </a></td><td>Barthel Index Score</td><td>Total score for Barthel Index assessment</td></tr><tr><td style="white-space:nowrap">news2-score<a name="onc-observation-codes-news2-score"> </a></td><td>NEWS2 Score</td><td>National Early Warning Score 2 Total Score</td></tr><tr><td style="white-space:nowrap">news2-subscore<a name="onc-observation-codes-news2-subscore"> </a></td><td>NEWS2 Sub-score</td><td>Sub-score for NEWS2 parameter</td></tr><tr><td style="white-space:nowrap">wound-stage<a name="onc-observation-codes-wound-stage"> </a></td><td>Wound Stage</td><td>Stage of the wound</td></tr><tr><td style="white-space:nowrap">stage-1<a name="onc-observation-codes-stage-1"> </a></td><td>Stage 1</td><td>Stage 1 pressure ulcer</td></tr><tr><td style="white-space:nowrap">stage-2<a name="onc-observation-codes-stage-2"> </a></td><td>Stage 2</td><td>Stage 2 pressure ulcer</td></tr><tr><td style="white-space:nowrap">stage-3<a name="onc-observation-codes-stage-3"> </a></td><td>Stage 3</td><td>Stage 3 pressure ulcer</td></tr><tr><td style="white-space:nowrap">stage-4<a name="onc-observation-codes-stage-4"> </a></td><td>Stage 4</td><td>Stage 4 pressure ulcer</td></tr><tr><td style="white-space:nowrap">unstageable<a name="onc-observation-codes-unstageable"> </a></td><td>Unstageable</td><td>Unstageable pressure ulcer</td></tr><tr><td style="white-space:nowrap">deep-tissue<a name="onc-observation-codes-deep-tissue"> </a></td><td>Deep Tissue Injury</td><td>Deep tissue injury</td></tr><tr><td style="white-space:nowrap">risk-falls<a name="onc-observation-codes-risk-falls"> </a></td><td>Risk of Falls</td><td>Risk of falls diagnosis</td></tr><tr><td style="white-space:nowrap">fitzpatrick-1<a name="onc-observation-codes-fitzpatrick-1"> </a></td><td>Type I</td><td>Pale white; always burns, never tans</td></tr><tr><td style="white-space:nowrap">fitzpatrick-2<a name="onc-observation-codes-fitzpatrick-2"> </a></td><td>Type II</td><td>White; usually burns, tans with difficulty</td></tr><tr><td style="white-space:nowrap">fitzpatrick-3<a name="onc-observation-codes-fitzpatrick-3"> </a></td><td>Type III</td><td>Cream white; sometimes mild burn, gradually tans</td></tr><tr><td style="white-space:nowrap">fitzpatrick-4<a name="onc-observation-codes-fitzpatrick-4"> </a></td><td>Type IV</td><td>Moderate brown; rarely burns, tans with ease</td></tr><tr><td style="white-space:nowrap">fitzpatrick-5<a name="onc-observation-codes-fitzpatrick-5"> </a></td><td>Type V</td><td>Dark brown; very rarely burns, tans very easily</td></tr><tr><td style="white-space:nowrap">fitzpatrick-6<a name="onc-observation-codes-fitzpatrick-6"> </a></td><td>Type VI</td><td>Deeply pigmented dark brown to black; never burns, tans very easily</td></tr><tr><td style="white-space:nowrap">what-matters<a name="onc-observation-codes-what-matters"> </a></td><td>What Matters to Me</td><td>Patient-identified priorities and non-clinical goals</td></tr><tr><td style="white-space:nowrap">patient-story<a name="onc-observation-codes-patient-story"> </a></td><td>Patient Story</td><td>Narrative summary of patient background, preferences, and autobiography</td></tr><tr><td style="white-space:nowrap">relational-engagement<a name="onc-observation-codes-relational-engagement"> </a></td><td>Relational Engagement Score</td><td>Assessment of the quality of nurse-patient engagement (1-5)</td></tr><tr><td style="white-space:nowrap">cfs-score<a