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

Generated Narrative: CodeSystem clinical-score-codesystem

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

CodeDisplayDefinition
braden-sensory-1 Completely limitedBraden sensory perception: unresponsive to painful stimuli, or limited ability to feel pain over most of the body.
braden-sensory-2 Very limitedBraden sensory perception: responds only to painful stimuli, or a sensory impairment over half the body.
braden-sensory-3 Slightly limitedBraden sensory perception: responds to verbal commands but cannot always communicate discomfort.
braden-sensory-4 No impairmentBraden sensory perception: responds to verbal commands, no sensory deficit.
braden-moisture-1 Constantly moistBraden moisture: skin kept moist almost constantly by perspiration or urine.
braden-moisture-2 Often moistBraden moisture: skin often but not always moist; linen changed at least once a shift.
braden-moisture-3 Occasionally moistBraden moisture: skin occasionally moist, requiring an extra linen change about once a day.
braden-moisture-4 Rarely moistBraden moisture: skin usually dry; linen changed at routine intervals.
braden-activity-1 BedfastBraden activity: confined to bed.
braden-activity-2 ChairfastBraden activity: ability to walk severely limited or non-existent; cannot bear own weight.
braden-activity-3 Walks occasionallyBraden activity: walks short distances during the day, with or without assistance.
braden-activity-4 Walks frequentlyBraden activity: walks outside the room at least twice a day and inside it every two hours while awake.
braden-mobility-1 Completely immobileBraden mobility: makes no change in body or extremity position without assistance.
braden-mobility-2 Very limitedBraden mobility: makes occasional slight changes in position but cannot make frequent or significant changes independently.
braden-mobility-3 Slightly limitedBraden mobility: makes frequent though slight changes in position independently.
braden-mobility-4 No limitationBraden mobility: makes major and frequent changes in position without assistance.
braden-nutrition-1 Very poorBraden nutrition: never eats a complete meal, or is nil by mouth or on clear fluids for more than five days.
braden-nutrition-2 Probably inadequateBraden nutrition: rarely eats a complete meal; generally eats about half of what is offered.
braden-nutrition-3 AdequateBraden nutrition: eats over half of most meals, or is fed by tube or parenterally to meet most needs.
braden-nutrition-4 ExcellentBraden nutrition: eats most of every meal and never refuses one.
braden-friction-1 ProblemBraden friction and shear: requires moderate to maximum assistance to move; slides against sheets and cannot lift clear of them.
braden-friction-2 Potential problemBraden friction and shear: moves feebly or requires minimum assistance; skin probably slides against sheets to some extent.
braden-friction-3 No apparent problemBraden 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 monthsFalls risk history: no fall recorded in the last twelve months.
falls-history-25 Fall in the last 12 monthsFalls risk history: at least one fall recorded in the last twelve months.
falls-diagnoses-0 One active diagnosis or noneFalls risk: no more than one active diagnosis on the problem list.
falls-diagnoses-15 More than one active diagnosisFalls risk: more than one active diagnosis on the problem list.
falls-aid-0 No walking aid, or bedrestFalls risk walking aid: none needed, on bedrest, or assisted by a nurse.
falls-aid-15 Crutch, stick or walkerFalls risk walking aid: mobilises with a crutch, stick or walking frame.
falls-aid-30 Holds onto furnitureFalls risk walking aid: mobilises by holding onto furniture.
falls-iv-0 No intravenous accessFalls risk: no cannula, line or heparin lock in place.
falls-iv-20 Intravenous access in placeFalls risk: a cannula, line or heparin lock is in place.
falls-gait-0 Normal gait, or bedrestFalls risk gait: normal gait, or immobile.
falls-gait-10 Weak gaitFalls risk gait: short steps, possibly shuffling, seeks support from furniture but not leaning on it.
falls-gait-20 Impaired gaitFalls risk gait: short steps with difficulty rising, head down, grasps furniture for support.
falls-mental-0 Oriented to own abilityFalls risk awareness: the patient's account of what they can manage matches what the nursing team observes.
falls-mental-15 Overestimates or forgets limitsFalls risk awareness: the patient overestimates what they can manage, or forgets their limits.
must-bmi-0 BMI 20 or overMUST body mass index step: 20 kg/m2 or above.
must-bmi-1 BMI 18.5 to 20MUST body mass index step: 18.5 to 20 kg/m2.
must-bmi-2 BMI under 18.5MUST 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 normallyMUST 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 moreMUST 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 openingGCS eye opening: none.
gcs-eye-2 Eye opening to pressureGCS eye opening: to pressure.
gcs-eye-3 Eye opening to soundGCS eye opening: to sound.
gcs-eye-4 Spontaneous eye openingGCS eye opening: spontaneous.
gcs-verbal-1 No verbal responseGCS verbal response: none.
gcs-verbal-2 SoundsGCS verbal response: sounds only, no recognisable words.
gcs-verbal-3 WordsGCS verbal response: recognisable words, not conversation.
gcs-verbal-4 ConfusedGCS verbal response: converses but is disoriented.
gcs-verbal-5 OrientedGCS verbal response: oriented conversation.
gcs-motor-1 No motor responseGCS motor response: none.
gcs-motor-2 ExtensionGCS motor response: extension to pain.
gcs-motor-3 Abnormal flexionGCS motor response: abnormal flexion to pain.
gcs-motor-4 Normal flexionGCS motor response: normal flexion, withdraws from pain.
gcs-motor-5 LocalisingGCS motor response: localises to pain.
gcs-motor-6 Obeys commandsGCS motor response: obeys commands.
