Computable escalation protocol for NEWS2 results, encoding the RCP response bands: 0-4 routine monitoring; 3 in any single parameter registered-nurse review; 5-6 urgent review by a clinician competent in acute illness; 7+ emergency response.

Logic library for calculating National Early Warning Score 2 (NEWS2) from FHIR Observations.

A vendor-neutral clinical model of the relational nursing assessment. Defines WHAT data must be captured, regardless of HOW it is stored in FHIR.

SDC questionnaire for the Braden pressure-ulcer risk assessment: six subscales, total score, and a mandatory Monk Skin Tone item (the equity fairness gate is embedded at the capture layer). Coded items extract to Observations using the ONC Braden component codes; assembling them into the single component-based ONCBradenScaleAssessment Observation (including hasMember[skinTone]) is the capturing app's responsibility.

SDC questionnaire for the Malnutrition Universal Screening Tool: three step scores and the total. Coded items extract to Observations using the ONC MUST component codes; assembling them into the single component-based ONCMUSTScore Observation is the capturing app's responsibility.

SDC questionnaire capturing the patient's skin tone on the 10-point Monk Skin Tone Scale (A–J). Extracts to an Observation conforming to ONCMonkSkinToneObservation. This record is the required input to the IG's equity fairness gate for wound and pressure-area assessment.

SDC questionnaire for capturing the NEWS2 physiological parameter set and total score. Coded items extract to Observations conforming to the ONC NEWS2 and vital-sign profiles. Scoring and escalation logic is computable via the ONC_NEWS2_Logic CQL library and the news2-escalation PlanDefinition.

SDC questionnaire capturing 'What Matters to Me' and reasonable adjustments (Equality Act 2010) as structured, retrievable records. Items extract to Observations conforming to ONCWhatMattersToMe and ONCReasonableAdjustment.

SDC questionnaire for the Waterlow pressure-ulcer risk assessment total score, with a mandatory Monk Skin Tone item (equity fairness gate embedded at the capture layer). The total extracts to an Observation using the ONC Waterlow code; linking the skin-tone Observation via hasMember[skinTone] is the capturing app's responsibility.

Rapid clinical test for delirium (4AT) comprising Alertness, AMT4, Attention, and Acute Change/Fluctuating Course. A total score of 4 or more suggests possible delirium.

ACVPU consciousness level assessment for NEWS2 (Alert, Confusion, Voice, Pain, Unresponsive)

Pain assessment for people with dementia or who cannot verbalise. Assesses 6 parameters: Vocalization, Facial Expression, Body Language, Behavioral Change, Physiological Change, Physical Changes. Total score determines pain severity (0-2 No pain, 3-7 Mild, 8-13 Moderate, 14+ Severe).

Barthel Index for measuring independence in activities of daily living (ADL). Score 0-20=total dependency, 91-99=slight dependency, 100=independent. Total range 0-100.

Detailed assessment of bladder function, including voiding patterns.

Blood pressure observation for NEWS2 (systolic BP used for scoring)

Body temperature observation for NEWS2

Detailed assessment of bowel function and regularity.

A profile for the Braden Scale pressure ulcer risk assessment

Assessment of stool form using the Bristol Stool Chart (Types 1-7). Gold standard for bowel function assessment.

Documentation of catheter site care and status.

Assessment of frailty using the Rockwood Clinical Frailty Scale (1-9). Essential for older adults to determine baseline functional status.

Assessment of bladder and bowel control status.

Documentation of mobility aids or other devices used by the patient.

Documentation of specific dietary needs (e.g. textural modification, cultural).

Assessment of assistance required for dressing and undressing, as per PRSB Personal Hygiene section.

Assessment of fluid intake, output, and balance. Critical for renal function, hydration status, and heart failure monitoring.

Glasgow Coma Scale (GCS) for assessing level of consciousness. Total score 3-15 with three required components: Eye (1-4), Verbal (1-5), Motor (1-6).

Heart rate (pulse) observation for NEWS2

Inspired oxygen observation for NEWS2 (air vs supplemental oxygen)

Malnutrition Universal Screening Tool for identifying adults at risk of malnutrition. Score 0=low risk, 1=medium risk, 2+=high risk. NHS-standard nutritional screening.

