SGHI FHIR Profile Implementation Guide
0.1.0 - ci-build

SGHI FHIR Profile Implementation Guide, published by Kathurima Kimathi. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/savannahghi/sil_fhir_profile_ig/ and changes regularly. See the Directory of published versions

CodeSystem: SGHI Clinical Score Code System

Official URL: https://fhir.slade360.co.ke/fhir/CodeSystem/clinical-score-codesystem Version: 0.1.0
Active as of 2026-09-15 Computable Name: SGHIClinicalScoreCodeSystem

The answers to the scored instruments used on inpatient assessments: the Braden pressure ulcer scale, the Morse falls score, MUST nutrition screening and the Glasgow Coma Scale. Each answer is a concept so a response records what was observed rather than a bare number. Codes are namespaced instrument-item-weight; the weight is in the code because within an item it is what tells one answer from another, and because two items in an instrument can share a label. The extraction maps rely on that: they read the weight off the tail of the code when a client submits no calculated total.

This Code system is referenced in the content logical definition of the following value sets:

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

CodeDisplayDefinition
braden-sensory-1 Completely limited Braden sensory perception: unresponsive to painful stimuli, or limited ability to feel pain over most of the body.
braden-sensory-2 Very limited Braden sensory perception: responds only to painful stimuli, or a sensory impairment over half the body.
braden-sensory-3 Slightly limited Braden sensory perception: responds to verbal commands but cannot always communicate discomfort.
braden-sensory-4 No impairment Braden sensory perception: responds to verbal commands, no sensory deficit.
braden-moisture-1 Constantly moist Braden moisture: skin kept moist almost constantly by perspiration or urine.
braden-moisture-2 Often moist Braden moisture: skin often but not always moist; linen changed at least once a shift.
braden-moisture-3 Occasionally moist Braden moisture: skin occasionally moist, requiring an extra linen change about once a day.
braden-moisture-4 Rarely moist Braden moisture: skin usually dry; linen changed at routine intervals.
braden-activity-1 Bedfast Braden activity: confined to bed.
braden-activity-2 Chairfast Braden activity: ability to walk severely limited or non-existent; cannot bear own weight.
braden-activity-3 Walks occasionally Braden activity: walks short distances during the day, with or without assistance.
braden-activity-4 Walks frequently Braden activity: walks outside the room at least twice a day and inside it every two hours while awake.
braden-mobility-1 Completely immobile Braden mobility: makes no change in body or extremity position without assistance.
braden-mobility-2 Very limited Braden mobility: makes occasional slight changes in position but cannot make frequent or significant changes independently.
braden-mobility-3 Slightly limited Braden mobility: makes frequent though slight changes in position independently.
braden-mobility-4 No limitation Braden mobility: makes major and frequent changes in position without assistance.
braden-nutrition-1 Very poor Braden nutrition: never eats a complete meal, or is nil by mouth or on clear fluids for more than five days.
braden-nutrition-2 Probably inadequate Braden nutrition: rarely eats a complete meal; generally eats about half of what is offered.
braden-nutrition-3 Adequate Braden nutrition: eats over half of most meals, or is fed by tube or parenterally to meet most needs.
braden-nutrition-4 Excellent Braden nutrition: eats most of every meal and never refuses one.
braden-friction-1 Problem Braden friction and shear: requires moderate to maximum assistance to move; slides against sheets and cannot lift clear of them.
braden-friction-2 Potential problem Braden friction and shear: moves feebly or requires minimum assistance; skin probably slides against sheets to some extent.
braden-friction-3 No apparent problem Braden friction and shear: moves independently in bed and chair, with enough muscle strength to lift clear of the sheets.
falls-history-0 No fall in the last 12 months Falls risk history: no fall recorded in the last twelve months.
falls-history-25 Fall in the last 12 months Falls risk history: at least one fall recorded in the last twelve months.
falls-diagnoses-0 One active diagnosis or none Falls risk: no more than one active diagnosis on the problem list.
falls-diagnoses-15 More than one active diagnosis Falls risk: more than one active diagnosis on the problem list.
falls-aid-0 No walking aid, or bedrest Falls risk walking aid: none needed, on bedrest, or assisted by a nurse.
falls-aid-15 Crutch, stick or walker Falls risk walking aid: mobilises with a crutch, stick or walking frame.
falls-aid-30 Holds onto furniture Falls risk walking aid: mobilises by holding onto furniture.
falls-iv-0 No intravenous access Falls risk: no cannula, line or heparin lock in place.
falls-iv-20 Intravenous access in place Falls risk: a cannula, line or heparin lock is in place.
falls-gait-0 Normal gait, or bedrest Falls risk gait: normal gait, or immobile.
falls-gait-10 Weak gait Falls risk gait: short steps, possibly shuffling, seeks support from furniture but not leaning on it.
falls-gait-20 Impaired gait Falls risk gait: short steps with difficulty rising, head down, grasps furniture for support.
falls-mental-0 Oriented to own ability Falls risk awareness: the patient's account of what they can manage matches what the nursing team observes.
falls-mental-15 Overestimates or forgets limits Falls risk awareness: the patient overestimates what they can manage, or forgets their limits.
must-bmi-0 BMI 20 or over MUST body mass index step: 20 kg/m2 or above.
must-bmi-1 BMI 18.5 to 20 MUST body mass index step: 18.5 to 20 kg/m2.
must-bmi-2 BMI under 18.5 MUST body mass index step: below 18.5 kg/m2.
must-loss-0 Weight loss under 5% MUST weight loss step: unplanned loss of less than 5% of body weight in the last three to six months.
must-loss-1 Weight loss 5 to 10% MUST weight loss step: unplanned loss of 5 to 10% of body weight in the last three to six months.
must-loss-2 Weight loss over 10% MUST weight loss step: unplanned loss of more than 10% of body weight in the last three to six months.
must-acute-0 Eating normally MUST acute disease effect step: the patient is eating, or a break in intake of five days or more is not expected.
must-acute-2 No nutritional intake for 5 days or more MUST acute disease effect step: acutely ill with no nutritional intake for five days or more, or none expected for that long.
gcs-eye-1 No eye opening GCS eye opening: none.
gcs-eye-2 Eye opening to pressure GCS eye opening: to pressure.
gcs-eye-3 Eye opening to sound GCS eye opening: to sound.
gcs-eye-4 Spontaneous eye opening GCS eye opening: spontaneous.
gcs-verbal-1 No verbal response GCS verbal response: none.
gcs-verbal-2 Sounds GCS verbal response: sounds only, no recognisable words.
gcs-verbal-3 Words GCS verbal response: recognisable words, not conversation.
gcs-verbal-4 Confused GCS verbal response: converses but is disoriented.
gcs-verbal-5 Oriented GCS verbal response: oriented conversation.
gcs-motor-1 No motor response GCS motor response: none.
gcs-motor-2 Extension GCS motor response: extension to pain.
gcs-motor-3 Abnormal flexion GCS motor response: abnormal flexion to pain.
gcs-motor-4 Normal flexion GCS motor response: normal flexion, withdraws from pain.
gcs-motor-5 Localising GCS motor response: localises to pain.
gcs-motor-6 Obeys commands GCS motor response: obeys commands.