{ "resourceType" : "CodeSystem", "id" : "answer-codesystem", "text" : { "status" : "generated", "div" : "

Generated Narrative: CodeSystem answer-codesystem

This case-sensitive code system https://fhir.slade360.co.ke/fhir/CodeSystem/answer-codesystem defines the following codes:

CodeDisplayDefinition
triage-emergency EmergencyNeeds a clinician immediately. An emergency sign is present.
triage-priority PriorityNeeds a clinician within fifteen minutes. A priority sign is present.
triage-less-urgent Less urgentCan safely wait in the queue.
triage-well-baby Well babyAttending for a routine check, not for illness.
grade-absent 0 — absentThe finding is not present.
grade-mild + — mildThe finding is present and mild.
grade-severe +++ — severeThe finding is present and severe.
avpu-alert A — alertAwake and alert.
avpu-verbal V — responds to voiceResponds to voice but is not fully alert.
avpu-pain P — responds to painResponds only to a painful stimulus.
avpu-unresponsive U — unresponsiveDoes not respond to a painful stimulus.
oedema-none NoneNo oedema.
oedema-feet FeetOedema of the feet only.
oedema-knee To the kneeOedema extending to the knees.
oedema-face FaceOedema involving the face, which is the most severe grade.
umbilicus-normal NormalThe cord stump is clean and dry.
umbilicus-pus PusThe cord stump is discharging pus.
umbilicus-pus-and-redness Pus and red skinThe cord stump is discharging pus and the surrounding skin is red, which is periumbilical cellulitis.
cord-fresh FreshThe cord is still fresh.
cord-dry DryThe cord has dried.
cord-infected InfectedThe cord is infected.
pmtct-positive PositiveThe mother is known to be HIV positive and in the PMTCT programme.
pmtct-negative NegativeThe mother tested HIV negative.
pmtct-unknown UnknownThe mother's status could not be established.
delivery-svd SVDSpontaneous vaginal delivery.
delivery-breech BreechBreech vaginal delivery.
delivery-caesarean C/SCaesarean section.
delivery-assisted-vacuum VacuumAssisted vaginal delivery by vacuum extraction.
delivery-assisted-forceps ForcepsAssisted vaginal delivery by forceps.
place-of-birth-home HomeBorn at home.
place-of-birth-hospital HospitalBorn in a health facility.
place-of-birth-other OtherBorn somewhere other than home or a facility, such as in transit.
lie-longitudinal LongitudinalThe fetus lies along the axis of the uterus.
lie-transverse TransverseThe fetus lies across the uterus.
lie-oblique ObliqueThe fetus lies obliquely.
membranes-intact IntactThe membranes are intact.
membranes-ruptured RupturedThe membranes have ruptured.
placenta-complete CompletePlacenta and membranes delivered complete.
placenta-incomplete IncompletePlacenta or membranes incomplete, so the uterus must be explored.
perineum-intact IntactThe perineum is intact.
perineum-tear TearThe perineum tore.
perineum-episiotomy Episiotomy repairedAn episiotomy was performed and repaired.
anaesthesia-general GeneralGeneral anaesthesia.
anaesthesia-spinal SpinalSpinal anaesthesia.
anaesthesia-regional-block Regional blockA peripheral or plexus block.
anaesthesia-sedation SedationConscious sedation.
anaesthesia-local Local infiltrationLocal infiltration by the operator.
check-confirmed ConfirmedThe item was checked and confirmed.
check-not-applicable Not applicableThe item does not apply to this case.
check-not-done Not doneThe item was not checked.
phase-sign-in Sign in — before induction of anaesthesiaThe first phase, with at least the nurse and the anaesthetist present.
phase-time-out Time out — before skin incisionThe second phase, with the nurse, the anaesthetist and the surgeon present.
phase-sign-out Sign out — before the patient leaves the operating roomThe third phase, with the nurse, the anaesthetist and the surgeon present.
access-av-fistula Arteriovenous fistulaA surgically created arteriovenous fistula.
access-av-graft Arteriovenous graftA prosthetic arteriovenous graft.
access-tunnelled-catheter Tunnelled catheterA cuffed, tunnelled central venous catheter.
access-temporary-catheter Temporary catheterA non-tunnelled temporary central venous catheter.
donor-replacement ReplacementDonating to replace blood used for a named patient.
donor-voluntary VoluntaryDonating voluntarily, for no named recipient.
donor-autologous AutologousDonating for their own later use.
donation-normal NormalA whole-blood collection.
donation-apheresis ApheresisA component collection by apheresis.
line-first First lineFirst-line therapy.
line-second Second lineSecond-line therapy, after progression or intolerance on first line.
line-third Third lineThird-line therapy.
line-subsequent Fourth line or laterFourth-line therapy or beyond.
yes YesYes.
no NoNo.
not-known Not knownThe answer could not be established.
abdominal-ultrasound Abdominal ultrasoundUltrasound of the abdomen.
pelvic-ultrasound Pelvic ultrasoundUltrasound of the pelvis.
kub-ultrasound KUB ultrasoundUltrasound of the kidneys, ureters and bladder.
early-obstetric-ultrasound Early obstetric ultrasoundFirst-trimester dating and viability scan.
routine-obstetric-ultrasound Routine obstetric ultrasoundRoutine growth and anatomy scan.
obstetric-ultrasound-biophysical-profile Obstetric ultrasound with biophysical profileObstetric scan including the biophysical profile.
thyroid-ultrasound Thyroid ultrasoundUltrasound of the thyroid.
scrotal-ultrasound Scrotal ultrasoundUltrasound of the scrotum.
breast-ultrasound Breast ultrasoundUltrasound of the breast.
musculoskeletal-ultrasound Musculoskeletal or regional ultrasoundUltrasound of a joint, muscle or soft-tissue region.
cranial-ultrasound Cranial ultrasoundUltrasound of the head, through the fontanelle in an infant.
renal-doppler Renal Doppler ultrasoundDoppler study of the renal vessels.
carotid-doppler Carotid Doppler ultrasoundDoppler study of the carotid arteries.
upper-limb-venous-doppler Upper limb venous Doppler ultrasoundDoppler study of the upper limb veins.
