| Code | Display | Definition |
| admission-route-accompanied-by |
Accompanied by |
How a patient reached the ward: where they were admitted from, how they physically arrived, and which unit, room and bed they went to. Recorded on the admission form. |
| admission-route-admitted-from |
Admitted from |
How a patient reached the ward: where they were admitted from, how they physically arrived, and which unit, room and bed they went to. Recorded on the admission form. |
| admission-route-bed |
Bed |
How a patient reached the ward: where they were admitted from, how they physically arrived, and which unit, room and bed they went to. Recorded on the admission form. |
| admission-route-how-the-patient-arrived |
How the patient arrived |
How a patient reached the ward: where they were admitted from, how they physically arrived, and which unit, room and bed they went to. Recorded on the admission form. |
| admission-route-mode-of-arrival |
Mode of arrival |
How a patient reached the ward: where they were admitted from, how they physically arrived, and which unit, room and bed they went to. Recorded on the admission form. |
| admission-route-room |
Room |
How a patient reached the ward: where they were admitted from, how they physically arrived, and which unit, room and bed they went to. Recorded on the admission form. |
| admission-route-unit-admitted-to |
Unit admitted to |
How a patient reached the ward: where they were admitted from, how they physically arrived, and which unit, room and bed they went to. Recorded on the admission form. |
| anaesthesia-used-as-recorded-on-the-theatre-note |
Anaesthesia used, as recorded on the theatre note |
A fact about the anaesthetic given. Recorded on the theatre note. |
| anticoagulation-anticoagulant-agent-and-dose |
Anticoagulant agent and dose |
Whether a patient is on stabilised oral anticoagulant therapy, and on what. It governs whether the INR reference range printed on the coagulation form applies at all, or the coagulation profile as ordered. Recorded on the coagulation profile requisition. |
| anticoagulation-coagulation-profile |
Coagulation profile |
Whether a patient is on stabilised oral anticoagulant therapy, and on what. It governs whether the INR reference range printed on the coagulation form applies at all, or the coagulation profile as ordered. Recorded on the coagulation profile requisition. |
| anticoagulation-on-stabilised-oral-anticoagulant-therapy |
On stabilised oral anticoagulant therapy |
Whether a patient is on stabilised oral anticoagulant therapy, and on what. It governs whether the INR reference range printed on the coagulation form applies at all, or the coagulation profile as ordered. Recorded on the coagulation profile requisition. |
| bishop-cervical-dilation |
Cervical dilation |
An item of the Bishop score for cervical ripeness, or the total. LOINC has no term for the score or for cervical dilation at all. Recorded on the maternity record. |
| bishop-consistency |
Cervical consistency (Bishop) |
The cervical consistency item of the Bishop score — firm, medium or soft — scored 0 to 2. |
| bishop-dilation |
Cervical dilation (Bishop) |
The cervical dilation item of the Bishop score, scored 0 to 3. LOINC has no term for cervical dilation at all, measured or scored — searching its implicit value set for both "Dilation Cervix" and "Cervical dilat" returns nothing — so the item and the measurement behind it are both local. |
| bishop-effacement |
Cervical effacement (Bishop) |
The cervical effacement item of the Bishop score, scored 0 to 3, read either as a percentage or as cervical length. LOINC 11867-9 Effacement Cervix is the measurement; this is the banded item that carries a weight, so the extraction map records both — 11867-9 for what was seen and this code for what it scored. |
| bishop-head-station |
Head station |
An item of the Bishop score for cervical ripeness, or the total. LOINC has no term for the score or for cervical dilation at all. Recorded on the maternity record. |
| bishop-position |
Cervical position (Bishop) |
The cervical position item of the Bishop score — posterior, midline or anterior — scored 0 to 2. |
| bishop-station |
Head station (Bishop) |
The station of the presenting part relative to the ischial spines, scored 0 to 3 as the Bishop item. |
| body-part-removal-body-part-removed |
Body part removed |
The procedure a body part was removed at, which part, and the theatre and mortuary staff who handed it over. Recorded on the body part disposal consent form. |
| body-part-removal-body-part-removed-at-surgery |
Body part removed at surgery |
The procedure a body part was removed at, which part, and the theatre and mortuary staff who handed it over. Recorded on the body part disposal consent form. |
| body-part-removal-diagnosis-before-the-procedure |
Diagnosis before the procedure |
The procedure a body part was removed at, which part, and the theatre and mortuary staff who handed it over. Recorded on the body part disposal consent form. |
| body-part-removal-mortuary-staff-receiving-the-body-part |
Mortuary staff receiving the body part |
The procedure a body part was removed at, which part, and the theatre and mortuary staff who handed it over. Recorded on the body part disposal consent form. |
| body-part-removal-procedure-or-surgery-performed |
Procedure or surgery performed |
The procedure a body part was removed at, which part, and the theatre and mortuary staff who handed it over. Recorded on the body part disposal consent form. |
| body-part-removal-theatre-staff-handing-over-the-body-part |
Theatre staff handing over the body part |
The procedure a body part was removed at, which part, and the theatre and mortuary staff who handed it over. Recorded on the body part disposal consent form. |
| chemo-remarks-on-a-chemotherapy-cycle |
Remarks on a chemotherapy cycle |
A fact about a cycle of systemic anti-cancer therapy: the regimen, the cycle number, the line of treatment, or what has to happen before the cycle runs. Recorded on the chemotherapy protocol cycle sheet. |
| cord-condition |
Cord condition |
Whether the umbilical cord is fresh, dry or infected, as recorded on the newborn handover. |
| cord-mode-of-delivery |
Mode of delivery |
The condition of a newborn’s cord, or how and where the baby was born. Recorded on the newborn admission record and the newborn observation chart. |
| cord-nature-of-birth |
Nature of birth |
The condition of a newborn’s cord, or how and where the baby was born. Recorded on the mortuary consent form for the disposal of a baby. |
| cord-place-of-birth |
Place of birth |
The condition of a newborn’s cord, or how and where the baby was born. Recorded on the newborn admission record. |
| dialysis-bath-k-plus |
Bath K+ |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-clotting-time |
Clotting time |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-dialyser |
Dialyser |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-fluid |
Fluid |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-hbs-ag |
HBs Ag |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-hcv |
HCV |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-heparin-given |
Heparin given |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-heparin-loading-dose |
Heparin loading dose |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-heparin-units-per-hour |
Heparin units per hour |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-hiv |
HIV |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-prescription |
Dialysis prescription |
The prescription for one session: treatment time, priming, dialyser, bath potassium and heparinisation. Carried as components on one Observation because none of the five means anything without the others. |
| dialysis-prime |
Prime |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-session-reading |
Dialysis session reading |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-target-weight |
Target weight |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| dialysis-treatment-time |
Treatment time |
A prescription setting, machine reading or circuit pressure from the dialysis flow chart. The circuit pressures are deliberately not coded to the blood pressure LOINC codes: they are machine readings on tubing. Recorded on the haemodialysis flow chart. |
| discharge-ward-of-admission |
Ward of admission |
A fact recorded on the discharge summary. Recorded on the medical report. |
| discharge-ward-of-discharge |
Ward of discharge |
A fact recorded on the discharge summary. Recorded on the medical report. |
| donor-eligibility-question |
Donor eligibility question |
One of the thirteen deferral questions on the KTTA donor form. The answer says whether the donor answered yes. |
| donor-eligible |
Donor is eligible |
The screening decision: whether this donor may give blood today. |
| donor-type |
Type of donor |
Whether the donor is a replacement donor, a voluntary donor, or donating for their own later use. |
| donor-ae-convulsion |
Convulsion |
One of the nine adverse events the KTTA form asks about after every donation. The set is the haemovigilance record. Recorded on the KTTA blood donor questionnaire. |
| donor-ae-fainting |
Fainting |
One of the nine adverse events the KTTA form asks about after every donation. The set is the haemovigilance record. Recorded on the KTTA blood donor questionnaire. |
| donor-ae-haematoma |
Haematoma |
One of the nine adverse events the KTTA form asks about after every donation. The set is the haemovigilance record. Recorded on the KTTA blood donor questionnaire. |
| donor-ae-headache |
Headache |
One of the nine adverse events the KTTA form asks about after every donation. The set is the haemovigilance record. Recorded on the KTTA blood donor questionnaire. |
| donor-ae-incontinence-of-urine-or-stool |
Incontinence of urine or stool |
One of the nine adverse events the KTTA form asks about after every donation. The set is the haemovigilance record. Recorded on the KTTA blood donor questionnaire. |
| donor-ae-more-than-one-venipuncture |
More than one venipuncture |
One of the nine adverse events the KTTA form asks about after every donation. The set is the haemovigilance record. Recorded on the KTTA blood donor questionnaire. |
| donor-ae-nausea |
Nausea |
One of the nine adverse events the KTTA form asks about after every donation. The set is the haemovigilance record. Recorded on the KTTA blood donor questionnaire. |
| donor-ae-underweight-unit |
Underweight unit |
One of the nine adverse events the KTTA form asks about after every donation. The set is the haemovigilance record. Recorded on the KTTA blood donor questionnaire. |