name="onc-observation-codes-cfs-score"> </a></td><td>Clinical Frailty Scale Score</td><td>Total score for Rockwood Clinical Frailty Scale</td></tr><tr><td style="white-space:nowrap">cfs-1<a name="onc-observation-codes-cfs-1"> </a></td><td>Very Fit</td><td>Robus, active, energetic and motivated</td></tr><tr><td style="white-space:nowrap">cfs-2<a name="onc-observation-codes-cfs-2"> </a></td><td>Well</td><td>No active disease symptoms but less fit than category 1</td></tr><tr><td style="white-space:nowrap">cfs-3<a name="onc-observation-codes-cfs-3"> </a></td><td>Managing Well</td><td>Medical problems are well controlled, but not regularly active</td></tr><tr><td style="white-space:nowrap">cfs-4<a name="onc-observation-codes-cfs-4"> </a></td><td>Vulnerable</td><td>Not dependent for daily help, but symptoms limit activities</td></tr><tr><td style="white-space:nowrap">cfs-5<a name="onc-observation-codes-cfs-5"> </a></td><td>Mildly Frail</td><td>Need help with high order IADLs (finances, transportation, heavy housework)</td></tr><tr><td style="white-space:nowrap">cfs-6<a name="onc-observation-codes-cfs-6"> </a></td><td>Moderately Frail</td><td>Need help with all outside activities and some housekeeping</td></tr><tr><td style="white-space:nowrap">cfs-7<a name="onc-observation-codes-cfs-7"> </a></td><td>Severely Frail</td><td>Completely dependent for personal care</td></tr><tr><td style="white-space:nowrap">cfs-8<a name="onc-observation-codes-cfs-8"> </a></td><td>Very Severely Frail</td><td>Completely dependent, approaching end of life</td></tr><tr><td style="white-space:nowrap">cfs-9<a name="onc-observation-codes-cfs-9"> </a></td><td>Terminally Ill</td><td>Approaching the end of life (life expectancy <6 months)</td></tr><tr><td style="white-space:nowrap">4at-score<a name="onc-observation-codes-4at-score"> </a></td><td>4AT Delirium Score</td><td>Total score for 4AT assessment</td></tr><tr><td style="white-space:nowrap">4at-alertness<a name="onc-observation-codes-4at-alertness"> </a></td><td>Alertness</td><td>4AT Item 1: Alertness</td></tr><tr><td style="white-space:nowrap">4at-amt4<a name="onc-observation-codes-4at-amt4"> </a></td><td>AMT4 Score</td><td>4AT Item 2: Abbreviated Mental Test 4</td></tr><tr><td style="white-space:nowrap">4at-attention<a name="onc-observation-codes-4at-attention"> </a></td><td>Attention</td><td>4AT Item 3: Attention (Months Backwards)</td></tr><tr><td style="white-space:nowrap">4at-acute-change<a name="onc-observation-codes-4at-acute-change"> </a></td><td>Acute Change</td><td>4AT Item 4: Acute Change or Fluctuating Course</td></tr><tr><td style="white-space:nowrap">reasonable-adjustment<a name="onc-observation-codes-reasonable-adjustment"> </a></td><td>Reasonable Adjustment</td><td>Requirement for adjustment to care delivery (Equality Act)</td></tr><tr><td style="white-space:nowrap">mca-assessment<a name="onc-observation-codes-mca-assessment"> </a></td><td>Mental Capacity Assessment</td><td>Assessment of capacity to make a specific decision</td></tr><tr><td style="white-space:nowrap">capacity-present<a name="onc-observation-codes-capacity-present"> </a></td><td>Capacity Present</td><td>Patient has capacity for this decision</td></tr><tr><td style="white-space:nowrap">capacity-absent<a name="onc-observation-codes-capacity-absent"> </a></td><td>Capacity Absent</td><td>Patient lacks capacity for this decision</td></tr><tr><td