" }, "url" : "https://fhir.slade360.co.ke/fhir/CodeSystem/clinical-score-codesystem", "version" : "0.1.0", "name" : "SGHIClinicalScoreCodeSystem", "title" : "SGHI Clinical Score 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 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.", "caseSensitive" : true, "content" : "complete", "count" : 60, "concept" : [{ "code" : "braden-sensory-1", "display" : "Completely limited", "definition" : "Braden sensory perception: unresponsive to painful stimuli, or limited ability to feel pain over most of the body." }, { "code" : "braden-sensory-2", "display" : "Very limited", "definition" : "Braden sensory perception: responds only to painful stimuli, or a sensory impairment over half the body." }, { "code" : "braden-sensory-3", "display" : "Slightly limited", "definition" : "Braden sensory perception: responds to verbal commands but cannot always communicate discomfort." }, { "code" : "braden-sensory-4", "display" : "No impairment", "definition" : "Braden sensory perception: responds to verbal commands, no sensory deficit." }, { "code" : "braden-moisture-1", "display" : "Constantly moist", "definition" : "Braden moisture: skin kept moist almost constantly by perspiration or urine." }, { "code" : "braden-moisture-2", "display" : "Often moist", "definition" : "Braden moisture: skin often but not always moist; linen changed at least once a shift." }, { "code" : "braden-moisture-3", "display" : "Occasionally moist", "definition" : "Braden moisture: skin occasionally moist, requiring an extra linen change about once a day." }, { "code" : "braden-moisture-4", "display" : "Rarely moist", "definition" : "Braden moisture: skin usually dry; linen changed at routine intervals." }, { "code" : "braden-activity-1", "display" : "Bedfast", "definition" : "Braden activity: confined to bed." }, { "code" : "braden-activity-2", "display" : "Chairfast", "definition" : "Braden activity: ability to walk severely limited or non-existent; cannot bear own weight." }, { "code" : "braden-activity-3", "display" : "Walks occasionally", "definition" : "Braden activity: walks short distances during the day, with or without assistance." }, { "code" : "braden-activity-4", "display" : "Walks frequently", "definition" : "Braden activity: walks outside the room at least twice a day and inside it every two hours while awake." }, { "code" : "braden-mobility-1", "display" : "Completely immobile", "definition" : "Braden mobility: makes no change in body or extremity position without assistance." }, { "code" : "braden-mobility-2", "display" : "Very limited", "definition" : "Braden mobility: makes occasional slight changes in position but cannot make frequent or significant changes independently." }, { "code" : "braden-mobility-3", "display" : "Slightly limited", "definition" : "Braden mobility: makes frequent though slight changes in position independently." }, { "code" : "braden-mobility-4", "display" : "No limitation", "definition" : "Braden mobility: makes major and frequent changes in position without assistance." }, { "code" : "braden-nutrition-1", "display" : "Very poor", "definition" : "Braden nutrition: never eats a complete meal, or is nil by mouth or on clear fluids for more than five days." }, { "code" : "braden-nutrition-2", "display" : "Probably inadequate", "definition" : "Braden nutrition: rarely eats a complete meal; generally eats about half of what is offered." }, { "code" : "braden-nutrition-3", "display" : "Adequate", "definition" : "Braden nutrition: eats over half of most meals, or is fed by tube or parenterally to meet most needs." }, { "code" : "braden-nutrition-4", "display" : "Excellent", "definition" : "Braden nutrition: eats most of every meal and never refuses one." }, { "code" : "braden-friction-1", "display" : "Problem", "definition" : "Braden friction and shear: requires moderate to maximum assistance to move; slides against sheets and cannot lift clear of them." }, { "code" : "braden-friction-2", "display" : "Potential problem", "definition" : "Braden friction and shear: moves feebly or requires minimum assistance; skin probably slides against sheets to some extent." }, { "code" : "braden-friction-3", "display" : "No apparent problem", "definition" : "Braden friction and shear: moves independently in bed and chair, with enough muscle strength to lift clear of the sheets." }, { "code" : "falls-history-0", "display" : "No fall in the last 12 months", "definition" : "Falls risk history: no fall recorded in the last twelve months." }, { "code" : "falls-history-25", "display" : "Fall in the last 12 months", "definition" : "Falls risk history: at least one fall recorded in the last twelve months." }, { "code" : "falls-diagnoses-0", "display" : "One active diagnosis or none", "definition" : "Falls risk: no more than one active diagnosis