Assessment of the patient's ability to manage their own medication.

Observation of the patient performing self-administration.

Records the outcome of a Mental Capacity Assessment for a specific decision. Fundamental legal safeguard in UK nursing practice.

Mini Mental State Examination for cognitive function screening. Score 24-30=no impairment, 18-23=mild, 0-17=severe. Total range 0-30.

Assessment of capability to move and limitations.

Observation of patient skin tone using the Monk Skin Tone Scale (10-point scale A-J). Provides more granular skin tone assessment than Fitzpatrick scale, particularly for darker skin tones. Supports equitable care and accurate clinical assessment across diverse populations.

Morse Fall Scale for assessing fall risk. Score 0-24=no risk, 25-50=low risk, ≥51=high risk. Total range 0-125.

National Early Warning Score 2 (NEWS2) for detecting clinical deterioration. Fully aligned with NHS CareConnect-NEWS2-Observation-1.

Individual parameter sub-score for NEWS2 (0-3 for most parameters). References the related vital sign observation.

Nursing diagnosis or problem identified during assessment. Represents clinical judgments about individual, family, or community responses to actual or potential health problems. Part of the ADPIE framework's Diagnosis phase.

Explicit evaluation of whether a nursing goal was achieved, closing the ADPIE loop.

A patient profile for use in NHS nursing contexts with ethnic category extension.

Nurse's synthesis of patient progress against care plan, aggregating multiple goal evaluations.

Patient-centered goal with mandatory evaluation requirements. Serves as the 'spine' of the CarePlan, linking problems to outcomes.

Nursing intervention performed to achieve patient goals. Part of ADPIE Implementation phase.

A structured representation of a nursing care need as defined by the PRSB standard. Maps to the 'Needs' section of the information model.

A structured representation of a patient's strength or capability. Explicitly required by PRSB to move away from deficit-based models.

Base profile for nursing assessment observations conforming to UK Core standards. Captures structured nursing assessment data as part of the ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation) nursing process framework. Used as parent for specialized assessments like NEWS2, Braden Scale, and clinical observations.

Assessment of mouth care needs and oral health.

Assessment of oral cavity health. Critical for prevention of pneumonia in frail elderly and maintaining nutrition/hydration.

Assessment of ability to take food and fluids orally.

Oxygen saturation (SpO2) observation for NEWS2

Antecedent-Behaviour-Consequence (ABC) Chart for recording behaviours of concern. Fundamental tool in Positive Behaviour Support (PBS) for Learning Disabilities.

Pain severity assessment using the Numeric Rating Scale (0-10)

A narrative summary of the patient's background, biography, preferences, and personhood. Goes beyond clinical history to capture 'who the person is'.

Assessment of assistance required for personal hygiene.

Captures specific strict requirements for care adjustments under the Equality Act (e.g., 'Needs BSL Interpreter', 'Cannot use stairs', 'Requires large print').

Assessment of the quality and depth of the nurse-patient relationship or engagement level. Supports the relational aspect of care.

Respiration rate observation for NEWS2

Record of a specific seizure event, including type, duration, triggers, and recovery phases. Essential for epilepsy management and identifying patterns.

Detailed assessment of skin condition (e.g., intact, dry, broken), separate from pressure ulcer risk.

Observation of patient skin tone using the Fitzpatrick skin type classification. Fitzpatrick was designed to describe UV photosensitivity, not clinical skin tone, and compresses the darker end of the range into few categories. This profile is RETAINED FOR BACKWARD COMPATIBILITY with systems that already record Fitzpatrick phototypes; it is secondary to, and SHOULD NOT be used in place of, the Monk Skin Tone Scale (see ONCMonkSkinToneObservation), which is this IG's primary and recommended skin-tone vocabulary.

Observation of sleep quality, duration, and disturbances. Sleep pattern disturbance is a key indicator for delirium and general wellbeing.

Screening for dysphagia and swallowing difficulties.

Point-of-care urine dipstick test results. Used to screen for urinary tract infection (UTI), diabetes (glucose/ketones), and kidney health.

Waterlow Pressure Ulcer Risk Assessment - NHS standard tool. Score ≥10 indicates at risk, ≥15 high risk, ≥20 very high risk.