style="white-space:nowrap">best-interest<a name="onc-observation-codes-best-interest"> </a></td><td>Best Interest Decision</td><td>Decision made in patient's best interest</td></tr><tr><td style="white-space:nowrap">bristol-score<a name="onc-observation-codes-bristol-score"> </a></td><td>Bristol Stool Score</td><td>Bristol Stool Form Scale Score (1-7)</td></tr><tr><td style="white-space:nowrap">bristol-1<a name="onc-observation-codes-bristol-1"> </a></td><td>Type 1</td><td>Separate hard lumps, like nuts (hard to pass)</td></tr><tr><td style="white-space:nowrap">bristol-2<a name="onc-observation-codes-bristol-2"> </a></td><td>Type 2</td><td>Sausage-shaped but lumpy</td></tr><tr><td style="white-space:nowrap">bristol-3<a name="onc-observation-codes-bristol-3"> </a></td><td>Type 3</td><td>Like a sausage but with cracks on its surface</td></tr><tr><td style="white-space:nowrap">bristol-4<a name="onc-observation-codes-bristol-4"> </a></td><td>Type 4</td><td>Like a sausage or snake, smooth and soft</td></tr><tr><td style="white-space:nowrap">bristol-5<a name="onc-observation-codes-bristol-5"> </a></td><td>Type 5</td><td>Soft blobs with clear-cut edges (passed easily)</td></tr><tr><td style="white-space:nowrap">bristol-6<a name="onc-observation-codes-bristol-6"> </a></td><td>Type 6</td><td>Fluffy pieces with ragged edges, a mushy stool</td></tr><tr><td style="white-space:nowrap">bristol-7<a name="onc-observation-codes-bristol-7"> </a></td><td>Type 7</td><td>Watery, no solid pieces. Entirely liquid</td></tr><tr><td style="white-space:nowrap">abbey-score<a name="onc-observation-codes-abbey-score"> </a></td><td>Abbey Pain Scale Score</td><td>Total Abbey Pain Scale Score (0-100+ but usually 0-18+)</td></tr><tr><td style="white-space:nowrap">abbey-vocalization<a name="onc-observation-codes-abbey-vocalization"> </a></td><td>Vocalization</td><td>Whimpering, groaning, crying</td></tr><tr><td style="white-space:nowrap">abbey-facial-expression<a name="onc-observation-codes-abbey-facial-expression"> </a></td><td>Facial Expression</td><td>Looking tense, frowning, grimacing, looking frightened</td></tr><tr><td style="white-space:nowrap">abbey-body-language<a name="onc-observation-codes-abbey-body-language"> </a></td><td>Body Language</td><td>Fidgeting, rocking, guarding part of body, withdrawn</td></tr><tr><td style="white-space:nowrap">abbey-behavioral-change<a name="onc-observation-codes-abbey-behavioral-change"> </a></td><td>Behavioral Change</td><td>Increased confusion, refusing to eat, alteration in usual pattern</td></tr><tr><td style="white-space:nowrap">abbey-psychological-change<a name="onc-observation-codes-abbey-psychological-change"> </a></td><td>Psychological Change</td><td>Temperature, pulse, blood pressure changes, perspiration, pallor</td></tr><tr><td style="white-space:nowrap">abbey-physical-changes<a name="onc-observation-codes-abbey-physical-changes"> </a></td><td>Physical Changes</td><td>Skin tears, pressure areas, arthritis, contractures, previous injuries</td></tr><tr><td style="white-space:nowrap">fluid-input-total<a name="onc-observation-codes-fluid-input-total"> </a></td><td>Total Fluid Input</td><td>Total fluid input over specified period (e.g. 24h)</td></tr><tr><td style="white-space:nowrap">fluid-output-total<a name="onc-observation-codes-fluid-output-total"> </a></td><td>Total Fluid Output</td><td>Total fluid output over specified period (e.g. 24h)</td></tr><tr><td