| donor-ae-vomiting |
Vomiting |
One of the nine adverse events the KTTA form asks about after every donation. The set is the haemovigilance record. Recorded on the KTTA blood donor questionnaire. |
| donor-q-eaten-in-the-last-6-hours |
Eaten in the last 6 hours |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-ever-had-hepatitis-or-yellow-eyes |
Ever had hepatitis or yellow eyes |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-exposed-to-a-suspected-case-of-covid-19-in-the-last |
Exposed to a suspected case of COVID-19 in the last 14 days |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-fainted-within-the-past-one-year |
Fainted within the past one year |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-feeling-well-today |
Feeling well today |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-on-regular-medication-antibiotics-or-analgesics |
On regular medication, antibiotics or analgesics |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-pregnant-or-lactating |
Pregnant or lactating |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-received-blood-or-blood-products-in-the-past-6 |
Received blood or blood products in the past 6 months |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-sexual-activity-in-the-last-3-months-with-a-person |
Sexual activity in the last 3 months with a person of unknown health status |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-surgery-or-medical-treatment-in-the-past-6-months |
Surgery or medical treatment in the past 6 months |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-tattooing-or-body-piercing-in-the-last-3-months |
Tattooing or body piercing in the last 3 months |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-travelled-in-the-last-14-days-outside-the-usual-area |
Travelled in the last 14 days outside the usual area of residence |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| donor-q-vaccination-in-the-last-3-months |
Vaccination in the last 3 months |
One of the thirteen deferral questions on the KTTA donor form. Eligibility is judged over the whole set, which is why they travel together as one panel. Recorded on the KTTA blood donor questionnaire. |
| emergency-sign |
Emergency sign present |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. The answer says which sign. |
| emergency-sign-avpu-is-p-or-u |
AVPU is P or U |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| emergency-sign-capillary-refill-over-3-seconds |
Capillary refill over 3 seconds |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| emergency-sign-central-cyanosis |
Central cyanosis |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| emergency-sign-coma |
Coma |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| emergency-sign-confusion |
Confusion |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| emergency-sign-convulsing |
Convulsing |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| emergency-sign-diarrhoea-with-sunken-eyes |
Diarrhoea with sunken eyes |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| emergency-sign-severe-respiratory-distress |
Severe respiratory distress |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| emergency-sign-skin-pinch-over-2-seconds |
Skin pinch over 2 seconds |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| emergency-sign-weak-absent-or-fast-pulse |
Weak, absent or fast pulse |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| emergency-sign-weak-or-absent-breathing |
Weak or absent breathing |
One of the emergency signs the paediatric triage sheet looks for, which sends the child to a clinician immediately. Recorded on the paediatric triage record. |
| endoscopy-endoscopic-findings |
Endoscopic findings |
Something the endoscopy investigation form records — what the endoscopist saw, or the conclusion drawn from it. Recorded on the endoscopy service investigation form. |
| feeding-and-position-entry |
Feeding and position entry |
How a patient is being fed, or a nutrition assessment. Recorded on the feeding and position chart. |
| feeding-expressed-breast-milk-given |
Expressed breast milk given |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-feed-frequency-in-hours |
Feed frequency in hours |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-feed-volume-given |
Feed volume given |
How a patient is being fed, or a nutrition assessment. Recorded on the milk feeding chart. |
| feeding-feed-volume-retained |
Feed volume retained |
How a patient is being fed, or a nutrition assessment. Recorded on the milk feeding chart. |
| feeding-fluid-given-on-a-newborn-round |
Fluid given on a newborn round |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-formula-given |
Formula given |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-growth-and-development |
Growth and development |
How a patient is being fed, or a nutrition assessment. Recorded on the paediatric admission record. |
| feeding-intravenous-fluid-nursing-plan |
Intravenous fluid nursing plan |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-intravenous-volume-given |
Intravenous volume given |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-iv-drops-per-minute |
IV drops per minute |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-iv-fluid-rate |
IV fluid rate |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-iv-line-working |
IV line working |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-iv-volume-planned-over-24-hours |
IV volume planned over 24 hours |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-milk-feed |
Milk feed |
How a patient is being fed, or a nutrition assessment. Recorded on the milk feeding chart. |
| feeding-milk-feed-record |
Milk feed record |
How a patient is being fed, or a nutrition assessment. Recorded on the milk feeding chart. |
| feeding-nutritional-history |
Nutritional history |
How a patient is being fed, or a nutrition assessment. Recorded on the paediatric admission record. |
| feeding-passed-stool |
Passed stool |
How a patient is being fed, or a nutrition assessment. Recorded on the milk feeding chart. |
| feeding-passed-urine |
Passed urine |
How a patient is being fed, or a nutrition assessment. Recorded on the milk feeding chart. |
| feeding-position-of-the-patient |
Position of the patient |
How a patient is being fed, or a nutrition assessment. Recorded on the feeding and position chart. |
| feeding-prescribed-volume-per-kilogram-per-day |
Prescribed volume per kilogram per day |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| feeding-three-hourly-feed-target |
Three-hourly feed target |
How a patient is being fed, or a nutrition assessment. Recorded on the milk feeding chart. |
| feeding-volume-fed |
Volume fed |
How a patient is being fed, or a nutrition assessment. Recorded on the feeding and position chart. |
| feeding-volume-per-feed |
Volume per feed |
How a patient is being fed, or a nutrition assessment. Recorded on the newborn comprehensive chart. |
| fetal-lie |
Fetal lie |
Whether the fetus lies longitudinally, transversely or obliquely in the uterus. |
| fluid-balance-blood-volume-given |
Blood volume given |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-colour-of-the-irrigation-return |
Colour of the irrigation return |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the surgical continuous irrigation record. |
| fluid-balance-continuous-irrigation-entry |
Continuous irrigation entry |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the surgical continuous irrigation record. |
| fluid-balance-drain-volume |
Drain volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-drainage-volume |
Drainage volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the intake and output record. |
| fluid-balance-fluid-output-total-24-hour |
Fluid output total 24 hour |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-fluid-output-total-24-hours |
Fluid output total 24 hours |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the intake and output record. |
| fluid-balance-hourly-fluid-intake |
Hourly fluid intake |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-hourly-fluid-output |
Hourly fluid output |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-irrigation-solution |
Irrigation solution |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the surgical continuous irrigation record. |
| fluid-balance-irrigation-volume-instilled |
Irrigation volume instilled |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the surgical continuous irrigation record. |
| fluid-balance-irrigation-volume-instilled-over-24-hours |
Irrigation volume instilled over 24 hours |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the surgical continuous irrigation record. |
| fluid-balance-irrigation-volume-returned |
Irrigation volume returned |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the surgical continuous irrigation record. |
| fluid-balance-irrigation-volume-returned-over-24-hours |
Irrigation volume returned over 24 hours |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the surgical continuous irrigation record. |
| fluid-balance-iv-fluid-volume |
IV fluid volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the intake and output record. |
| fluid-balance-iv-infusion-given |
IV infusion given |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the intake and output record. |
| fluid-balance-nasogastric-aspirate-volume |
Nasogastric aspirate volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-nasogastric-feed-volume |
Nasogastric feed volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the intake and output record. |
| fluid-balance-nasogastric-suction-volume |
Nasogastric suction volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the intake and output record. |
| fluid-balance-oral-fluid-volume |
Oral fluid volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the intake and output record. |
| fluid-balance-oral-or-nasogastric-feed-given |
Oral or nasogastric feed given |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-oral-or-nasogastric-volume |
Oral or nasogastric volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-output-on-a-newborn-round |
Output on a newborn round |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the newborn comprehensive chart. |
| fluid-balance-over-24-hours |
Fluid balance over 24 hours |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-parenteral-fluid-given |
Parenteral fluid given |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-parenteral-fluid-volume |
Parenteral fluid volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-passed-stool |