upper-limb-arterial-doppler Upper limb arterial Doppler ultrasoundDoppler study of the upper limb arteries.
lower-limb-venous-doppler Lower limb venous Doppler ultrasoundDoppler study of the lower limb veins, usually for deep vein thrombosis.
lower-limb-arterial-doppler Lower limb arterial Doppler ultrasoundDoppler study of the lower limb arteries.
upper-gi-endoscopy Upper gastrointestinal endoscopyEndoscopy of the oesophagus, stomach and duodenum.
colonoscopy ColonoscopyEndoscopy of the whole colon.
flexible-sigmoidoscopy Flexible sigmoidoscopyEndoscopy of the rectum and sigmoid colon.
ercp Endoscopic retrograde cholangiopancreatographyEndoscopic cannulation of the biliary and pancreatic ducts, with contrast.
pulse-normal NormalPeripheral pulse of normal volume.
pulse-weak WeakPeripheral pulse weak or thready.
warm-to-hand HandSkin warm as far as the hand — normal peripheral perfusion.
warm-to-elbow ElbowSkin warm only as far as the elbow — the extremities are cold.
warm-to-shoulder ShoulderSkin warm only as far as the shoulder — the worst grade the sheet records.
malaria-blood-slide Blood slideMalaria microscopy on a blood slide.
malaria-rapid-test Rapid testMalaria rapid diagnostic test.
review-medical-6-hours Medical review within 6 hoursThe child is to be seen by a clinician within six hours.
review-priority-nursing Priority nursing observationsThe child is to be kept on priority nursing observations.
capillary-refill-under-2s Under 2 secondsCapillary refill returns in under two seconds.
capillary-refill-2-to-3s 2 to 3 secondsCapillary refill takes two to three seconds.
capillary-refill-over-3s Over 3 secondsCapillary refill takes more than three seconds, which is shock.
colour-pink PinkThe baby is pink.
colour-blue BlueThe baby is blue.
round-morning MorningThe morning round — the chart's M column.
round-evening EveningThe evening round — the chart's E column.
round-night NightThe night round — the chart's N column.
pain-mild MildMild pain, as the triage sheet bands it.
pain-moderate ModerateModerate pain.
pain-severe SevereSevere pain. A priority sign by ETAT+.
referral-clinic ClinicReferred from a clinic.
referral-ward WardReferred from a ward.
referral-self-or-private Private, staff or selfCame without an internal referral — privately, as a member of staff, or self-referred. The three the palliative care sheet prints separately, which all mean the same thing for the service's own workflow.
consciousness-alert AlertAwake and alert.
consciousness-sedated SedatedSedated.
consciousness-agitated AgitatedAgitated.
modality-x-ray X-rayA plain radiograph.
modality-ultrasound UltrasoundAn ultrasound study.
consent-general-operation General operation or treatmentThe hospital's general consent form for an operation or treatment.
consent-endoscopy EndoscopyThe endoscopy-specific consent form.
consent-anti-cancer-therapy Systemic anti-cancer therapyThe cancer centre's consent form for chemotherapy, hormonal or targeted therapy.
consenter-patient The patient themselvesThe patient is giving their own consent.
consenter-next-of-kin Next of kin or guardianConsent is being given by the next of kin or a guardian, because the patient cannot.
arm-power-5 Normal powerArm power: normal.
arm-power-4 Mild weaknessArm power: mild weakness.
arm-power-3 Severe weaknessArm power: severe weakness.
arm-power-2 Spastic flexionArm power: spastic flexion.
arm-power-1 ExtensionArm power: extension only.
arm-power-0 No responseArm power: no response.
leg-power-4 Normal powerLeg power: normal.
leg-power-3 Mild weaknessLeg power: mild weakness.
leg-power-2 Severe weaknessLeg power: severe weakness.
leg-power-1 ExtensionLeg power: extension only.
leg-power-0 No responseLeg power: no response.
pupil-brisk BriskPupil reacts briskly to light.
pupil-sluggish SluggishPupil reacts sluggishly to light.
pupil-fixed FixedPupil does not react to light.
pupil-closed ClosedEye closed — the pupil could not be assessed. Distinct from fixed, which is a finding.
oesophagogastroduodenoscopy OesophagogastroduodenoscopyEndoscopy of the oesophagus, stomach and duodenum. The form spells it OESOPHAGAGASTRODUODENOSCOPY.
oesophagogastroscopy OesophagogastroscopyEndoscopy of the oesophagus and stomach.
oesophagoscopy OesophagoscopyEndoscopy of the oesophagus alone.
rectosigmoidoscopy RectosigmoidoscopyEndoscopy of the rectum and sigmoid colon.
colonoscopy-investigation ColonoscopyEndoscopy of the whole colon, as recorded on the investigation form.
packed-red-blood-cells Packed red blood cellsRed cells with most of the plasma removed.
fresh-frozen-plasma Fresh frozen plasmaPlasma frozen within hours of collection.
platelet-concentrate Platelet concentratePlatelets concentrated from whole blood or collected by apheresis.
whole-blood Whole bloodUnseparated blood as collected.
urgency-desperate DesperateNeeded immediately — the patient is bleeding now.
urgency-urgent UrgentNeeded within hours.
urgency-elective ElectivePlanned, for a scheduled procedure.
abo-a ABlood group A.
abo-b BBlood group B.
abo-ab ABBlood group AB.
abo-o OBlood group O.
rh-positive PositiveRhesus D positive.
rh-negative NegativeRhesus D negative.
xmatch-compatible CompatibleCross-match compatible — the unit may be issued.
xmatch-incompatible IncompatibleCross-match incompatible — the unit must not be issued.
decline-care Care in the wardRefusing ward care — the patient is leaving.
decline-procedure A procedureRefusing a specific procedure.
decline-assessment An assessment or investigationRefusing an assessment or investigation.
decline-destination-home HomeGoing home.
decline-destination-other-hospital Hospital of choiceTransferring to a hospital of their own choosing.
vent-mode-cmv CMVControlled mandatory ventilation, as printed on the ICU observation chart.
vent-mode-simv SIMVSynchronised intermittent mandatory ventilation.
