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.
 <status value="active"/> <experimental value="false"/> <date value="2026-09-15T11:40:24+00:00"/> <publisher value="Kathurima Kimathi"/> <contact> <name value="Kathurima Kimathi"/> <telecom> <system value="url"/> <value value="https://www.linkedin.com/in/kathurima-kimathi/"/> </telecom> <telecom> <system value="email"/> <value value="kathurimakimathi415@gmail.com"/> </telecom> </contact> <contact> <name value="Oscar John"/> <telecom> <system value="email"/> <value value="oscarjohnotieno@gmail.com"/> <use value="work"/> </telecom> </contact> <contact> <name value="Kennedy Omondi"/> <telecom> <system value="email"/> <value value="kennankole@gmail.com"/> <use value="work"/> </telecom> </contact> <description value="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 value="true"/> <content value="complete"/> <count value="60"/> <concept> <code value="braden-sensory-1"/> <display value="Completely limited"/> <definition value="Braden sensory perception: unresponsive to painful stimuli, or limited ability to feel pain over most of the body."/> </concept> <concept> <code value="braden-sensory-2"/> <display value="Very limited"/> <definition value="Braden sensory perception: responds only to painful stimuli, or a sensory impairment over half the body."/> </concept> <concept> <code value="braden-sensory-3"/> <display value="Slightly limited"/> <definition value="Braden sensory perception: responds to verbal commands but cannot always communicate discomfort."/> </concept> <concept> <code value="braden-sensory-4"/> <display value="No impairment"/> <definition value="Braden sensory perception: responds to verbal commands, no sensory deficit."/> </concept> <concept> <code value="braden-moisture-1"/> <display value="Constantly moist"/> <definition value="Braden moisture: skin kept moist almost constantly by perspiration or urine."/> </concept> <concept> <code value="braden-moisture-2"/> <display value="Often moist"/> <definition value="Braden moisture: skin often but not always moist; linen changed at least once a shift."/> </concept> <concept> <code value="braden-moisture-3"/> <display value="Occasionally moist"/> <definition value="Braden moisture: skin occasionally moist, requiring an extra linen change about once a day."/> </concept> <concept> <code value="braden-moisture-4"/> <display value="Rarely moist"/> <definition value="Braden moisture: skin usually dry; linen changed at routine intervals."/> </concept> <concept> <code value="braden-activity-1"/> <display value="Bedfast"/> <definition value="Braden activity: confined to bed."/> </concept> <concept> <code value="braden-activity-2"/> <display value="Chairfast"/> <definition value="Braden activity: ability to walk severely limited or non-existent; cannot bear own weight."/> </concept> <concept> <code value="braden-activity-3"/> <display value="Walks occasionally"/> <definition value="Braden activity: walks short distances during the day, with or without assistance."/> </concept> <concept> <code value="braden-activity-4"/> <display value="Walks frequently"/> <definition value="Braden activity: walks outside the room at least twice a day and inside it every two hours while awake."/> </concept> <concept> <code value="braden-mobility-1"/> <display value="Completely immobile"/> <definition value="Braden mobility: makes no change in body or extremity position without assistance."/> </concept> <concept> <code value="braden-mobility-2"/> <display value="Very limited"/> <definition value="Braden mobility: makes occasional slight changes in position but cannot make frequent or significant changes independently."/> </concept> <concept> <code value="braden-mobility-3"/> <display value="Slightly limited"/> <definition value="Braden mobility: makes frequent though slight changes in position independently."/> </concept> <concept> <code value="braden-mobility-4"/> <display value="No limitation"/> <definition value="Braden mobility: makes major and frequent changes in position without assistance."/> </concept> <concept> <code value="braden-nutrition-1"/> <display value="Very poor"/> <definition value="Braden nutrition: never eats a complete meal, or is nil by mouth or on clear fluids for more than five days."/> </concept> <concept> <code value="braden-nutrition-2"/> <display value="Probably inadequate"/> <definition value="Braden nutrition: rarely eats a complete meal; generally eats about half of what is offered."/> </concept> <concept> <code value="braden-nutrition-3"/> <display value="Adequate"/> <definition value="Braden nutrition: eats over half of most meals, or is fed by tube or parenterally to meet most needs."/> </concept> <concept> <code value="braden-nutrition-4"/> <display value="Excellent"/> <definition value="Braden nutrition: eats most of every meal and never refuses one."/> </concept> <concept> <code value="braden-friction-1"/> <display value="Problem"/> <definition value="Braden friction and shear: requires moderate to maximum assistance to move; slides against sheets and cannot lift clear of them."/> </concept> <concept> <code value="braden-friction-2"/> <display value="Potential problem"/> <definition value="Braden friction and shear: moves feebly or requires minimum assistance; skin probably slides against sheets to some extent."/> </concept> <concept> <code value="braden-friction-3"/> <display value="No apparent problem"/> <definition value="Braden friction and shear: moves independently in bed and chair, with enough muscle strength to lift clear of the sheets."/> </concept> <concept> <code value="falls-history-0"/> <display value="No fall in the last 12 months"/> <definition value="Falls risk history: no fall recorded in the last twelve months."/> </concept> <concept> <code value="falls-history-25"/> <display value="Fall in the last 12 months"/> <definition value="Falls risk history: at least one fall recorded in the last twelve months."