Passed stool |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the newborn comprehensive chart. |
| fluid-balance-passed-urine |
Passed urine |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the newborn comprehensive chart. |
| fluid-balance-remarks-on-the-fluid-balance-chart |
Remarks on the fluid balance chart |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-remarks-on-the-intake-and-output-record |
Remarks on the intake and output record |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the intake and output record. |
| fluid-balance-second-parenteral-fluid-given |
Second parenteral fluid given |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-second-parenteral-fluid-volume |
Second parenteral fluid volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-stool-passed |
Stool passed |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-stool-volume |
Stool volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the intake and output record. |
| fluid-balance-urine-volume |
Urine volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-vomit-volume |
Vomit volume |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the HDU input and output chart. |
| fluid-balance-vomited |
Vomited |
An intake or output figure from a fluid balance chart, or a total or balance derived from one. The output total and the balance carry local codes because LOINC names a 24-hour intake and a 24-hour urine output but nothing for the balance between them. Recorded on the newborn comprehensive chart. |
| grade-jaundice-grade |
Jaundice grade |
An examination finding recorded on the sheet’s three-point 0 / + / +++ scale, or on a distribution scale that grades it. Recorded on the newborn admission record, the newborn observation chart and the paediatric admission record. |
| grade-pallor-or-anaemia-grade |
Pallor or anaemia grade |
An examination finding recorded on the sheet’s three-point 0 / + / +++ scale, or on a distribution scale that grades it. Recorded on the newborn admission record and the paediatric admission record. |
| head-injury-conscious-level-on-the-head-injury-chart |
Conscious level on the head injury chart |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-paralysis-by-limb |
Paralysis by limb |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-paralysis-left-arm |
Paralysis, left arm |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-paralysis-left-leg |
Paralysis, left leg |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-paralysis-right-arm |
Paralysis, right arm |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-paralysis-right-leg |
Paralysis, right leg |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-remarks-on-a-head-injury-round |
Remarks on a head injury round |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-spontaneous-movement-by-limb |
Spontaneous movement by limb |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-spontaneous-movement-left-arm |
Spontaneous movement, left arm |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-spontaneous-movement-left-leg |
Spontaneous movement, left leg |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-spontaneous-movement-right-arm |
Spontaneous movement, right arm |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| head-injury-spontaneous-movement-right-leg |
Spontaneous movement, right leg |
A finding from the head injury and craniotomy chart: its own four-point conscious level, or spontaneous movement or paralysis in one named limb. The conscious level is deliberately not mapped onto the Glasgow Coma Scale or AVPU — this sheet prints four levels with its own wording. Recorded on the head injury and craniotomy chart. |
| icu-care-chest-physiotherapy-given |
Chest physiotherapy given |
Something the ICU observation chart records about the nursing round itself: turning, suctioning, chest physiotherapy or sighs. These are what prevent the complications this population dies of, and the chart is where they are evidenced. Recorded on the ICU observation chart. |
| icu-care-intensive-care-nursing-round |
Intensive care nursing round |
Something the ICU observation chart records about the nursing round itself: turning, suctioning, chest physiotherapy or sighs. These are what prevent the complications this population dies of, and the chart is where they are evidenced. Recorded on the ICU observation chart. |
| icu-care-nebuliser-given |
Nebuliser given |
Something the ICU observation chart records about the nursing round itself: turning, suctioning, chest physiotherapy or sighs. These are what prevent the complications this population dies of, and the chart is where they are evidenced. Recorded on the ICU observation chart. |
| icu-care-position-of-the-patient |
Position of the patient |
Something the ICU observation chart records about the nursing round itself: turning, suctioning, chest physiotherapy or sighs. These are what prevent the complications this population dies of, and the chart is where they are evidenced. Recorded on the ICU observation chart. |
| icu-care-remarks-on-an-intensive-care-round |
Remarks on an intensive care round |
Something the ICU observation chart records about the nursing round itself: turning, suctioning, chest physiotherapy or sighs. These are what prevent the complications this population dies of, and the chart is where they are evidenced. Recorded on the ICU observation chart. |
| icu-care-sighs-given |
Sighs given |
Something the ICU observation chart records about the nursing round itself: turning, suctioning, chest physiotherapy or sighs. These are what prevent the complications this population dies of, and the chart is where they are evidenced. Recorded on the ICU observation chart. |
| icu-care-suctioned |
Suctioned |
Something the ICU observation chart records about the nursing round itself: turning, suctioning, chest physiotherapy or sighs. These are what prevent the complications this population dies of, and the chart is where they are evidenced. Recorded on the ICU observation chart. |
| imaging-indication |
Indication for imaging |
Why the imaging was asked for, in the requester's words. ServiceRequest.reason is bound required to LOINC by the SGHI profile and the form takes free text, so the indication rides here as a supporting Observation the request points at. |
| injury-other-injury-present |
Other injury present |
An injury recorded outside the head on the head injury chart. Recorded on the head injury and craniotomy chart. |
| injury-site |
Site of another injury |
An injury recorded outside the head on the head injury chart. Recorded on the head injury and craniotomy chart. |
| limb-power |
Limb power |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the ICU neurological observation chart. |
| machine-conductivity |
Conductivity |
Part of the machine’s own function check, recorded before the run starts. Recorded on the haemodialysis flow chart. |
| machine-dialyser-flow-rate |
Dialyser flow rate |
Part of the machine’s own function check, recorded before the run starts. Recorded on the haemodialysis flow chart. |
| machine-function-check |
Machine function check |
The automated machine self-test, its conductivity, temperature and dialyser flow rate, recorded before the run starts. |
| machine-t1-test-passed |
T1 test passed |
Part of the machine’s own function check, recorded before the run starts. Recorded on the haemodialysis flow chart. |
| machine-temperature |
Machine temperature |
Part of the machine’s own function check, recorded before the run starts. Recorded on the haemodialysis flow chart. |
| maternal-fevers-in-pregnancy |
Maternal fevers in pregnancy |
A fact about the mother that governs the baby’s management. Recorded on the newborn unit handover form. |
| maternal-hepatitis-b-result |
Maternal hepatitis B result |
A fact about the mother that governs the baby’s management. Recorded on the newborn unit handover form. |
| maternal-history-on-newborn-handover |
Maternal history on newborn handover |
A fact about the mother that governs the baby’s management. Recorded on the newborn unit handover form. |
| maternal-hiv-status |
Maternal HIV status |
A fact about the mother that governs the baby’s management. Recorded on the newborn admission record. |
| maternal-other-commodities-given-in-pregnancy |
Other commodities given in pregnancy |
A fact about the mother that governs the baby’s management. Recorded on the newborn unit handover form. |
| maternal-parity |
Maternal parity |
A fact about the mother that governs the baby’s management. Recorded on the newborn unit handover form. |
| maternal-pmtct |
PMTCT |
A fact about the mother that governs the baby’s management. Recorded on the maternity record. |
| maternal-pmtct-status |
Maternal PMTCT status |
The mother's status in the programme for prevention of mother-to-child transmission of HIV, as known at the child's admission. Distinct from the mother's own HIV test result, which is a laboratory Observation on the mother. |
| maternal-third-trimester-urinalysis-result |
Third-trimester urinalysis result |
A fact about the mother that governs the baby’s management. Recorded on the newborn unit handover form. |
| maternal-treatment-given-in-pregnancy |
Treatment given in pregnancy |
A fact about the mother that governs the baby’s management. Recorded on the newborn unit handover form. |
| maternal-urinalysis-done-in-the-third-trimester |
Urinalysis done in the third trimester |
A fact about the mother that governs the baby’s management. Recorded on the newborn unit handover form. |
| maternal-vdrl-result |
Maternal VDRL result |
A fact about the mother that governs the baby’s management. Recorded on the newborn admission record. |
| membrane-status |
Membrane status |
Whether the membranes are intact or ruptured at the time of examination. |
| mortality-review-provisional-diagnosis-made-by-the-first-clinician |
Provisional diagnosis made by the first clinician |
A fact from the mortality committee review that is asked across deaths rather than within one: which grade of clinician saw the patient first, what they thought it was, and when a senior clinician reviewed. Recorded on the mortality committee review. |
| mortality-review-rank-of-the-first-clinician-who-attended |
Rank of the first clinician who attended |
A fact from the mortality committee review that is asked across deaths rather than within one: which grade of clinician saw the patient first, what they thought it was, and when a senior clinician reviewed. Recorded on the mortality committee review. |
| mortality-review-time-of-first-senior-clinician-review |
Time of first senior clinician review |