vent-mode-cpap CPAPContinuous positive airway pressure.
vent-mode-psv PSVPressure support ventilation.
vent-mode-spontaneous SpontaneousBreathing spontaneously, off mandatory ventilation.
position-supine SupinePatient positioned on the back.
position-left-lateral Left lateralPatient turned onto the left side.
position-right-lateral Right lateralPatient turned onto the right side.
position-prone PronePatient positioned face down.
position-semi-fowler Semi-FowlerHead of bed raised between 30 and 45 degrees.
conscious-fully Fully consciousAnswers questions intelligently, as the head injury chart words it.
conscious-confused Conscious but confusedAnswers simple questions only.
conscious-semi Semi consciousResponds to pain only.
conscious-coma ComaNo response to pain.
finding-present PresentThe finding was observed.
finding-absent AbsentThe finding was looked for and not observed.
injury-chest ChestChest injury, from the other-injuries tick list on the head injury chart.
injury-abdomen AbdomenAbdominal injury.
injury-arm ArmArm injury.
injury-leg LegLeg injury.
injury-neck NeckNeck injury.
injury-spine SpineSpinal injury.
feed-breast Breast feedingFed at the breast.
feed-ebm Expressed breast milkFed the mother’s own expressed milk.
feed-term-formula Term formulaFed a term infant formula.
feed-preterm-formula Pre-term formulaFed a preterm infant formula.
route-cup CupFed by cup.
route-ngt Nasogastric tubeFed through a nasogastric tube.
route-ogt Orogastric tubeFed through an orogastric tube.
newborn-category-a Category AAcutely ill on ventilator, CPAP or oxygen, as graded at the foot of the newborn comprehensive chart.
newborn-category-b Category BStabilising on intensive phototherapy, IV fluids and assisted feeds.
newborn-category-c Category CA stable baby.
oxygen-prongs Nasal prongsOxygen given through nasal prongs.
oxygen-non-rebreather Non-rebreather maskOxygen given through a non-rebreather mask.
oxygen-bub Bubble CPAPOxygen given through bubble CPAP.
art-azt AZTZidovudine prophylaxis, as printed on the newborn handover form.
art-nvp NVPNevirapine prophylaxis.
lab-urgency-desperate DesperateThe most urgent of the three degrees the lab requisition prints.
lab-urgency-urgent UrgentThe middle degree of urgency.
lab-urgency-routine RoutineThe routine degree of urgency, as the lab forms word it — the blood requisition says "elective" instead.
rating-poor PoorThe lowest of the four ratings on the satisfaction questionnaire.
rating-fair FairThe second of four.
rating-good GoodThe third of four.
rating-excellent ExcellentThe highest of the four.
resus-dnr Do not resuscitateA recorded decision not to attempt resuscitation.
resus-full Full resuscitationA recorded decision that resuscitation is to be attempted.
body-part-home Taken homeThe removed body part is released to the family.
body-part-hospital Disposed by the hospitalThe removed body part is disposed of by the hospital.
mortuary-from-ward From a ward of this hospitalThe body came from a ward here, so the deceased was a patient.
mortuary-from-casualty From casualtyThe body came from casualty.
mortuary-from-home From homeThe body was brought from home; the deceased may never have been a patient here.
mortuary-from-other-facility From another facilityThe body was transferred from another facility, with a permit.
mortuary-police-case Police caseThe body was brought by the police, under an OB number.
dressing-grade-b BThe first of the three grading letters printed on the surgical dressing sheet. The sheet does not expand the letters anywhere on it.
dressing-grade-m MThe second of the three grading letters printed on the surgical dressing sheet.
dressing-grade-s SThe third of the three grading letters printed on the surgical dressing sheet.
admitted-from-opd Out-patient departmentAdmitted from the out-patient department.
admitted-from-casualty CasualtyAdmitted from casualty.
arrival-walked WalkedArrived on foot.
arrival-ambulance AmbulanceArrived by ambulance.
arrival-wheelchair WheelchairArrived by wheelchair.
arrival-cart CartArrived on a cart or trolley, as the admission form words it.
chronic-tb TuberculosisFrom the chronic illness tick list on the admission form.
chronic-hiv HIVThe admission form prints this column as CD4.
chronic-arthritis ArthritisFrom the chronic illness tick list.
chronic-hypertension HypertensionThe admission form prints this as HPN.
chronic-pneumonia PneumoniaFrom the chronic illness tick list.
chronic-malaria MalariaFrom the chronic illness tick list.
chronic-diabetes DiabetesFrom the chronic illness tick list.
chronic-skin Skin diseaseFrom the chronic illness tick list.
chronic-cardiac Cardiac diseaseFrom the chronic illness tick list.
chronic-renal Renal diseaseFrom the chronic illness tick list.
chronic-psychiatric Psychiatric illnessThe admission form prints this as Psych.
chronic-carcinoma CarcinomaFrom the chronic illness tick list.
presentation-cephalic CephalicHead presenting.
presentation-breech BreechButtocks or feet presenting.
presentation-shoulder ShoulderShoulder presenting, with the fetus lying transversely.
presentation-face FaceFace presenting.
presentation-brow BrowBrow presenting.
bowels-opened OpenedBowels opened.
bowels-not-opened Not openedBowels not opened.
milk-breast Breast milkExpressed or direct breast milk, as the milk feeding chart prints it.
milk-nan NAN formulaThe formula the milk feeding chart names by its brand column.
urine-clear ClearClear irrigation return.
urine-straw StrawStraw-coloured return.
urine-rose RoseRose or lightly blood-tinged return.
urine-blood-stained Blood stainedFrankly blood-stained return.
urine-clots With clotsReturn carrying clots -- the finding that stops an irrigation and calls a surgeon.
