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.

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. Supports equitable care by enabling skin tone-aware clinical decision making, particularly for conditions that present differently across skin tones (e.g., pressure ulcers, cyanosis).

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

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.

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

Monk and Fitzpatrick scales for equitable skin 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.

Demonstration of the ONCDressingAssessment profile.

Demonstration of the ONCNursingNeed profile.

Demonstration of the ONCNursingStrength profile.

Demonstration of the ONCSkinAssessment profile for general skin integrity.

Patient will remain free from falls.