A fact from the mortality committee review that is asked across deaths rather than within one: which grade of clinician saw the patient first, what they thought it was, and when a senior clinician reviewed. Recorded on the mortality committee review. |
| mortuary-source-facility-the-body-was-transferred-from |
Facility the body was transferred from |
Where a body received into the mortuary came from, and the ward or facility behind that answer. Coded because it is the field that decides whether the deceased was ever a patient of this hospital. Recorded on the mortuary services request form. |
| mortuary-source-place-of-death |
Place of death |
Where a body received into the mortuary came from, and the ward or facility behind that answer. Coded because it is the field that decides whether the deceased was ever a patient of this hospital. Recorded on the mortuary admission form. |
| mortuary-source-ward-the-body-came-from |
Ward the body came from |
Where a body received into the mortuary came from, and the ward or facility behind that answer. Coded because it is the field that decides whether the deceased was ever a patient of this hospital. Recorded on the mortuary services request form. |
| mortuary-source-where-the-body-came-from |
Where the body came from |
Where a body received into the mortuary came from, and the ward or facility behind that answer. Coded because it is the field that decides whether the deceased was ever a patient of this hospital. Recorded on the mortuary admission form and the mortuary services request form. |
| mortuary-source-witness-to-an-embalming-authorisation |
Witness to an embalming authorisation |
Where a body received into the mortuary came from, and the ward or facility behind that answer. Coded because it is the field that decides whether the deceased was ever a patient of this hospital. Recorded on the embalming authorization form. |
| neuro-arm-power |
Arm power |
A finding from the ICU neurological observation chart: limb power on either of the two scales the chart prints, or one pupil’s size and reaction. Each pupil carries a bodySite, because a unilaterally dilating unreactive pupil is the sign that matters and which side it is on is the whole question. Recorded on the ICU neurological observation chart. |
| neuro-left-pupil-assessment |
Left pupil assessment |
A finding from the ICU neurological observation chart: limb power on either of the two scales the chart prints, or one pupil’s size and reaction. Each pupil carries a bodySite, because a unilaterally dilating unreactive pupil is the sign that matters and which side it is on is the whole question. Recorded on the head injury and craniotomy chart. |
| neuro-leg-power |
Leg power |
A finding from the ICU neurological observation chart: limb power on either of the two scales the chart prints, or one pupil’s size and reaction. Each pupil carries a bodySite, because a unilaterally dilating unreactive pupil is the sign that matters and which side it is on is the whole question. Recorded on the ICU neurological observation chart. |
| neuro-pupil-reaction |
Pupil reaction |
A finding from the ICU neurological observation chart: limb power on either of the two scales the chart prints, or one pupil’s size and reaction. Each pupil carries a bodySite, because a unilaterally dilating unreactive pupil is the sign that matters and which side it is on is the whole question. Recorded on the ICU neurological observation chart. |
| neuro-pupil-size |
Pupil size |
A finding from the ICU neurological observation chart: limb power on either of the two scales the chart prints, or one pupil’s size and reaction. Each pupil carries a bodySite, because a unilaterally dilating unreactive pupil is the sign that matters and which side it is on is the whole question. Recorded on the ICU neurological observation chart. |
| neuro-right-pupil-assessment |
Right pupil assessment |
A finding from the ICU neurological observation chart: limb power on either of the two scales the chart prints, or one pupil’s size and reaction. Each pupil carries a bodySite, because a unilaterally dilating unreactive pupil is the sign that matters and which side it is on is the whole question. Recorded on the head injury and craniotomy chart. |
| newborn-apgar-score-as-recorded-on-handover |
Apgar score as recorded on handover |
A finding or intervention recorded on a newborn record. Recorded on the newborn unit handover form. |
| newborn-duration-of-resuscitation |
Duration of resuscitation |
A finding or intervention recorded on a newborn record. Recorded on the newborn unit handover form. |
| newborn-follow-up-round |
Newborn follow-up round |
One morning, evening or night round of the routine newborn follow-up over the first four days of life. Its components carry what was checked on that round. |
| newborn-meconium-stained-liquor |
Meconium stained liquor |
A finding or intervention recorded on a newborn record. Recorded on the newborn unit handover form. |
| newborn-passed-urine-or-stool-since-birth |
Passed urine or stool since birth |
A finding or intervention recorded on a newborn record. Recorded on the newborn unit handover form. |
| newborn-resuscitated-at-birth |
Resuscitated at birth |
A finding or intervention recorded on a newborn record. Recorded on the newborn unit handover form. |
| newborn-resuscitation |
Resuscitation of a newborn |
Resuscitation given to a baby at birth, as recorded on the newborn observation chart. The chart records that it was done, for how long, and what was given. |
| newborn-route-oxygen-was-given-by |
Route oxygen was given by |
A finding or intervention recorded on a newborn record. Recorded on the newborn unit handover form. |
| newborn-care-arvs-started |
ARVs started |
One element of essential newborn care, recorded as given or not given. The chart records no dose and no time, which is why these are observations and not medication administrations. Recorded on the newborn observation chart. |
| newborn-care-cord-care-with-chlorhexidine |
Cord care with chlorhexidine |
One element of essential newborn care, recorded as given or not given. The chart records no dose and no time, which is why these are observations and not medication administrations. Recorded on the newborn observation chart. |
| newborn-care-delayed-cord-clamp |
Delayed cord clamp |
One element of essential newborn care, recorded as given or not given. The chart records no dose and no time, which is why these are observations and not medication administrations. Recorded on the newborn observation chart. |
| newborn-care-eye-care |
Eye care |
One element of essential newborn care, recorded as given or not given. The chart records no dose and no time, which is why these are observations and not medication administrations. Recorded on the newborn observation chart. |
| newborn-care-infant-arv-prophylaxis-given |
Infant ARV prophylaxis given |
One element of essential newborn care, recorded as given or not given. The chart records no dose and no time, which is why these are observations and not medication administrations. Recorded on the newborn unit handover form. |
| newborn-care-obvious-malformation |
Obvious malformation |
One element of essential newborn care, recorded as given or not given. The chart records no dose and no time, which is why these are observations and not medication administrations. Recorded on the newborn observation chart. |
| newborn-care-sero-exposed |
Sero-exposed |
One element of essential newborn care, recorded as given or not given. The chart records no dose and no time, which is why these are observations and not medication administrations. Recorded on the newborn observation chart. |
| newborn-care-tetracycline-eye-ointment-given |
Tetracycline eye ointment given |
One element of essential newborn care, recorded as given or not given. The chart records no dose and no time, which is why these are observations and not medication administrations. Recorded on the newborn unit handover form. |
| newborn-care-vitamin-k |
Vitamin K |
One element of essential newborn care, recorded as given or not given. The chart records no dose and no time, which is why these are observations and not medication administrations. Recorded on the newborn observation chart. |
| newborn-care-vitamin-k-given |
Vitamin K given |
One element of essential newborn care, recorded as given or not given. The chart records no dose and no time, which is why these are observations and not medication administrations. Recorded on the newborn unit handover form. |
| newborn-intervention-apnoea |
Apnoea |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the NICU monitoring chart. |
| newborn-intervention-blood-transfusion-in-progress |
Blood transfusion in progress |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-colour |
Colour |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the NICU monitoring chart. |
| newborn-intervention-cpap-in-use |
CPAP in use |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-cpap-pressure |
CPAP pressure |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-hours-on-cpap |
Hours on CPAP |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-incubator-care |
Incubator care |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the NICU monitoring chart. |
| newborn-intervention-incubator-in-use |
Incubator in use |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-incubator-oxygen-port-in-use |
Incubator oxygen port in use |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-inspired-oxygen-fraction |
Inspired oxygen fraction |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-jaundice-grade |
Jaundice grade |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the NICU monitoring chart. |
| newborn-intervention-kangaroo-mother-care |
Kangaroo mother care |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-monitoring-frequency-in-hours |
Monitoring frequency in hours |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-newborn-acuity-category |
Newborn acuity category |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-newborn-assessment-on-a-nicu-round |
Newborn assessment on a NICU round |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the NICU monitoring chart. |
| newborn-intervention-newborn-interventions-in-place |
Newborn interventions in place |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-oxygen-flow |
Oxygen flow |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-oxygen-in-use |
Oxygen in use |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-phototherapy-in-use |
Phototherapy in use |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-respiratory-distress-grade |