" }, "url" : "https://fhir.slade360.co.ke/fhir/CodeSystem/answer-codesystem", "version" : "0.1.0", "name" : "SGHIAnswerCodeSystem", "title" : "SGHI Answer Code System", "status" : "active", "experimental" : false, "date" : "2026-09-15T11:40:24+00:00", "publisher" : "Kathurima Kimathi", "contact" : [{ "name" : "Kathurima Kimathi", "telecom" : [{ "system" : "url", "value" : "https://www.linkedin.com/in/kathurima-kimathi/" }, { "system" : "email", "value" : "kathurimakimathi415@gmail.com" }] }, { "name" : "Oscar John", "telecom" : [{ "system" : "email", "value" : "oscarjohnotieno@gmail.com", "use" : "work" }] }, { "name" : "Kennedy Omondi", "telecom" : [{ "system" : "email", "value" : "kennankole@gmail.com", "use" : "work" }] }], "description" : "The answers the pick lists offer, where the list is local to these forms and carries no ordinal weight. Displays are the wording printed on the paper form and should not be reworded without reprinting the form, because the form is the contract with the ward. Answers that belong to a scored instrument live in SGHIScoreCodeSystem instead, since those also carry a weight.", "caseSensitive" : true, "content" : "complete", "count" : 251, "concept" : [{ "code" : "triage-emergency", "display" : "Emergency", "definition" : "Needs a clinician immediately. An emergency sign is present." }, { "code" : "triage-priority", "display" : "Priority", "definition" : "Needs a clinician within fifteen minutes. A priority sign is present." }, { "code" : "triage-less-urgent", "display" : "Less urgent", "definition" : "Can safely wait in the queue." }, { "code" : "triage-well-baby", "display" : "Well baby", "definition" : "Attending for a routine check, not for illness." }, { "code" : "grade-absent", "display" : "0 — absent", "definition" : "The finding is not present." }, { "code" : "grade-mild", "display" : "+ — mild", "definition" : "The finding is present and mild." }, { "code" : "grade-severe", "display" : "+++ — severe", "definition" : "The finding is present and severe." }, { "code" : "avpu-alert", "display" : "A — alert", "definition" : "Awake and alert." }, { "code" : "avpu-verbal", "display" : "V — responds to voice", "definition" : "Responds to voice but is not fully alert." }, { "code" : "avpu-pain", "display" : "P — responds to pain", "definition" : "Responds only to a painful stimulus." }, { "code" : "avpu-unresponsive", "display" : "U — unresponsive", "definition" : "Does not respond to a painful stimulus." }, { "code" : "oedema-none", "display" : "None", "definition" : "No oedema." }, { "code" : "oedema-feet", "display" : "Feet", "definition" : "Oedema of the feet only." }, { "code" : "oedema-knee", "display" : "To the knee", "definition" : "Oedema extending to the knees." }, { "code" : "oedema-face", "display" : "Face", "definition" : "Oedema involving the face, which is the most severe grade." }, { "code" : "umbilicus-normal", "display" : "Normal", "definition" : "The cord stump is clean and dry." }, { "code" : "umbilicus-pus", "display" : "Pus", "definition" : "The cord stump is discharging pus." }, { "code" : "umbilicus-pus-and-redness", "display" : "Pus and red skin", "definition" : "The cord stump is discharging pus and the surrounding skin is red, which is periumbilical cellulitis." }, { "code" : "cord-fresh", "display" : "Fresh", "definition" : "The cord is still fresh." }, { "code" : "cord-dry", "display" : "Dry", "definition" : "The cord has dried." }, { "code" : "cord-infected", "display" : "Infected", "definition" : "The cord is infected." }, { "code" : "pmtct-positive", "display" : "Positive", "definition" : "The mother is known to be HIV positive and in the PMTCT programme." }, { "code" : "pmtct-negative", "display" : "Negative", "definition" : "The mother tested HIV negative." }, { "code" : "pmtct-unknown", "display" : "Unknown", "definition" : "The mother's status could not be established." }, { "code" : "delivery-svd", "display" : "SVD", "definition" : "Spontaneous vaginal delivery." }, { "code" : "delivery-breech", "display" : "Breech", "definition" : "Breech vaginal delivery." }, { "code" : "delivery-caesarean", "display" : "C/S", "definition" : "Caesarean section." }, { "code" : "delivery-assisted-vacuum", "display" : "Vacuum", "definition" : "Assisted vaginal delivery by vacuum extraction." }, { "code" : "delivery-assisted-forceps", "display" : "Forceps", "definition" : "Assisted vaginal delivery by forceps." }, { "code" : "place-of-birth-home", "display" : "Home", "definition" : "Born at home." }, { "code" : "place-of-birth-hospital", "display" : "Hospital", "definition" : "Born in a health facility." }, { "code" : "place-of-birth-other", "display" : "Other", "definition" : "Born somewhere other than home or a facility, such as in transit." }, { "code" : "lie-longitudinal", "display" : "Longitudinal", "definition" : "The fetus lies along the axis of the uterus." }, { "code" : "lie-transverse", "display" : "Transverse", "definition" : "The fetus lies across the uterus." }, { "code" : "lie-oblique", "display" : "Oblique", "definition" : "The fetus lies obliquely." }, { "code" : "membranes-intact", "display" : "Intact", "definition" : "The membranes are intact." }, { "code" : "membranes-ruptured", "display" : "Ruptured", "definition" : "The membranes have ruptured." }, { "code" : "placenta-complete", "display" : "Complete", "definition" : "Placenta and membranes delivered complete." }, { "code" : "placenta-incomplete", "display" : "Incomplete", "definition" : "Placenta or membranes incomplete, so the uterus must be explored." }, { "code" : "perineum-intact", "display" : "Intact", "definition" : "The perineum is intact." }, { "code" : "perineum-tear", "display" : "Tear", "definition" : "The perineum tore." }, { "code" : "perineum-episiotomy", "display" : "Episiotomy repaired", "definition" : "An episiotomy was performed and repaired." }, { "code" : "anaesthesia-general", "display" : "General", "definition" : "General anaesthesia." }, { "code" : "anaesthesia-spinal", "display" : "Spinal", "definition" : "Spinal anaesthesia." }, { "code" : "anaesthesia-regional-block", "display" : "Regional block", "definition" : "A peripheral