on the problem list." }, { "code" : "falls-diagnoses-15", "display" : "More than one active diagnosis", "definition" : "Falls risk: more than one active diagnosis on the problem list." }, { "code" : "falls-aid-0", "display" : "No walking aid, or bedrest", "definition" : "Falls risk walking aid: none needed, on bedrest, or assisted by a nurse." }, { "code" : "falls-aid-15", "display" : "Crutch, stick or walker", "definition" : "Falls risk walking aid: mobilises with a crutch, stick or walking frame." }, { "code" : "falls-aid-30", "display" : "Holds onto furniture", "definition" : "Falls risk walking aid: mobilises by holding onto furniture." }, { "code" : "falls-iv-0", "display" : "No intravenous access", "definition" : "Falls risk: no cannula, line or heparin lock in place." }, { "code" : "falls-iv-20", "display" : "Intravenous access in place", "definition" : "Falls risk: a cannula, line or heparin lock is in place." }, { "code" : "falls-gait-0", "display" : "Normal gait, or bedrest", "definition" : "Falls risk gait: normal gait, or immobile." }, { "code" : "falls-gait-10", "display" : "Weak gait", "definition" : "Falls risk gait: short steps, possibly shuffling, seeks support from furniture but not leaning on it." }, { "code" : "falls-gait-20", "display" : "Impaired gait", "definition" : "Falls risk gait: short steps with difficulty rising, head down, grasps furniture for support." }, { "code" : "falls-mental-0", "display" : "Oriented to own ability", "definition" : "Falls risk awareness: the patient's account of what they can manage matches what the nursing team observes." }, { "code" : "falls-mental-15", "display" : "Overestimates or forgets limits", "definition" : "Falls risk awareness: the patient overestimates what they can manage, or forgets their limits." }, { "code" : "must-bmi-0", "display" : "BMI 20 or over", "definition" : "MUST body mass index step: 20 kg/m2 or above." }, { "code" : "must-bmi-1", "display" : "BMI 18.5 to 20", "definition" : "MUST body mass index step: 18.5 to 20 kg/m2." }, { "code" : "must-bmi-2", "display" : "BMI under 18.5", "definition" : "MUST body mass index step: below 18.5 kg/m2." }, { "code" : "must-loss-0", "display" : "Weight loss under 5%", "definition" : "MUST weight loss step: unplanned loss of less than 5% of body weight in the last three to six months." }, { "code" : "must-loss-1", "display" : "Weight loss 5 to 10%", "definition" : "MUST weight loss step: unplanned loss of 5 to 10% of body weight in the last three to six months." }, { "code" : "must-loss-2", "display" : "Weight loss over 10%", "definition" : "MUST weight loss step: unplanned loss of more than 10% of body weight in the last three to six months." }, { "code" : "must-acute-0", "display" : "Eating normally", "definition" : "MUST acute disease effect step: the patient is eating, or a break in intake of five days or more is not expected." }, { "code" : "must-acute-2", "display" : "No nutritional intake for 5 days or more", "definition" : "MUST acute disease effect step: acutely ill with no nutritional intake for five days or more, or none expected for that long." }, { "code" : "gcs-eye-1", "display" : "No eye opening", "definition" : "GCS eye opening: none." }, { "code" : "gcs-eye-2", "display" : "Eye opening to pressure", "definition" : "GCS eye opening: to pressure." }, { "code" : "gcs-eye-3", "display" : "Eye opening to sound", "definition" : "GCS eye opening: to sound." }, { "code" : "gcs-eye-4", "display" : "Spontaneous eye opening", "definition" : "GCS eye opening: spontaneous." }, { "code" : "gcs-verbal-1", "display" : "No verbal response", "definition" : "GCS verbal response: none." }, { "code" : "gcs-verbal-2", "display" : "Sounds", "definition" : "GCS verbal response: sounds only, no recognisable words." }, { "code" : "gcs-verbal-3", "display" : "Words", "definition" : "GCS verbal response: recognisable words, not conversation." }, { "code" : "gcs-verbal-4", "display" : "Confused", "definition" : "GCS verbal response: converses but is disoriented." }, { "code" : "gcs-verbal-5", "display" : "Oriented", "definition" : "GCS verbal response: oriented conversation." }, { "code" : "gcs-motor-1", "display" : "No motor response", "definition" : "GCS motor response: none." }, { "code" : "gcs-motor-2", "display" : "Extension", "definition" : "GCS motor response: extension to pain." }, { "code" : "gcs-motor-3", "display" : "Abnormal flexion", "definition" : "GCS motor response: abnormal flexion to pain." }, { "code" : "gcs-motor-4", "display" : "Normal flexion", "definition" : "GCS motor response: normal flexion, withdraws from pain." }, { "code" : "gcs-motor-5", "display" : "Localising", "definition" : "GCS motor response: localises to pain." }, { "code" : "gcs-motor-6", "display" : "Obeys commands", "definition" : "GCS motor response: obeys commands." }] }