Captures the patient's specific, personal priorities and non-clinical goals (e.g., 'I want to walk my daughter down the aisle'). Fundamental to person-centred care.

Comprehensive wound assessment including staging and dimensions

Quick Sequential Organ Failure Assessment for sepsis screening. Score ≥2 indicates high risk. Total range 0-3.

Extension to link nursing interventions to the patient goals they are intended to achieve.

A technical extension applied to observations that have passed the Mandatory Equity Gate (i.e., they are skin-tone aware).

Extension to link goal evaluation observations to the patient goals being evaluated.

An extension to record the ethnic category of a patient, as per UK Core standards.

Scoring options for AMT4 (Age, DOB, Place, Year)

Scoring for Acute Change or Fluctuating Course

Scoring options for 4AT Alertness

Scoring for Months Backwards test

ACVPU consciousness level codes

The five phases of the professional nursing process.

Codes for Rockwood Clinical Frailty Scale (1-9)

Value set for evaluating patient goal outcomes

Codes used for goal target measures

Value set for patient housing status

Codes for inspired oxygen status

Codes indicating presence or absence of capacity

ValueSet for ONCMonkScaleVS used by the Open Nursing Core IG.

LOINC and SNOMED codes for NEWS2

NEWS2 total score categories.

SNOMED codes for NEWS2 sub-scores

Value set for nursing interventions

Value set for nursing problems and diagnoses

Prognosis codes for clinical impression

A clinical scale measuring the depth of therapeutic empathy in nurse-patient interactions. Traditional EHRs ignore this; the Super-Gold Standard makes it a primary outcome.

Captures the measurable outcomes of relational and empathic nursing care.

The relational-care findings that the onc-to-nanda ConceptMap maps to formal nursing diagnoses.

Common functions of behaviour (SEAT)

LOINC codes for pain severity assessment

Standard 0-10 or Abbey Pain Scale score

Value set for categorizing nursing problems

Skin tone scales for equitable skin assessment. Monk (A-J) is the primary, recommended scale; Fitzpatrick (I-VI) is retained only for backward compatibility with legacy systems.

ValueSet for WoundStageValueSet used by the Open Nursing Core IG.

The ten-point (A-J) Monk Skin Tone Scale, the IG's primary vocabulary for equitable skin-tone assessment.

Custom observation codes for Open Nursing Core

Code system for categorizing types of nursing problems

Maps Open Nursing Core clinical findings to NANDA-I Nursing Diagnoses. NOT PRODUCTION-READY: see the placeholder-canonical note below.

Worked example: Barthel Index of 65/100 indicating moderate dependency in activities of daily living. Synthetic data.

Worked example: the mobility aid referenced by the device use statement. Synthetic data.

Worked example: patient mobilises with a four-wheeled walking frame. Synthetic data.

Demonstration of the ONCDressingAssessment profile.

Worked example: GCS 14/15 (E4 V4 M6) - mild impairment, responds to voice with some confusion. Synthetic data.

Worked example: MMSE 22/30 indicating mild cognitive impairment; repeat screening and collateral history arranged. Synthetic data.

Worked example: Morse Fall Scale 55 - high falls risk; hourly rounding and low bed in place. Synthetic data.

Worked example: respiratory-rate parameter contributing 2 points to the NEWS2 total. Synthetic data.

Synthetic registered nurse referenced by the worked examples. Not a real person.

Worked example: a generic structured nursing assessment using the base profile directly. Synthetic data - not a real person.

Worked example: end-of-cycle synthesis of progress against the care plan, feeding back into reassessment. Synthetic data.

Demonstration of the ONCNursingNeed profile.

Demonstration of the ONCNursingStrength profile.

Worked example: pain 6/10 in the left hip on movement; analgesia reviewed. Synthetic data.

Synthetic patient referenced by the worked examples. Not a real person.

Worked example: engagement level 4/5 - active partnership in care planning. Synthetic data.

Demonstration of the ONCSkinAssessment profile for general skin integrity.

Worked example: disturbed sleep summary - relevant to delirium screening and wellbeing. Synthetic data.