or plexus block." }, { "code" : "anaesthesia-sedation", "display" : "Sedation", "definition" : "Conscious sedation." }, { "code" : "anaesthesia-local", "display" : "Local infiltration", "definition" : "Local infiltration by the operator." }, { "code" : "check-confirmed", "display" : "Confirmed", "definition" : "The item was checked and confirmed." }, { "code" : "check-not-applicable", "display" : "Not applicable", "definition" : "The item does not apply to this case." }, { "code" : "check-not-done", "display" : "Not done", "definition" : "The item was not checked." }, { "code" : "phase-sign-in", "display" : "Sign in — before induction of anaesthesia", "definition" : "The first phase, with at least the nurse and the anaesthetist present." }, { "code" : "phase-time-out", "display" : "Time out — before skin incision", "definition" : "The second phase, with the nurse, the anaesthetist and the surgeon present." }, { "code" : "phase-sign-out", "display" : "Sign out — before the patient leaves the operating room", "definition" : "The third phase, with the nurse, the anaesthetist and the surgeon present." }, { "code" : "access-av-fistula", "display" : "Arteriovenous fistula", "definition" : "A surgically created arteriovenous fistula." }, { "code" : "access-av-graft", "display" : "Arteriovenous graft", "definition" : "A prosthetic arteriovenous graft." }, { "code" : "access-tunnelled-catheter", "display" : "Tunnelled catheter", "definition" : "A cuffed, tunnelled central venous catheter." }, { "code" : "access-temporary-catheter", "display" : "Temporary catheter", "definition" : "A non-tunnelled temporary central venous catheter." }, { "code" : "donor-replacement", "display" : "Replacement", "definition" : "Donating to replace blood used for a named patient." }, { "code" : "donor-voluntary", "display" : "Voluntary", "definition" : "Donating voluntarily, for no named recipient." }, { "code" : "donor-autologous", "display" : "Autologous", "definition" : "Donating for their own later use." }, { "code" : "donation-normal", "display" : "Normal", "definition" : "A whole-blood collection." }, { "code" : "donation-apheresis", "display" : "Apheresis", "definition" : "A component collection by apheresis." }, { "code" : "line-first", "display" : "First line", "definition" : "First-line therapy." }, { "code" : "line-second", "display" : "Second line", "definition" : "Second-line therapy, after progression or intolerance on first line." }, { "code" : "line-third", "display" : "Third line", "definition" : "Third-line therapy." }, { "code" : "line-subsequent", "display" : "Fourth line or later", "definition" : "Fourth-line therapy or beyond." }, { "code" : "yes", "display" : "Yes", "definition" : "Yes." }, { "code" : "no", "display" : "No", "definition" : "No." }, { "code" : "not-known", "display" : "Not known", "definition" : "The answer could not be established." }, { "code" : "abdominal-ultrasound", "display" : "Abdominal ultrasound", "definition" : "Ultrasound of the abdomen." }, { "code" : "pelvic-ultrasound", "display" : "Pelvic ultrasound", "definition" : "Ultrasound of the pelvis." }, { "code" : "kub-ultrasound", "display" : "KUB ultrasound", "definition" : "Ultrasound of the kidneys, ureters and bladder." }, { "code" : "early-obstetric-ultrasound", "display" : "Early obstetric ultrasound", "definition" : "First-trimester dating and viability scan." }, { "code" : "routine-obstetric-ultrasound", "display" : "Routine obstetric ultrasound", "definition" : "Routine growth and anatomy scan." }, { "code" : "obstetric-ultrasound-biophysical-profile", "display" : "Obstetric ultrasound with biophysical profile", "definition" : "Obstetric scan including the biophysical profile." }, { "code" : "thyroid-ultrasound", "display" : "Thyroid ultrasound", "definition" : "Ultrasound of the thyroid." }, { "code" : "scrotal-ultrasound", "display" : "Scrotal ultrasound", "definition" : "Ultrasound of the scrotum." }, { "code" : "breast-ultrasound", "display" : "Breast ultrasound", "definition" : "Ultrasound of the breast." }, { "code" : "musculoskeletal-ultrasound", "display" : "Musculoskeletal or regional ultrasound", "definition" : "Ultrasound of a joint, muscle or soft-tissue region." }, { "code" : "cranial-ultrasound", "display" : "Cranial ultrasound", "definition" : "Ultrasound of the head, through the fontanelle in an infant." }, { "code" : "renal-doppler", "display" : "Renal Doppler ultrasound", "definition" : "Doppler study of the renal vessels." }, { "code" : "carotid-doppler", "display" : "Carotid Doppler ultrasound", "definition" : "Doppler study of the carotid arteries." }, { "code" : "upper-limb-venous-doppler", "display" : "Upper limb venous Doppler ultrasound", "definition" : "Doppler study of the upper limb veins." }, { "code" : "upper-limb-arterial-doppler", "display" : "Upper limb arterial Doppler ultrasound", "definition" : "Doppler study of the upper limb arteries." }, { "code" : "lower-limb-venous-doppler", "display" : "Lower limb venous Doppler ultrasound", "definition" : "Doppler study of the lower limb veins, usually for deep vein thrombosis." }, { "code" : "lower-limb-arterial-doppler", "display" : "Lower limb arterial Doppler ultrasound", "definition" : "Doppler study of the lower limb arteries." }, { "code" : "upper-gi-endoscopy", "display" : "Upper gastrointestinal endoscopy", "definition" : "Endoscopy of the oesophagus, stomach and duodenum." }, { "code" : "colonoscopy", "display" : "Colonoscopy", "definition" : "Endoscopy of the whole colon." }, { "code" : "flexible-sigmoidoscopy", "display" : "Flexible sigmoidoscopy", "definition" : "Endoscopy of the rectum and sigmoid colon." }, { "code" : "ercp", "display" : "Endoscopic retrograde cholangiopancreatography", "definition" : "Endoscopic cannulation of the biliary and pancreatic ducts, with contrast." }, { "code" : "pulse-normal", "display" : "Normal", "definition" : "Peripheral pulse of normal volume." }, { "code" : "pulse-weak", "display" : "Weak", "definition" : "Peripheral pulse weak or thready." }, { "code" : "warm-to-hand", "display" : "Hand", "definition" : "Skin warm as far as the hand — normal peripheral