/> </concept> <concept> <code value="falls-diagnoses-0"/> <display value="One active diagnosis or none"/> <definition value="Falls risk: no more than one active diagnosis on the problem list."/> </concept> <concept> <code value="falls-diagnoses-15"/> <display value="More than one active diagnosis"/> <definition value="Falls risk: more than one active diagnosis on the problem list."/> </concept> <concept> <code value="falls-aid-0"/> <display value="No walking aid, or bedrest"/> <definition value="Falls risk walking aid: none needed, on bedrest, or assisted by a nurse."/> </concept> <concept> <code value="falls-aid-15"/> <display value="Crutch, stick or walker"/> <definition value="Falls risk walking aid: mobilises with a crutch, stick or walking frame."/> </concept> <concept> <code value="falls-aid-30"/> <display value="Holds onto furniture"/> <definition value="Falls risk walking aid: mobilises by holding onto furniture."/> </concept> <concept> <code value="falls-iv-0"/> <display value="No intravenous access"/> <definition value="Falls risk: no cannula, line or heparin lock in place."/> </concept> <concept> <code value="falls-iv-20"/> <display value="Intravenous access in place"/> <definition value="Falls risk: a cannula, line or heparin lock is in place."/> </concept> <concept> <code value="falls-gait-0"/> <display value="Normal gait, or bedrest"/> <definition value="Falls risk gait: normal gait, or immobile."/> </concept> <concept> <code value="falls-gait-10"/> <display value="Weak gait"/> <definition value="Falls risk gait: short steps, possibly shuffling, seeks support from furniture but not leaning on it."/> </concept> <concept> <code value="falls-gait-20"/> <display value="Impaired gait"/> <definition value="Falls risk gait: short steps with difficulty rising, head down, grasps furniture for support."/> </concept> <concept> <code value="falls-mental-0"/> <display value="Oriented to own ability"/> <definition value="Falls risk awareness: the patient's account of what they can manage matches what the nursing team observes."/> </concept> <concept> <code value="falls-mental-15"/> <display value="Overestimates or forgets limits"/> <definition value="Falls risk awareness: the patient overestimates what they can manage, or forgets their limits."/> </concept> <concept> <code value="must-bmi-0"/> <display value="BMI 20 or over"/> <definition value="MUST body mass index step: 20 kg/m2 or above."/> </concept> <concept> <code value="must-bmi-1"/> <display value="BMI 18.5 to 20"/> <definition value="MUST body mass index step: 18.5 to 20 kg/m2."/> </concept> <concept> <code value="must-bmi-2"/> <display value="BMI under 18.5"/> <definition value="MUST body mass index step: below 18.5 kg/m2."/> </concept> <concept> <code value="must-loss-0"/> <display value="Weight loss under 5%"/> <definition value="MUST weight loss step: unplanned loss of less than 5% of body weight in the last three to six months."/> </concept> <concept> <code value="must-loss-1"/> <display value="Weight loss 5 to 10%"/> <definition value="MUST weight loss step: unplanned loss of 5 to 10% of body weight in the last three to six months."/> </concept> <concept> <code value="must-loss-2"/> <display value="Weight loss over 10%"/> <definition value="MUST weight loss step: unplanned loss of more than 10% of body weight in the last three to six months."/> </concept> <concept> <code value="must-acute-0"/> <display value="Eating normally"/> <definition value="MUST acute disease effect step: the patient is eating, or a break in intake of five days or more is not expected."/> </concept> <concept> <code value="must-acute-2"/> <display value="No nutritional intake for 5 days or more"/> <definition value="MUST acute disease effect step: acutely ill with no nutritional intake for five days or more, or none expected for that long."/> </concept> <concept> <code value="gcs-eye-1"/> <display value="No eye opening"/> <definition value="GCS eye opening: none."/> </concept> <concept> <code value="gcs-eye-2"/> <display value="Eye opening to pressure"/> <definition value="GCS eye opening: to pressure."/> </concept> <concept> <code value="gcs-eye-3"/> <display value="Eye opening to sound"/> <definition value="GCS eye opening: to sound."/> </concept> <concept> <code value="gcs-eye-4"/> <display value="Spontaneous eye opening"/> <definition value="GCS eye opening: spontaneous."/> </concept> <concept> <code value="gcs-verbal-1"/> <display value="No verbal response"/> <definition value="GCS verbal response: none."/> </concept> <concept> <code value="gcs-verbal-2"/> <display value="Sounds"/> <definition value="GCS verbal response: sounds only, no recognisable words."/> </concept> <concept> <code value="gcs-verbal-3"/> <display value="Words"/> <definition value="GCS verbal response: recognisable words, not conversation."/> </concept> <concept> <code value="gcs-verbal-4"/> <display value="Confused"/> <definition value="GCS verbal response: converses but is disoriented."/> </concept> <concept> <code value="gcs-verbal-5"/> <display value="Oriented"/> <definition value="GCS verbal response: oriented conversation."/> </concept> <concept> <code value="gcs-motor-1"/> <display value="No motor response"/> <definition value="GCS motor response: none."/> </concept> <concept> <code value="gcs-motor-2"/> <display value="Extension"/> <definition value="GCS motor response: extension to pain."/> </concept> <concept> <code value="gcs-motor-3"/> <display value="Abnormal flexion"/> <definition value="GCS motor response: abnormal flexion to pain."/> </concept> <concept> <code value="gcs-motor-4"/> <display value="Normal flexion"/> <definition value="GCS motor response: normal flexion, withdraws from pain."/> </concept> <concept> <code value="gcs-motor-5"/> <display value="Localising"/> <definition value="GCS motor response: localises to pain."/> </concept> <concept> <code value="gcs-motor-6"/> <display value="Obeys commands"/> <definition value="GCS motor response: obeys commands."/> </concept> </CodeSystem>