Respiratory distress grade |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-respiratory-support-on-a-newborn-round |
Respiratory support on a newborn round |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-shift |
Shift |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the newborn comprehensive chart. |
| newborn-intervention-suctioned |
Suctioned |
Something the newborn comprehensive chart records about the support a baby is on — CPAP, oxygen, phototherapy, an incubator or kangaroo mother care — or the acuity category that sets how often the baby is observed. Recorded on the NICU monitoring chart. |
| newborn-round-breastfeeding |
Breastfeeding |
One thing checked on a routine newborn follow-up round over the first four days of life. Recorded on the newborn observation chart. |
| newborn-round-day-of-life |
Day of life |
One thing checked on a routine newborn follow-up round over the first four days of life. Recorded on the newborn observation chart. |
| newborn-round-eyes |
Eyes |
One thing checked on a routine newborn follow-up round over the first four days of life. Recorded on the newborn observation chart. |
| newborn-round-fontanelle |
Fontanelle |
One thing checked on a routine newborn follow-up round over the first four days of life. Recorded on the newborn observation chart. |
| newborn-round-respiratory |
Respiratory |
One thing checked on a routine newborn follow-up round over the first four days of life. Recorded on the newborn observation chart. |
| newborn-round-round-of-the-day |
Round of the day |
One thing checked on a routine newborn follow-up round over the first four days of life. Recorded on the newborn observation chart. |
| newborn-round-stool |
Stool |
One thing checked on a routine newborn follow-up round over the first four days of life. Recorded on the newborn observation chart. |
| newborn-round-tone |
Tone |
One thing checked on a routine newborn follow-up round over the first four days of life. Recorded on the newborn observation chart. |
| newborn-round-urine |
Urine |
One thing checked on a routine newborn follow-up round over the first four days of life. Recorded on the newborn observation chart. |
| nursing-assessment-cardiovascular-examination-on-admission |
Cardiovascular examination on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-education |
Education |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-extremities-on-admission |
Extremities on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-eyes-on-admission |
Eyes on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-family-circumstances |
Family circumstances |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-gastrointestinal-examination-on-admission |
Gastrointestinal examination on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-genitourinary-examination-on-admission |
Genitourinary examination on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-hearing-on-admission |
Hearing on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-lungs-on-admission |
Lungs on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-mouth-and-teeth-on-admission |
Mouth and teeth on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-occupation |
Occupation |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-orientation-on-admission |
Orientation on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-pain-and-its-location |
Pain and its location |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-previous-admissions-reported-on-admission |
Previous admissions reported on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-skin-on-admission |
Skin on admission |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-smokes-cigarettes |
Smokes cigarettes |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-assessment-takes-alcohol |
Takes alcohol |
One line of the head-to-toe assessment a nurse makes on admission, or a fact from the family and social history beside it. Free text per line as the sheet prints it: a coded scale would claim a precision a nursing admission does not have. Recorded on the admission form. |
| nursing-process-evaluation-of-the-nursing-plan |
Evaluation of the nursing plan |
One column of the nursing care plan — assessment, expected outcome, intervention, the scientific rationale for it, implementation or evaluation. The rationale is kept because this sheet is the only place the reasoning behind a nursing action is written down. Recorded on the nursing care plan. |
| nursing-process-expected-outcome-or-goal |
Expected outcome or goal |
One column of the nursing care plan — assessment, expected outcome, intervention, the scientific rationale for it, implementation or evaluation. The rationale is kept because this sheet is the only place the reasoning behind a nursing action is written down. Recorded on the nursing care plan. |
| nursing-process-implementation-of-the-nursing-plan |
Implementation of the nursing plan |
One column of the nursing care plan — assessment, expected outcome, intervention, the scientific rationale for it, implementation or evaluation. The rationale is kept because this sheet is the only place the reasoning behind a nursing action is written down. Recorded on the nursing care plan. |
| nursing-process-nursing-assessment |
Nursing assessment |
One column of the nursing care plan — assessment, expected outcome, intervention, the scientific rationale for it, implementation or evaluation. The rationale is kept because this sheet is the only place the reasoning behind a nursing action is written down. Recorded on the nursing care plan. |
| nursing-process-nursing-intervention |
Nursing intervention |
One column of the nursing care plan — assessment, expected outcome, intervention, the scientific rationale for it, implementation or evaluation. The rationale is kept because this sheet is the only place the reasoning behind a nursing action is written down. Recorded on the nursing care plan. |
| nursing-process-record |
Nursing process record |
One column of the nursing care plan — assessment, expected outcome, intervention, the scientific rationale for it, implementation or evaluation. The rationale is kept because this sheet is the only place the reasoning behind a nursing action is written down. Recorded on the nursing care plan. |
| nursing-process-scientific-rationale-for-the-intervention |
Scientific rationale for the intervention |
One column of the nursing care plan — assessment, expected outcome, intervention, the scientific rationale for it, implementation or evaluation. The rationale is kept because this sheet is the only place the reasoning behind a nursing action is written down. Recorded on the nursing care plan. |
| nutrition-age-of-the-father |
Age of the father |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-age-of-the-mother |
Age of the mother |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-age-other-foods-were-introduced |
Age other foods were introduced |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-ages-of-siblings |
Ages of siblings |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-birth-order-of-the-child |
Birth order of the child |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-diet-history |
Diet history |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-family-and-psychosocial-history |
Family and psychosocial history |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-marital-status-of-the-parents |
Marital status of the parents |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-occupation-of-the-father |
Occupation of the father |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-occupation-of-the-mother |
Occupation of the mother |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-residence-of-the-child |
Residence of the child |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-social-economic-and-education-status |
Social, economic and education status |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-usual-and-current-dietary-intake |
Usual and current dietary intake |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| nutrition-weight-for-height-ratio |
Weight-for-height ratio |
Something the paediatric nutrition assessment records: family or psychosocial history, feeding history, or an anthropometric derivation the form computes rather than measures. Recorded on the paediatric nutrition assessment. |
| arterial-pressure-circuit |
Arterial pressure (extracorporeal circuit) |
The pressure on the arterial limb of the dialysis circuit. A machine reading on the circuit, not the patient's arterial blood pressure, so it is deliberately not coded to 8480-6. |
| blood-donation |
Blood donation |
One donation episode: the collection itself, from needle in to needle out, with the volume taken and the bag used. |
| blood-pump-rate |
Blood pump rate |
The rate the dialysis machine pumps blood through the circuit, in millilitres per minute. |
| can-drink-or-breastfeed |
Able to drink or breastfeed |
Whether the child can still take fluid by mouth. The single most important feeding question on the IMCI assessment. |
| carer-goals |
Carer goals and expectations |
What the person caring for the patient says they want, and what stresses they carry. Kept apart from the patient's own goals because the two often differ and the form asks both. |
| chemotherapy-cycle-number |
Cycle number |
Which cycle of the regimen this prescription is for. |
| chemotherapy-regimen |
Chemotherapy regimen |
The named regimen being prescribed, as free text: the hospital's formulary is not coded, so the name travels as written. |
| donation-adverse-event |
Post-donation adverse event |
One of the nine adverse events the KTTA form asks about after a donation. The answer says whether it happened. |
| donation-type |
Type of donation |
Whether the donation is a normal whole-blood collection or an apheresis procedure. |
| essential-newborn-care-given |
Essential newborn care given |
Which elements of essential newborn care were given — vitamin K, tetracycline eye ointment, chlorhexidine cord care, delayed clamping — as a checklist rather than as separate medication records, because the newborn chart records them as done or not done without dose or time. |
| fluid-removed |
Fluid removed |
The weight difference across the session, which is the fluid actually taken off. Recorded because pre- and post-dialysis weight are both charted and their difference is what the nephrologist reads. |
| instrument-count-complete |
Instrument, sponge and needle count complete |