perfusion." }, { "code" : "warm-to-elbow", "display" : "Elbow", "definition" : "Skin warm only as far as the elbow — the extremities are cold." }, { "code" : "warm-to-shoulder", "display" : "Shoulder", "definition" : "Skin warm only as far as the shoulder — the worst grade the sheet records." }, { "code" : "malaria-blood-slide", "display" : "Blood slide", "definition" : "Malaria microscopy on a blood slide." }, { "code" : "malaria-rapid-test", "display" : "Rapid test", "definition" : "Malaria rapid diagnostic test." }, { "code" : "review-medical-6-hours", "display" : "Medical review within 6 hours", "definition" : "The child is to be seen by a clinician within six hours." }, { "code" : "review-priority-nursing", "display" : "Priority nursing observations", "definition" : "The child is to be kept on priority nursing observations." }, { "code" : "capillary-refill-under-2s", "display" : "Under 2 seconds", "definition" : "Capillary refill returns in under two seconds." }, { "code" : "capillary-refill-2-to-3s", "display" : "2 to 3 seconds", "definition" : "Capillary refill takes two to three seconds." }, { "code" : "capillary-refill-over-3s", "display" : "Over 3 seconds", "definition" : "Capillary refill takes more than three seconds, which is shock." }, { "code" : "colour-pink", "display" : "Pink", "definition" : "The baby is pink." }, { "code" : "colour-blue", "display" : "Blue", "definition" : "The baby is blue." }, { "code" : "round-morning", "display" : "Morning", "definition" : "The morning round — the chart's M column." }, { "code" : "round-evening", "display" : "Evening", "definition" : "The evening round — the chart's E column." }, { "code" : "round-night", "display" : "Night", "definition" : "The night round — the chart's N column." }, { "code" : "pain-mild", "display" : "Mild", "definition" : "Mild pain, as the triage sheet bands it." }, { "code" : "pain-moderate", "display" : "Moderate", "definition" : "Moderate pain." }, { "code" : "pain-severe", "display" : "Severe", "definition" : "Severe pain. A priority sign by ETAT+." }, { "code" : "referral-clinic", "display" : "Clinic", "definition" : "Referred from a clinic." }, { "code" : "referral-ward", "display" : "Ward", "definition" : "Referred from a ward." }, { "code" : "referral-self-or-private", "display" : "Private, staff or self", "definition" : "Came without an internal referral — privately, as a member of staff, or self-referred. The three the palliative care sheet prints separately, which all mean the same thing for the service's own workflow." }, { "code" : "consciousness-alert", "display" : "Alert", "definition" : "Awake and alert." }, { "code" : "consciousness-sedated", "display" : "Sedated", "definition" : "Sedated." }, { "code" : "consciousness-agitated", "display" : "Agitated", "definition" : "Agitated." }, { "code" : "modality-x-ray", "display" : "X-ray", "definition" : "A plain radiograph." }, { "code" : "modality-ultrasound", "display" : "Ultrasound", "definition" : "An ultrasound study." }, { "code" : "consent-general-operation", "display" : "General operation or treatment", "definition" : "The hospital's general consent form for an operation or treatment." }, { "code" : "consent-endoscopy", "display" : "Endoscopy", "definition" : "The endoscopy-specific consent form." }, { "code" : "consent-anti-cancer-therapy", "display" : "Systemic anti-cancer therapy", "definition" : "The cancer centre's consent form for chemotherapy, hormonal or targeted therapy." }, { "code" : "consenter-patient", "display" : "The patient themselves", "definition" : "The patient is giving their own consent." }, { "code" : "consenter-next-of-kin", "display" : "Next of kin or guardian", "definition" : "Consent is being given by the next of kin or a guardian, because the patient cannot." }, { "code" : "arm-power-5", "display" : "Normal power", "definition" : "Arm power: normal." }, { "code" : "arm-power-4", "display" : "Mild weakness", "definition" : "Arm power: mild weakness." }, { "code" : "arm-power-3", "display" : "Severe weakness", "definition" : "Arm power: severe weakness." }, { "code" : "arm-power-2", "display" : "Spastic flexion", "definition" : "Arm power: spastic flexion." }, { "code" : "arm-power-1", "display" : "Extension", "definition" : "Arm power: extension only." }, { "code" : "arm-power-0", "display" : "No response", "definition" : "Arm power: no response." }, { "code" : "leg-power-4", "display" : "Normal power", "definition" : "Leg power: normal." }, { "code" : "leg-power-3", "display" : "Mild weakness", "definition" : "Leg power: mild weakness." }, { "code" : "leg-power-2", "display" : "Severe weakness", "definition" : "Leg power: severe weakness." }, { "code" : "leg-power-1", "display" : "Extension", "definition" : "Leg power: extension only." }, { "code" : "leg-power-0", "display" : "No response", "definition" : "Leg power: no response." }, { "code" : "pupil-brisk", "display" : "Brisk", "definition" : "Pupil reacts briskly to light." }, { "code" : "pupil-sluggish", "display" : "Sluggish", "definition" : "Pupil reacts sluggishly to light." }, { "code" : "pupil-fixed", "display" : "Fixed", "definition" : "Pupil does not react to light." }, { "code" : "pupil-closed", "display" : "Closed", "definition" : "Eye closed — the pupil could not be assessed. Distinct from fixed, which is a finding." }, { "code" : "oesophagogastroduodenoscopy", "display" : "Oesophagogastroduodenoscopy", "definition" : "Endoscopy of the oesophagus, stomach and duodenum. The form spells it OESOPHAGAGASTRODUODENOSCOPY." }, { "code" : "oesophagogastroscopy", "display" : "Oesophagogastroscopy", "definition" : "Endoscopy of the oesophagus and stomach." }, { "code" : "oesophagoscopy", "display" : "Oesophagoscopy", "definition" : "Endoscopy of the oesophagus alone." }, { "code" : "rectosigmoidoscopy", "display" : "Rectosigmoidoscopy", "definition" : "Endoscopy of the rectum and sigmoid colon." }, { "code" : "colonoscopy-investigation", "display" : "Colonoscopy", "definition" : "Endoscopy of the whole colon, as recorded on the investigation form." }, { "code" : "packed-red-blood-cells", "display" : "Packed red blood cells", "definition" : "Red cells with most of the