style="white-space:nowrap">fluid-balance<a name="onc-observation-codes-fluid-balance"> </a></td><td>Fluid Balance</td><td>Total Input minus Total Output</td></tr><tr><td style="white-space:nowrap">urine-output<a name="onc-observation-codes-urine-output"> </a></td><td>Urine Output</td><td>Volume of urine passed</td></tr><tr><td style="white-space:nowrap">abc-chart<a name="onc-observation-codes-abc-chart"> </a></td><td>ABC Chart</td><td>Antecedent-Behaviour-Consequence Chart for PBS</td></tr><tr><td style="white-space:nowrap">abc-antecedent<a name="onc-observation-codes-abc-antecedent"> </a></td><td>Antecedent</td><td>What happened immediately before the behaviour (triggers)</td></tr><tr><td style="white-space:nowrap">abc-behaviour<a name="onc-observation-codes-abc-behaviour"> </a></td><td>Behaviour</td><td>Description of the behaviour itself (observable actions)</td></tr><tr><td style="white-space:nowrap">abc-consequence<a name="onc-observation-codes-abc-consequence"> </a></td><td>Consequence</td><td>What happened immediately after (response/outcome)</td></tr><tr><td style="white-space:nowrap">abc-function<a name="onc-observation-codes-abc-function"> </a></td><td>Function of Behaviour</td><td>Hypothesized function (e.g. Sensory, Escape, Attention, Tangible)</td></tr><tr><td style="white-space:nowrap">abc-duration<a name="onc-observation-codes-abc-duration"> </a></td><td>Duration</td><td>Duration of the episode</td></tr><tr><td style="white-space:nowrap">abc-intensity<a name="onc-observation-codes-abc-intensity"> </a></td><td>Intensity</td><td>Intensity of the behaviour (1-10)</td></tr><tr><td style="white-space:nowrap">oral-health-score<a name="onc-observation-codes-oral-health-score"> </a></td><td>Oral Health Score</td><td>Total Oral Health Assessment Score</td></tr><tr><td style="white-space:nowrap">oral-lips<a name="onc-observation-codes-oral-lips"> </a></td><td>Lips</td><td>Condition of lips (Pink/Moist vs Dry/Cracked)</td></tr><tr><td style="white-space:nowrap">oral-tongue<a name="onc-observation-codes-oral-tongue"> </a></td><td>Tongue</td><td>Condition of tongue (Pink/Moist vs Coated/Red)</td></tr><tr><td style="white-space:nowrap">oral-gums<a name="onc-observation-codes-oral-gums"> </a></td><td>Gums</td><td>Condition of gums (Pink/Firm vs Bleeding/Receding)</td></tr><tr><td style="white-space:nowrap">oral-teeth<a name="onc-observation-codes-oral-teeth"> </a></td><td>Teeth/Dentures</td><td>Condition of teeth or dentures (Clean/Intact vs Decayed/Broken/Loose)</td></tr><tr><td style="white-space:nowrap">oral-saliva<a name="onc-observation-codes-oral-saliva"> </a></td><td>Saliva</td><td>Saliva quality (Moist/Watery vs Thick/Sticky/Absent)</td></tr><tr><td style="white-space:nowrap">seizure-record<a name="onc-observation-codes-seizure-record"> </a></td><td>Seizure Record</td><td>Record of a seizure event</td></tr><tr><td style="white-space:nowrap">seizure-type<a name="onc-observation-codes-seizure-type"> </a></td><td>Seizure Type</td><td>Type of seizure (Tonic-Clonic, Absence, Focal, etc)</td></tr><tr><td style="white-space:nowrap">seizure-duration<a name="onc-observation-codes-seizure-duration"> </a></td><td>Seizure Duration</td><td>Duration of the active seizure phase</td></tr><tr><td style="white-space:nowrap">seizure-recovery<a name="onc-observation-codes-seizure-recovery"> </a></td><td>Recovery Phase</td><td>Duration/Description of