Whether the counts were confirmed complete before the patient left the operating room. A never-event check, kept as its own concept rather than folded into the checklist items. |
| mortuary-disposal-of-a-body |
Disposal of a body |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the mortuary consent form for the disposal of a baby. |
| mortuary-embalming |
Embalming |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the embalming authorization form. |
| obs-abortions |
Abortions |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-age-in-days |
Age in days |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the newborn unit handover form. |
| obs-alcohol |
Alcohol |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-alcohol-detail |
Alcohol detail |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-any-other |
Any other |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-appearance |
Appearance |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-baby-admitted-to-nbu |
Baby admitted to NBU |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-bleeding-or-tenderness |
Bleeding or tenderness |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-contractions |
Contractions |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-course-of-the-pregnancy |
Course of the pregnancy |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-day-in-unit |
Day in unit |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the ICU neurological observation chart. |
| obs-day-of-life |
Day of life |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the newborn comprehensive chart. |
| obs-diabetes |
Diabetes |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-duration-of-labour |
Duration of labour |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the newborn unit handover form. |
| obs-duration-of-the-first-stage-of-labour |
Duration of the first stage of labour |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-duration-of-the-second-stage-of-labour |
Duration of the second stage of labour |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-folic-acid-taken-pre-conception-or-in-the-first |
Folic acid taken pre-conception or in the first trimester |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-general |
General |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-hypertension |
Hypertension |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-inherited-conditions |
Inherited conditions |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-jaundice-or-pallor |
Jaundice or pallor |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-labour |
Labour |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-marital-status |
Marital status |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-nst-or-ctg |
NST or CTG |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-number-of-antenatal-visits |
Number of antenatal visits |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-other-children-admitted-in-nbu |
Other children admitted in NBU |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-other-diet-issue |
Other diet issue |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-other-investigation |
Other investigation |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-other-social-history |
Other social history |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-outcome |
Outcome |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-puerperium |
Puerperium |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-smoker |
Smoker |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-smoking-detail |
Smoking detail |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-twins |
Twins |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-vegetarian |
Vegetarian |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| obs-year |
Year |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the maternity record. |
| oedema-distribution |
Oedema distribution |
How far up the body oedema extends — none, feet, to the knee, or the face — which is what grades it in a malnourished child. |
| patient-goals |
Patient goals and expectations |
What the patient says they want from their care. Recorded as narrative because the form asks for it in the patient's own words. |
| perineal-outcome |
Perineal outcome |
Whether the perineum was intact, tore, or was deliberately incised and repaired. |
| placenta-completeness |
Placenta and membrane completeness |
Whether the placenta and the membranes were delivered complete, which decides whether the uterus has to be explored. |
| postoperative-check |
Post-operative check |
One of the checks the ward nurse makes when a patient comes back from theatre: wound, drainage, vomiting, catheter, nasogastric tube, infusion and oxygen. |
| preoperative-preparation |
Pre-operative preparation completed |
Which items of ward preparation were done before theatre — fasting, dentures and jewellery removed, shaving, bath, gown, skin preparation — as a checklist. |
| previous-donation-count |
Number of previous donations |
How many times this donor has given blood before. |
| prior-oncological-treatment |
Prior oncological treatment |
Which of radiotherapy, chemotherapy or surgery the patient has already had, and when, as recorded on the palliative care assessment. |
| skin-pinch-time |
Skin pinch return time |
How long the abdominal skin takes to flatten after being pinched, in seconds. A dehydration sign. The nearest LOINC term is 44971-0 Capillary refill [Time], which is a different observation on a different site and measures perfusion rather than turgor, so it is not reused here — the triage sheet asks for both, side by side. |
| spiritual-assessment |
Spiritual assessment |
The spiritual assessment recorded on the palliative care form, as narrative. |
| surgical-safety-phase |
Surgical safety checklist phase |
Which of the WHO checklist's three phases the answers belong to: sign-in before induction, time-out before skin incision, or sign-out before the patient leaves the room. |
| transmembrane-pressure |
Transmembrane pressure |
The pressure across the dialyser membrane, in mmHg. |
| treatment-line |
Line of treatment |
Which line of systemic therapy this is — first, second, third or later — which is what decides the regimen. |
| ultrafiltration-volume |
Ultrafiltration volume |
The volume removed by ultrafiltration during the session, in millilitres. |
| venous-pressure-circuit |
Venous pressure (extracorporeal circuit) |
The pressure on the venous limb of the dialysis circuit. |
| volume-donated |
Volume donated |
The volume collected, in millilitres. |
| ward-clearance |
Ward clearance |
The ward's sign-off that a discharging patient's medication has been issued and the bed released. An administrative attestation, so it becomes an Observation with a boolean value rather than a clinical finding. |
| obstetric-antenatal-examination-on-a-round |
Antenatal examination on a round |
A finding from an obstetric examination or from the report on labour. Recorded on the antenatal vital signs sheet. |
| obstetric-bowels-opened |
Bowels opened |
A finding from an obstetric examination or from the report on labour. Recorded on the antenatal vital signs sheet. |
| obstetric-fetal-presentation |
Fetal presentation |
A finding from an obstetric examination or from the report on labour. Recorded on the antenatal vital signs sheet. |
| obstetric-mode-of-delivery |
Mode of delivery |
A finding from an obstetric examination or from the report on labour. Recorded on the maternity record. |
| obstetric-placenta-weight |
Placenta weight |
A finding from an obstetric examination or from the report on labour. Recorded on the maternity record. |
| obstetric-position |
Position |
A finding from an obstetric examination or from the report on labour. Recorded on the maternity record. |
| obstetric-history-parity |
Parity |
A fact about previous pregnancies carried on an antenatal sheet. Recorded on the antenatal vital signs sheet. |
| palliative-abdominal-pain |
Abdominal pain |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-body-weakness |
Body weakness |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-chest-pain |
Chest pain |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-constipation |
Constipation |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-cough |
Cough |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-diarrhoea |
Diarrhoea |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-dry-mouth |
Dry mouth |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-excessive-sleep |
Excessive sleep |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-fever |
Fever |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-hallucinations |
Hallucinations |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-headache |
Headache |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-incontinence |
Incontinence |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-jaundice |
Jaundice |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-loss-of-appetite |
Loss of appetite |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-melaena |
Melaena |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-nausea-or-vomiting |
Nausea or vomiting |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-per-rectal-bleeding |
Per rectal bleeding |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-per-rectal-pain |
Per rectal pain |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-poor-vision |
Poor vision |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-problem |
Palliative care problem |
One physical, psychosocial or spiritual problem identified on assessment, with the action planned for it. Becomes a CarePlan activity rather than a Condition unless it names a diagnosis. |
| palliative-referral-source |
Palliative referral source |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-sore-mouth |
Sore mouth |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-symptom |
Palliative care symptom |
One symptom from the palliative care assessment's twenty-two-item checklist. The answer says whether it is present. |
| palliative-weakness-of-limbs |
Weakness of limbs |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| palliative-weight-loss |
Weight loss |
A symptom, goal or problem from the palliative care assessment. The symptoms are the twenty-two-item checklist; the goals are recorded separately for the patient and for the carer, because the two often differ. Recorded on the palliative care assessment. |
| postop-analgesic-therapy-given |
Analgesic therapy given |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| postop-catheter-in-place |