plasma removed." }, { "code" : "fresh-frozen-plasma", "display" : "Fresh frozen plasma", "definition" : "Plasma frozen within hours of collection." }, { "code" : "platelet-concentrate", "display" : "Platelet concentrate", "definition" : "Platelets concentrated from whole blood or collected by apheresis." }, { "code" : "whole-blood", "display" : "Whole blood", "definition" : "Unseparated blood as collected." }, { "code" : "urgency-desperate", "display" : "Desperate", "definition" : "Needed immediately — the patient is bleeding now." }, { "code" : "urgency-urgent", "display" : "Urgent", "definition" : "Needed within hours." }, { "code" : "urgency-elective", "display" : "Elective", "definition" : "Planned, for a scheduled procedure." }, { "code" : "abo-a", "display" : "A", "definition" : "Blood group A." }, { "code" : "abo-b", "display" : "B", "definition" : "Blood group B." }, { "code" : "abo-ab", "display" : "AB", "definition" : "Blood group AB." }, { "code" : "abo-o", "display" : "O", "definition" : "Blood group O." }, { "code" : "rh-positive", "display" : "Positive", "definition" : "Rhesus D positive." }, { "code" : "rh-negative", "display" : "Negative", "definition" : "Rhesus D negative." }, { "code" : "xmatch-compatible", "display" : "Compatible", "definition" : "Cross-match compatible — the unit may be issued." }, { "code" : "xmatch-incompatible", "display" : "Incompatible", "definition" : "Cross-match incompatible — the unit must not be issued." }, { "code" : "decline-care", "display" : "Care in the ward", "definition" : "Refusing ward care — the patient is leaving." }, { "code" : "decline-procedure", "display" : "A procedure", "definition" : "Refusing a specific procedure." }, { "code" : "decline-assessment", "display" : "An assessment or investigation", "definition" : "Refusing an assessment or investigation." }, { "code" : "decline-destination-home", "display" : "Home", "definition" : "Going home." }, { "code" : "decline-destination-other-hospital", "display" : "Hospital of choice", "definition" : "Transferring to a hospital of their own choosing." }, { "code" : "vent-mode-cmv", "display" : "CMV", "definition" : "Controlled mandatory ventilation, as printed on the ICU observation chart." }, { "code" : "vent-mode-simv", "display" : "SIMV", "definition" : "Synchronised intermittent mandatory ventilation." }, { "code" : "vent-mode-cpap", "display" : "CPAP", "definition" : "Continuous positive airway pressure." }, { "code" : "vent-mode-psv", "display" : "PSV", "definition" : "Pressure support ventilation." }, { "code" : "vent-mode-spontaneous", "display" : "Spontaneous", "definition" : "Breathing spontaneously, off mandatory ventilation." }, { "code" : "position-supine", "display" : "Supine", "definition" : "Patient positioned on the back." }, { "code" : "position-left-lateral", "display" : "Left lateral", "definition" : "Patient turned onto the left side." }, { "code" : "position-right-lateral", "display" : "Right lateral", "definition" : "Patient turned onto the right side." }, { "code" : "position-prone", "display" : "Prone", "definition" : "Patient positioned face down." }, { "code" : "position-semi-fowler", "display" : "Semi-Fowler", "definition" : "Head of bed raised between 30 and 45 degrees." }, { "code" : "conscious-fully", "display" : "Fully conscious", "definition" : "Answers questions intelligently, as the head injury chart words it." }, { "code" : "conscious-confused", "display" : "Conscious but confused", "definition" : "Answers simple questions only." }, { "code" : "conscious-semi", "display" : "Semi conscious", "definition" : "Responds to pain only." }, { "code" : "conscious-coma", "display" : "Coma", "definition" : "No response to pain." }, { "code" : "finding-present", "display" : "Present", "definition" : "The finding was observed." }, { "code" : "finding-absent", "display" : "Absent", "definition" : "The finding was looked for and not observed." }, { "code" : "injury-chest", "display" : "Chest", "definition" : "Chest injury, from the other-injuries tick list on the head injury chart." }, { "code" : "injury-abdomen", "display" : "Abdomen", "definition" : "Abdominal injury." }, { "code" : "injury-arm", "display" : "Arm", "definition" : "Arm injury." }, { "code" : "injury-leg", "display" : "Leg", "definition" : "Leg injury." }, { "code" : "injury-neck", "display" : "Neck", "definition" : "Neck injury." }, { "code" : "injury-spine", "display" : "Spine", "definition" : "Spinal injury." }, { "code" : "feed-breast", "display" : "Breast feeding", "definition" : "Fed at the breast." }, { "code" : "feed-ebm", "display" : "Expressed breast milk", "definition" : "Fed the mother’s own expressed milk." }, { "code" : "feed-term-formula", "display" : "Term formula", "definition" : "Fed a term infant formula." }, { "code" : "feed-preterm-formula", "display" : "Pre-term formula", "definition" : "Fed a preterm infant formula." }, { "code" : "route-cup", "display" : "Cup", "definition" : "Fed by cup." }, { "code" : "route-ngt", "display" : "Nasogastric tube", "definition" : "Fed through a nasogastric tube." }, { "code" : "route-ogt", "display" : "Orogastric tube", "definition" : "Fed through an orogastric tube." }, { "code" : "newborn-category-a", "display" : "Category A", "definition" : "Acutely ill on ventilator, CPAP or oxygen, as graded at the foot of the newborn comprehensive chart." }, { "code" : "newborn-category-b", "display" : "Category B", "definition" : "Stabilising on intensive phototherapy, IV fluids and assisted feeds." }, { "code" : "newborn-category-c", "display" : "Category C", "definition" : "A stable baby." }, { "code" : "oxygen-prongs", "display" : "Nasal prongs", "definition" : "Oxygen given through nasal prongs." }, { "code" : "oxygen-non-rebreather", "display" : "Non-rebreather mask", "definition" : "Oxygen given through a non-rebreather mask." }, { "code" : "oxygen-bub", "display" : "Bubble CPAP", "definition" : "Oxygen given through bubble CPAP." }, { "code" : "art-azt", "display" : "AZT", "definition" : "Zidovudine prophylaxis, as printed on the newborn handover form." }, { "code" : "art-nvp", "display" : "NVP", "definition" : "Nevirapine