post-ictal recovery</td></tr><tr><td style="white-space:nowrap">seizure-trigger<a name="onc-observation-codes-seizure-trigger"> </a></td><td>Trigger</td><td>Suspected trigger for the seizure</td></tr><tr><td style="white-space:nowrap">sleep-record<a name="onc-observation-codes-sleep-record"> </a></td><td>Sleep Record</td><td>Record of a sleep period</td></tr><tr><td style="white-space:nowrap">sleep-quality<a name="onc-observation-codes-sleep-quality"> </a></td><td>Sleep Quality</td><td>Subjective or observed quality of sleep</td></tr><tr><td style="white-space:nowrap">sleep-hours<a name="onc-observation-codes-sleep-hours"> </a></td><td>Hours Slept</td><td>Total hours of sleep achieved</td></tr><tr><td style="white-space:nowrap">sleep-disturbances<a name="onc-observation-codes-sleep-disturbances"> </a></td><td>Disturbances</td><td>Number or description of distinct awakenings</td></tr><tr><td style="white-space:nowrap">urinalysis-panel<a name="onc-observation-codes-urinalysis-panel"> </a></td><td>Urinalysis Panel</td><td>Urine Dipstick Test Panel</td></tr><tr><td style="white-space:nowrap">ua-leukocytes<a name="onc-observation-codes-ua-leukocytes"> </a></td><td>Leukocytes</td><td>Leukocytes (WBCs) in urine</td></tr><tr><td style="white-space:nowrap">ua-nitrites<a name="onc-observation-codes-ua-nitrites"> </a></td><td>Nitrites</td><td>Nitrites in urine</td></tr><tr><td style="white-space:nowrap">ua-protein<a name="onc-observation-codes-ua-protein"> </a></td><td>Protein</td><td>Protein in urine</td></tr><tr><td style="white-space:nowrap">ua-blood<a name="onc-observation-codes-ua-blood"> </a></td><td>Blood</td><td>Blood (Hemoglobin) in urine</td></tr><tr><td style="white-space:nowrap">ua-glucose<a name="onc-observation-codes-ua-glucose"> </a></td><td>Glucose</td><td>Glucose in urine</td></tr><tr><td style="white-space:nowrap">ua-ketones<a name="onc-observation-codes-ua-ketones"> </a></td><td>Ketones</td><td>Ketones in urine</td></tr><tr><td style="white-space:nowrap">ua-ph<a name="onc-observation-codes-ua-ph"> </a></td><td>pH</td><td>Urine pH Level</td></tr><tr><td style="white-space:nowrap">ua-sg<a name="onc-observation-codes-ua-sg"> </a></td><td>Specific Gravity</td><td>Urine Specific Gravity</td></tr><tr><td style="white-space:nowrap">mca-present<a name="onc-observation-codes-mca-present"> </a></td><td>Capacity Present</td><td>Patient has capacity for this decision</td></tr><tr><td style="white-space:nowrap">4at-change-no<a name="onc-observation-codes-4at-change-no"> </a></td><td>No Acute Change</td><td>No indication of acute change or fluctuating course</td></tr><tr><td style="white-space:nowrap">4at-amt4-1error<a name="onc-observation-codes-4at-amt4-1error"> </a></td><td>1 Error</td><td>1 error in AMT4 test</td></tr><tr><td style="white-space:nowrap">4at-attention-gt7<a name="onc-observation-codes-4at-attention-gt7"> </a></td><td>Months Backwards < 7 months</td><td>Less than 7 months correctly recited backwards</td></tr><tr><td style="white-space:nowrap">4at-alert-normal<a name="onc-observation-codes-4at-alert-normal"> </a></td><td>Normal Alertness</td><td>Patient is fully alert</td></tr></table></div>
</text>
<url
value="https://clinyqai.github.io/open-nursing-core-ig/CodeSystem/onc-observation-codes"/>
<version value="0.1.0"/>
<name value="ONCObservationCodes"/>
<title value="ONC Observation Codes"/>
<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>