Open Nursing Core FHIR Implementation Guide (ONC-IG) - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Official URL: https://opennursingcoreig.com/ImplementationGuide/onc.ig				Version: 1.0.0
Active as of 2026-07-10				Computable Name: OpenNursingCoreIG

Open Nursing Core FHIR Implementation Guide

⚠️ Standards status: Trial Use — Pre-Ballot Community Release. This IG has not undergone formal HL7 standards balloting or independent clinical/peer review. Its active/release labels reflect development maturity within this project, not endorsement by HL7 International, PRSB, or any other standards body. It is a specification, not a deployed product, and does not by itself discharge an implementing organisation's clinical-safety (DCB0129/DCB0160) or information-governance obligations. See the Standards & Governance Roadmap for the path toward formal review and balloting.

The Open Nursing Core FHIR Implementation Guide (ONC-IG) provides a foundational set of standardised, nurse-led data models for the NHS and comparable health systems. It is built on HL7 FHIR R4 (4.0.1) and organised around the complete nursing process — Assessment, Diagnosis, Planning, Implementation and Evaluation (ADPIE) — rather than a purely pathology-driven medical model.

The IG is grounded in United Kingdom nursing and information standards, in particular the Professional Record Standards Body (PRSB) Nursing Care Needs standard, the NANDA International (NANDA-I) diagnostic taxonomy, and the person-centred practice principles of the Foundation of Nursing Studies (FONS).

Purpose and scope

This guide defines the structured data required to record nursing care in an interoperable, equitable and safety-aware manner. It is intended for use by NHS digital teams, electronic health record (EHR) suppliers, clinical safety officers, and nurse informaticians who need a shared vocabulary for the fundamentals of nursing.

The current release defines 60 profiles, 27 value sets, 3 code systems, 4 extensions, 1 logical model (the Relational Care model) and 49 worked examples. See the Published Versions page for the full release record.

Core principles

• Process-led — every profile maps to a phase of the ADPIE nursing process, making the reasoning of care computable, not only its outcomes.
• Person-centred — captures "What Matters to Me" and the Patient Story alongside clinical measurement, in line with FONS values-based practice.
• Equitable by design — leads with the Monk Skin Tone Scale for skin assessment and records Reasonable Adjustments under the Equality Act 2010. See the Health Equity & Inclusion page.
• Safety-aware — validated instruments such as NEWS2 and pressure-ulcer risk scores act as clinical safety gates.

Profile library

The profile library is organised below by function. For the full navigable list of every artifact, see the Artifacts index.

1. Nursing process core

Base profiles that carry the ADPIE spine.

• ONC Nursing Assessment — the base observation for all assessment instruments
• ONC Nursing Problem — nursing diagnosis (Condition)
• ONC Nursing Need and ONC Nursing Strength — PRSB needs-and-strengths framing
• ONC Nursing Goal — planned outcomes
• ONC Nursing Intervention — delivered care
• ONC Goal Evaluation and ONC Nursing Clinical Impression — evaluation

2. Clinical safety and deterioration

Validated risk instruments used as safety gates. See the Clinical Safety page.

• NEWS2 — National Early Warning Score 2 (deterioration)
• Braden Scale and Waterlow Score — pressure-ulcer risk
• MUST — malnutrition screening
• 4AT Delirium Screen, Morse Fall Scale, qSOFA

3. Relational and inclusive care

Capturing the person behind the patient. See Health Equity & Inclusion.

• What Matters To Me and Patient Story
• Monk Skin Tone Observation — 10-point equitable skin assessment (A–J)
• Skin Tone Observation — Fitzpatrick classification (secondary)
• Reasonable Adjustment — Equality Act 2010
• Mental Capacity Assessment — Mental Capacity Act 2005

4. Fundamental care

The essentials of daily nursing.

• Bristol Stool Chart — elimination
• Fluid Balance — hydration
• Abbey Pain Scale — non-verbal pain
• Oral Health and Sleep Pattern

5. Specialist and mental health

Instruments for learning disability, mental health and older-person care.

• ABC Chart — Positive Behaviour Support
• Seizure Record — epilepsy
• Clinical Frailty Scale and Glasgow Coma Scale
• MMSE, Urinalysis

Guidance pages

• The ADPIE Nursing Process — how the IG is structured around clinical reasoning
• Clinical Safety — safety gates, escalation and the DCB0129/0160 context
• Health Equity & Inclusion — Monk Skin Tone Scale and reasonable adjustments
• Security & Privacy — UK GDPR, DSPT and Caldicott
• Terminology — SNOMED CT, LOINC and the ONC code systems
• Structured Data Capture — SDC Questionnaires for offline-first capture (Open Health Stack compatible)
• Relational AI — the FONS-aligned language model
• Published Versions — release history

Getting started

1. Browse the artifacts — every profile, extension, value set and example is listed on the Artifacts page.
2. Read the process guide — start with ADPIE to understand how the profiles fit together.
3. Contribute — the IG is open source under the MIT licence. Issues and pull requests are welcome on GitHub.

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The Open Nursing Core is maintained by the Open Nursing Community. This guide is a technical specification and does not replace professional clinical judgement; all clinical documentation must be verified by a registered nurse.