| Code | Display | Definition |
| must-bmi-score |
BMI score (MUST) |
The body mass index step of the Malnutrition Universal Screening Tool, scored 0 to 2. LOINC has a code for the MUST screening itself (101789-6) but none for its three steps. |
| must-weight-loss-score |
Unplanned weight loss score (MUST) |
The unplanned weight loss step of the Malnutrition Universal Screening Tool, scored 0 to 2 over the preceding three to six months. |
| must-acute-disease-score |
Acute disease effect score (MUST) |
The acute disease effect step of the Malnutrition Universal Screening Tool, scored 0 or 2 on whether the patient has had no nutritional intake for five days or more. |
| organ-support |
Organ support needed |
A narrative account of the organ support a critically ill patient is receiving. LOINC has codes for individual supports but none for the summary the critical care assessment asks for. |
| feeding |
Feeding |
A narrative account of how a child is being fed, as recorded on a paediatric admission assessment. |
| mood-and-affect |
Mood and affect |
The mood and affect component of a mental state examination, recorded as narrative. |
| capacity-to-consent |
Capacity to consent |
Whether the patient has capacity to consent to the decision in front of them, and whether that capacity is fluctuating. |
| self-harm-risk |
Risk of self-harm |
The type of a risk assessment whose predicted outcome is self-harm. LOINC 93374-7 covers suicide risk specifically; self-harm is the wider concept the mental health assessment asks about. |
| ward-round-job |
Job for the team from a ward round |
A piece of work the ward round left for the team. The HL7 task-code system enumerates what to do to a request (fulfil, abort, replace) rather than what a ward round asks for. |
| discharge-follow-up |
Follow-up arranged on discharge |
The follow-up a discharge note arranges, as a request rather than a booked appointment. The discharge note captures it as free text, so no date is available to book against. |
| planned-procedure |
Planned procedure |
The procedure a pre-operative assessment was carried out for. The form captures it as free text, so the request carries the wording rather than a procedure code. |
| dietitian-referral |
Referral to a dietitian |
A request for dietetic assessment, raised from a nutrition screening that scored in the high-risk band. |
| falls-prevention-plan |
Falls and pressure ulcer prevention measures |
The category of a care plan recording the measures put in place because of a falls or pressure ulcer risk score. |
| nutrition-care-plan |
Nutritional plan |
The category of a care plan recording what will be done about a patient's nutrition after screening. |
| oral-intake-at-discharge |
Oral intake tolerated at discharge |
Whether the patient is managing food and drink well enough to leave. Answered from SGHIDischargeOralIntake. |
| mobility-at-discharge |
Mobility at discharge |
How much help the patient needs to move as they leave, which decides what has to be waiting for them at home. LOINC's mobility terms belong to scored instruments — the IRF-PAI and LCDS items, and 83186-7 for ambulation as functional ability — and carry those instruments' answer lists rather than this question's. Answered from SGHIDischargeMobility. |
| pain-control-at-discharge |
Pain control at discharge |
Whether pain is held well enough on what the patient can take at home. LOINC 99997-9, 'Demonstrates AndOr reports adequate pain control', is close in wording but is an instrument item answered yes or no, where this question grades the control on four levels. Answered from SGHIDischargePainControl. |
| patient-condition-at-discharge |
Condition at discharge |
The state the patient is leaving in, against the state they arrived in. Not the discharge disposition: LOINC 52523-8 and HL7's discharge-disposition both say where the patient went, which is a different axis with its own value set. Answered from SGHIConditionAtDischarge. |
| danger-signs-explained |
Danger signs explained at discharge |
What the patient and their family were told to watch for, in the clinician's words. The absence of this is what brings a patient back. |
| next-of-kin-briefed |
Next of kin briefed at discharge |
The person briefed alongside the patient, named as the ward wrote them down. Their relationship rides as a component rather than a second Observation, because a name and what that person is to the patient are two halves of one fact. |
| relationship-to-patient |
Relationship to the patient |
What the person briefed alongside the patient is to them. Names the Observation.component that carries it; the answer comes from SGHINextOfKinRelationship. |
| medicines-explained-at-discharge |
Take-home medicines explained at discharge |
Who had the take-home medicines gone through with them, including nobody, which is a fact worth stating rather than a blank. Answered from SGHIDischargeEducationRecipient. |
| account-settlement-at-discharge |
How the account was settled at discharge |
The cashier's or billing clerk's record that the account was dealt with before the patient left. Answered from SGHIAccountSettlement. |