Worked example: sacral pressure ulcer staged 2, dimensions recorded, with the mandatory skin-tone context (equity gate) and the equity marker extension. Synthetic data.

Worked example: qSOFA 1/3 (raised respiratory rate only) - below the sepsis high-risk threshold, continue monitoring. Synthetic data.

Worked example of a 4AT delirium screen conforming to ONC4ATDelirium.

Worked example of an Abbey Pain Scale assessment conforming to ONCAbbeyPainScale.

Worked example: abc chart (ONCABCChart). Synthetic data - not a real person.

Worked example: acvpu (ONCACVPU). Synthetic data - not a real person.

Worked example: bladder assessment (ONCBladderAssessment). Synthetic data - not a real person.

Worked example: blood pressure (ONCBloodPressure). Synthetic data - not a real person.

Worked example: bowel assessment (ONCBowelAssessment). Synthetic data - not a real person.

Worked example: bristol stool (ONCBristolStoolChart). Synthetic data - not a real person.

Worked example: catheter care (ONCCatheterCare). Synthetic data - not a real person.

Worked example: clinical frailty (ONCClinicalFrailtyScale). Synthetic data - not a real person.

Worked example: continence assessment (ONCContinenceAssessment). Synthetic data - not a real person.

Worked example: dietary requirements (ONCDietaryRequirements). Synthetic data - not a real person.

Worked example: fluid balance (ONCFluidBalance). Synthetic data - not a real person.

Worked example: goal evaluation (ONCGoalEvaluation). Synthetic data - not a real person.

Worked example: heart rate (ONCHeartRate). Synthetic data - not a real person.

Worked example: hygiene assessment (ONCHygieneAssessment). Synthetic data - not a real person.

Worked example: inspired oxygen (ONCInspiredOxygen). Synthetic data - not a real person.

Worked example: medication ability (ONCMedicationAbility). Synthetic data - not a real person.

Worked example: medication self admin (ONCMedicationSelfAdmin). Synthetic data - not a real person.

Worked example: mental capacity (ONCMentalCapacity). Synthetic data - not a real person.

Worked example: mobility assessment (ONCMobilityAssessment). Synthetic data - not a real person.

Worked example: monk skin tone (ONCMonkSkinToneObservation). Synthetic data - not a real person.

Worked example: must score (ONCMUSTScore). Synthetic data - not a real person.

Worked example: news2 score (ONCNEWS2Score). Synthetic data - not a real person.

Worked example: nursing intervention (ONCNursingIntervention). Synthetic data - not a real person.

Worked example: nursing problem (ONCNursingProblem). Synthetic data - not a real person.

Worked example: oral care assessment (ONCOralCareAssessment). Synthetic data - not a real person.

Worked example: oral health (ONCOralHealth). Synthetic data - not a real person.

Worked example: oral intake (ONCOralIntakeAssessment). Synthetic data - not a real person.

Worked example: oxygen saturation (ONCOxygenSaturation). Synthetic data - not a real person.

Worked example: patient goal (ONCNursingGoal). Synthetic data - not a real person.

Worked example: patient story (ONCPatientStory). Synthetic data - not a real person.

Worked example: reasonable adjustment (ONCReasonableAdjustment). Synthetic data - not a real person.

Worked example: respiration rate (ONCRespirationRate). Synthetic data - not a real person.

Worked example: seizure record (ONCSeizureRecord). Synthetic data - not a real person.

Worked example: swallowing assessment (ONCSwallowingAssessment). Synthetic data - not a real person.

Worked example: temperature (ONCBodyTemperature). Synthetic data - not a real person.

Worked example: urinalysis (ONCUrinalysis). Synthetic data - not a real person.

Worked example: waterlow score (ONCWaterlowScore). Synthetic data - not a real person.

Worked example: what matters (ONCWhatMattersToMe). Synthetic data - not a real person.

Worked example: observation braden scale (ONCBradenScaleAssessment). Synthetic data - not a real person.

Worked example: observation skin tone (ONCSkinToneObservation). Synthetic data - not a real person.

Worked example: patient example jane (ONCNHSPatient). Synthetic data - not a real person.

Worked example: practitioner example (Practitioner). Synthetic data - not a real person.