Catheter in place |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| postop-check-list-operative-complete |
Check-list operative complete |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| postop-drainage-checked |
Drainage checked |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| postop-infusion-therapy-running |
Infusion therapy running |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| postop-level-of-consciousness |
Level of consciousness |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| postop-nasogastric-tube-in-place |
Nasogastric tube in place |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| postop-oxygen-therapy-running |
Oxygen therapy running |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| postop-pain |
Pain |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| postop-vomiting-checked |
Vomiting checked |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| postop-wound-checked |
Wound checked |
One of the checks the ward nurse makes when a patient comes back from theatre. Recorded on the surgical safety checklist. |
| preop-artificial-limb-removed |
Artificial limb removed |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-bath |
Bath |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-blood-requested |
Blood requested |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-blood-requested-and-available-before-theatre |
Blood requested and available before theatre |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-catheter |
Catheter |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-dentures-removed |
Dentures removed |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-fasting |
Fasting |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-intravenous-infusion |
Intravenous infusion |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-jewellery-removed |
Jewellery removed |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-lines-and-tubes-in-place-before-theatre |
Lines and tubes in place before theatre |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-nail-varnish-removed |
Nail varnish removed |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-nasogastric-tube |
Nasogastric tube |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-pints-available |
Pints available |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-shaving |
Shaving |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-skin-cleaned |
Skin cleaned |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| preop-theatre-gown |
Theatre gown |
One item of ward preparation before theatre, or a line or tube the theatre needs to know is already in place. Recorded on the surgical safety checklist. |
| prior-treatment-not-discussed-with-the-patient |
Prior treatment not discussed with the patient |
Radiotherapy, chemotherapy or surgery the patient has already had, as recorded on the palliative care assessment. Recorded on the palliative care assessment. |
| priority-sign |
Priority sign present |
One of the priority signs the paediatric triage sheet looks for, which brings the child to a clinician within fifteen minutes. |
| pupil-assessment |
Pupil assessment |
Something one of the forms records that no LOINC or SNOMED concept says. The display is the wording printed on the paper. Recorded on the ICU neurological observation chart. |
| referral-other-pertinent-comments-on-referral |
Other pertinent comments on referral |
Something the patient referral form records. The reason for referral has its own code rather than riding in the history, because it is what tells the receiving unit what is being asked of them. Recorded on the patient referral form. |
| rehabilitation-treatment-diagnosis-for-rehabilitation |
Treatment diagnosis for rehabilitation |
Something the rehabilitation services record captures: the billable units for a contact, or what rehabilitation is actually treating as opposed to what the patient was admitted with. Recorded on the rehabilitation services record. |
| rehabilitation-units-billed |
Rehabilitation units billed |
Something the rehabilitation services record captures: the billable units for a contact, or what rehabilitation is actually treating as opposed to what the patient was admitted with. Recorded on the rehabilitation services record. |
| sign-abdominal-distension |
Abdominal distension |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-acidotic-breathing |
Acidotic breathing |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-apnoeas |
Apnoeas |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-bilirubin |
Bilirubin |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-bloody-diarrhoea |
Bloody diarrhoea |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-bulging-fontanelle |
Bulging fontanelle |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record and the paediatric admission record. |
| sign-burns |
Burns |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-capillary-refill-band |
Capillary refill band |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-central-cyanosis |
Central cyanosis |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record and the paediatric admission record. |
| sign-chest-indrawing |
Chest indrawing |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-contact-with-tb-or-a-chronic-cough-in-the-last-12 |
Contact with TB or a chronic cough in the last 12 months |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-convulsions |
Convulsions |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-convulsions-during-this-illness |
Convulsions during this illness |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-cough |
Cough |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-cough-for-more-than-two-weeks |
Cough for more than two weeks |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-crackles |
Crackles |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record and the paediatric admission record. |
| sign-days-of-cough |
Days of cough |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-days-of-diarrhoea |
Days of diarrhoea |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-days-of-fever |
Days of fever |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-diarrhoea |
Diarrhoea |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record and the paediatric admission record. |
| sign-diarrhoea-for-more-than-14-days |
Diarrhoea for more than 14 days |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-difficulty-breathing |
Difficulty breathing |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record and the paediatric admission record. |
| sign-difficulty-feeding |
Difficulty feeding |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record and the paediatric admission record. |
| sign-fever |
Fever |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record and the paediatric admission record. |
| sign-finger-clubbing |
Finger clubbing |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-floppy-or-unable-to-suck |
Floppy, or unable to suck |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-grunting |
Grunting |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record and the paediatric admission record. |
| sign-haemoglobin-or-haematocrit |
Haemoglobin or haematocrit |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-high-pitched-cry |
High pitched cry |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-irritable |
Irritable |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-length-of-illness-in-days |
Length of illness in days |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record and the paediatric admission record. |
| sign-lumbar-puncture |
Lumbar puncture |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-lymph-node-greater-than-1-cm |
Lymph node greater than 1 cm |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-malnutrition |
Malnutrition |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-meconium-stained-liquor |
Meconium stained liquor |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn observation chart. |
| sign-number-of-convulsions-this-illness |
Number of convulsions this illness |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-oedema |
Oedema |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-oral-thrush |
Oral thrush |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-pallor |
Pallor |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-partial-or-focal-fits |
Partial or focal fits |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record and the paediatric admission record. |
| sign-peripheral-pulse |
Peripheral pulse |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-poisoning |
Poisoning |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-prolonged-rupture-of-membranes-over-24-hours |
Prolonged rupture of membranes over 24 hours |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-reduced-movement-or-tone |
Reduced movement or tone |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-referral |
Referral |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-respiratory-distress |
Respiratory distress |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-restless-irritable-or-floppy |
Restless, irritable or floppy |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-severe-indrawing |
Severe indrawing |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-severe-pain |
Severe pain |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-severe-skin-pustules |
Severe skin pustules |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-severe-vomiting |
Severe vomiting |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the newborn admission record. |
| sign-skin-warm-as-far-as |
Skin warm as far as |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-stiff-neck |
Stiff neck |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-stridor |
Stridor |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-sunken-eyes |
Sunken eyes |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-temperature-over-39-5-degrees-celsius |
Temperature over 39.5 degrees Celsius |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-tiny-sick-infant-aged-under-2-months |
Tiny, sick infant aged under 2 months |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-trauma |
Trauma |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric triage record. |
| sign-vomiting |
Vomiting |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-vomiting-episodes-in-the-last-24-hours |
Vomiting episodes in the last 24 hours |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-vomits-everything |
Vomits everything |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-wheeze |