prophylaxis." }, { "code" : "lab-urgency-desperate", "display" : "Desperate", "definition" : "The most urgent of the three degrees the lab requisition prints." }, { "code" : "lab-urgency-urgent", "display" : "Urgent", "definition" : "The middle degree of urgency." }, { "code" : "lab-urgency-routine", "display" : "Routine", "definition" : "The routine degree of urgency, as the lab forms word it — the blood requisition says \"elective\" instead." }, { "code" : "rating-poor", "display" : "Poor", "definition" : "The lowest of the four ratings on the satisfaction questionnaire." }, { "code" : "rating-fair", "display" : "Fair", "definition" : "The second of four." }, { "code" : "rating-good", "display" : "Good", "definition" : "The third of four." }, { "code" : "rating-excellent", "display" : "Excellent", "definition" : "The highest of the four." }, { "code" : "resus-dnr", "display" : "Do not resuscitate", "definition" : "A recorded decision not to attempt resuscitation." }, { "code" : "resus-full", "display" : "Full resuscitation", "definition" : "A recorded decision that resuscitation is to be attempted." }, { "code" : "body-part-home", "display" : "Taken home", "definition" : "The removed body part is released to the family." }, { "code" : "body-part-hospital", "display" : "Disposed by the hospital", "definition" : "The removed body part is disposed of by the hospital." }, { "code" : "mortuary-from-ward", "display" : "From a ward of this hospital", "definition" : "The body came from a ward here, so the deceased was a patient." }, { "code" : "mortuary-from-casualty", "display" : "From casualty", "definition" : "The body came from casualty." }, { "code" : "mortuary-from-home", "display" : "From home", "definition" : "The body was brought from home; the deceased may never have been a patient here." }, { "code" : "mortuary-from-other-facility", "display" : "From another facility", "definition" : "The body was transferred from another facility, with a permit." }, { "code" : "mortuary-police-case", "display" : "Police case", "definition" : "The body was brought by the police, under an OB number." }, { "code" : "dressing-grade-b", "display" : "B", "definition" : "The first of the three grading letters printed on the surgical dressing sheet. The sheet does not expand the letters anywhere on it." }, { "code" : "dressing-grade-m", "display" : "M", "definition" : "The second of the three grading letters printed on the surgical dressing sheet." }, { "code" : "dressing-grade-s", "display" : "S", "definition" : "The third of the three grading letters printed on the surgical dressing sheet." }, { "code" : "admitted-from-opd", "display" : "Out-patient department", "definition" : "Admitted from the out-patient department." }, { "code" : "admitted-from-casualty", "display" : "Casualty", "definition" : "Admitted from casualty." }, { "code" : "arrival-walked", "display" : "Walked", "definition" : "Arrived on foot." }, { "code" : "arrival-ambulance", "display" : "Ambulance", "definition" : "Arrived by ambulance." }, { "code" : "arrival-wheelchair", "display" : "Wheelchair", "definition" : "Arrived by wheelchair." }, { "code" : "arrival-cart", "display" : "Cart", "definition" : "Arrived on a cart or trolley, as the admission form words it." }, { "code" : "chronic-tb", "display" : "Tuberculosis", "definition" : "From the chronic illness tick list on the admission form." }, { "code" : "chronic-hiv", "display" : "HIV", "definition" : "The admission form prints this column as CD4." }, { "code" : "chronic-arthritis", "display" : "Arthritis", "definition" : "From the chronic illness tick list." }, { "code" : "chronic-hypertension", "display" : "Hypertension", "definition" : "The admission form prints this as HPN." }, { "code" : "chronic-pneumonia", "display" : "Pneumonia", "definition" : "From the chronic illness tick list." }, { "code" : "chronic-malaria", "display" : "Malaria", "definition" : "From the chronic illness tick list." }, { "code" : "chronic-diabetes", "display" : "Diabetes", "definition" : "From the chronic illness tick list." }, { "code" : "chronic-skin", "display" : "Skin disease", "definition" : "From the chronic illness tick list." }, { "code" : "chronic-cardiac", "display" : "Cardiac disease", "definition" : "From the chronic illness tick list." }, { "code" : "chronic-renal", "display" : "Renal disease", "definition" : "From the chronic illness tick list." }, { "code" : "chronic-psychiatric", "display" : "Psychiatric illness", "definition" : "The admission form prints this as Psych." }, { "code" : "chronic-carcinoma", "display" : "Carcinoma", "definition" : "From the chronic illness tick list." }, { "code" : "presentation-cephalic", "display" : "Cephalic", "definition" : "Head presenting." }, { "code" : "presentation-breech", "display" : "Breech", "definition" : "Buttocks or feet presenting." }, { "code" : "presentation-shoulder", "display" : "Shoulder", "definition" : "Shoulder presenting, with the fetus lying transversely." }, { "code" : "presentation-face", "display" : "Face", "definition" : "Face presenting." }, { "code" : "presentation-brow", "display" : "Brow", "definition" : "Brow presenting." }, { "code" : "bowels-opened", "display" : "Opened", "definition" : "Bowels opened." }, { "code" : "bowels-not-opened", "display" : "Not opened", "definition" : "Bowels not opened." }, { "code" : "milk-breast", "display" : "Breast milk", "definition" : "Expressed or direct breast milk, as the milk feeding chart prints it." }, { "code" : "milk-nan", "display" : "NAN formula", "definition" : "The formula the milk feeding chart names by its brand column." }, { "code" : "urine-clear", "display" : "Clear", "definition" : "Clear irrigation return." }, { "code" : "urine-straw", "display" : "Straw", "definition" : "Straw-coloured return." }, { "code" : "urine-rose", "display" : "Rose", "definition" : "Rose or lightly blood-tinged return." }, { "code" : "urine-blood-stained", "display" : "Blood stained", "definition" : "Frankly blood-stained return." }, { "code" : "urine-clots", "display" : "With clots", "definition" : "Return carrying clots -- the finding that stops an irrigation and calls a surgeon." }] }