Wheeze |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| sign-wrist-or-rib-signs-of-rickets |
Wrist or rib signs of rickets |
A sign or symptom the sheet asks the examiner to look for and record as present or absent, or a count or duration recorded beside one. Recorded on the paediatric admission record. |
| skin-to-skin-colour |
Colour |
One reading from the timed observations taken while a newborn is in skin-to-skin contact during the first two hours. Recorded on the newborn observation chart. |
| skin-to-skin-observation |
Skin-to-skin observation |
One of the timed observations taken while a newborn is in skin-to-skin contact in the first two hours, at fifteen and thirty minutes and at one and two hours. |
| skin-to-skin-position-sniffing |
Position: sniffing |
One reading from the timed observations taken while a newborn is in skin-to-skin contact during the first two hours. Recorded on the newborn observation chart. |
| soap-counselling-session-number |
Counselling session number |
One section of a SOAP note from a counselling session. Four codes rather than one narrative, because the point of SOAP is that a reader can find the assessment without reading the subjective account first. Recorded on the psychological review notes. |
| temperature-control-action-taken-to-control-temperature |
Action taken to control temperature |
What was actually done about a temperature — fanned, tepid sponged, warmed — recorded beside the reading on the paediatric vital sign chart. Recorded on the paediatric vital sign observation chart. |
| transfusion-cross-match-result |
Cross-match result |
Something the blood requisition form records, from the indication for transfusion through to the cross-match result and any reaction observed. Recorded on the blood requisition form. |
| transfusion-indication-for-transfusion |
Indication for transfusion |
Something the blood requisition form records, from the indication for transfusion through to the cross-match result and any reaction observed. Recorded on the blood requisition form. |
| triage-avpu-conscious-level |
AVPU conscious level |
A triage decision or the conscious-level screen behind it. Recorded on the paediatric admission record and the paediatric triage record. |
| triage-level |
Triage level |
How urgently the child needs to be seen, from the four levels the paediatric triage sheet offers. |
| tb-screen |
Paediatric TB intensified case finding screen |
The five-question screen for TB in a child, as a whole: what the Observation carrying the result is about, and the kind of assessment the RiskAssessment beside it records. Recorded on the paediatric TB intensified case finding screening tool. |
| tb-screen-cough |
Cough of any duration |
Whether the child has a cough, of any duration. The first of the five intensified case finding questions -- duration is deliberately not asked, because the screen trades specificity for sensitivity. Recorded on the paediatric TB intensified case finding screening tool. |
| tb-screen-fever |
Fever |
Whether the child has fever. The second of the five intensified case finding questions. Recorded on the paediatric TB intensified case finding screening tool. |
| tb-screen-failure-to-thrive |
Failure to thrive or poor weight gain |
Whether the child is failing to thrive or gaining weight poorly. One question on the paper and one code here: the tool asks the two together, so splitting them would invent a distinction nobody was asked to make. Recorded on the paediatric TB intensified case finding screening tool. |
| tb-screen-lethargy |
Lethargy, less playful than usual |
Whether the child is lethargic or less playful than usual. Worded against the child's own baseline, which is what the parent is being asked to compare with. Recorded on the paediatric TB intensified case finding screening tool. |
| tb-screen-contact |
Contact with a TB case |
Whether the child has had contact with a known TB case. The one question of the five that is about exposure rather than about the child. Recorded on the paediatric TB intensified case finding screening tool. |
| tb-screen-tuberculosis |
Tuberculosis |
Tuberculosis at any site, as the outcome a positive screen predicts. Carried on RiskAssessment.prediction.outcome. Local rather than classified: the screen does not say where the disease would be, and every ICD-10 tuberculosis code does. |
| umbilicus-appearance |
Umbilical stump appearance |
Whether a newborn's cord stump is clean, discharging pus, or has surrounding redness of the skin. |
| ventilator-setting-assist-control-in-use |
Assist control in use |
A ventilator setting from the ICU observation chart that LOINC does not name — an I:E ratio, a tube size, or one of the on/off states the chart prints beside them. Recorded on the ICU observation chart. |
| ventilator-setting-breathing-spontaneously |
Breathing spontaneously |
A ventilator setting from the ICU observation chart that LOINC does not name — an I:E ratio, a tube size, or one of the on/off states the chart prints beside them. Recorded on the ICU observation chart. |
| ventilator-setting-cuff-deflated |
Cuff deflated |
A ventilator setting from the ICU observation chart that LOINC does not name — an I:E ratio, a tube size, or one of the on/off states the chart prints beside them. Recorded on the ICU observation chart. |
| ventilator-setting-endotracheal-tube-size |
Endotracheal tube size |
A ventilator setting from the ICU observation chart that LOINC does not name — an I:E ratio, a tube size, or one of the on/off states the chart prints beside them. Recorded on the ICU observation chart. |
| ventilator-setting-inspiratory-time |
Inspiratory time |
A ventilator setting from the ICU observation chart that LOINC does not name — an I:E ratio, a tube size, or one of the on/off states the chart prints beside them. Recorded on the NICU monitoring chart. |
| ventilator-setting-inspiratory-to-expiratory-ratio |
Inspiratory to expiratory ratio |
A ventilator setting from the ICU observation chart that LOINC does not name — an I:E ratio, a tube size, or one of the on/off states the chart prints beside them. Recorded on the ICU observation chart. |
| ventilator-setting-tidal-volume-actual |
Tidal volume actual |
A ventilator setting from the ICU observation chart that LOINC does not name — an I:E ratio, a tube size, or one of the on/off states the chart prints beside them. Recorded on the ICU observation chart. |
| ventilator-setting-tracheostomy-tube-size |
Tracheostomy tube size |
A ventilator setting from the ICU observation chart that LOINC does not name — an I:E ratio, a tube size, or one of the on/off states the chart prints beside them. Recorded on the ICU observation chart. |
| ventilator-setting-weaning-from-the-ventilator |
Weaning from the ventilator |
A ventilator setting from the ICU observation chart that LOINC does not name — an I:E ratio, a tube size, or one of the on/off states the chart prints beside them. Recorded on the ICU observation chart. |
| who-check-all-team-members-introduced-by-name-and-role |
All team members introduced by name and role |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-anaesthesia-machine-and-medication-check-complete |
Anaesthesia machine and medication check complete |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-anaesthetist-s-patient-specific-concerns-reviewed |
Anaesthetist's patient-specific concerns reviewed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-antibiotic-prophylaxis-given-within-the-last-60 |
Antibiotic prophylaxis given within the last 60 minutes |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-anticipated-blood-loss-reviewed |
Anticipated blood loss reviewed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-case-duration-reviewed |
Case duration reviewed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-critical-or-non-routine-steps-reviewed |
Critical or non-routine steps reviewed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-difficult-airway-or-aspiration-risk-assessed |
Difficult airway or aspiration risk assessed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-equipment-issues-or-concerns-reviewed |
Equipment issues or concerns reviewed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-equipment-problems-to-be-addressed-identified |
Equipment problems to be addressed identified |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-essential-imaging-displayed |
Essential imaging displayed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-instrument-sponge-and-needle-counts-complete |
Instrument, sponge and needle counts complete |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-key-concerns-for-recovery-and-management-reviewed |
Key concerns for recovery and management reviewed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-known-allergy-reviewed |
Known allergy reviewed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-name-of-the-procedure-verbally-confirmed |
Name of the procedure verbally confirmed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-no-known-allergies |
No known allergies |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-patient-confirmed-identity-site-procedure-and |
Patient confirmed identity, site, procedure and consent |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-patient-procedure-and-incision-site-confirmed |
Patient, procedure and incision site confirmed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-pulse-oximeter-on-the-patient-and-functioning |
Pulse oximeter on the patient and functioning |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-risk-of-over-500-ml-blood-loss-assessed-access-and |
Risk of over 500 ml blood loss assessed, access and fluids planned |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-site-marked |
Site marked |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-specimen-labelling-read-aloud-including-the-patient |
Specimen labelling read aloud, including the patient name |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| who-check-sterility-including-indicator-results-confirmed |
Sterility, including indicator results, confirmed |
One confirmation on the surgical safety checklist. The answer says whether it was confirmed, was not applicable, or was not done — three distinct answers, because a correctly skipped item is not a missed one. Recorded on the surgical safety checklist. |
| wound-care-surgical-dressing-grade |
Surgical dressing grade |
The grading a nurse ticked on the surgical dressing sheet. The sheet prints three bare letters and never expands them, so the answer records the letter rather than an invented meaning. Recorded on the surgical dressing chart. |