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Packagesilfhirprofileig
Resource TypeCodeSystem
IdCodeSystem-clinical-score-codesystem.json
FHIR VersionR5
Sourcehttps://build.fhir.org/ig/savannahghi/sil_fhir_profile_ig/CodeSystem-clinical-score-codesystem.html
URLhttps://fhir.slade360.co.ke/fhir/CodeSystem/clinical-score-codesystem
Version0.1.0
Statusactive
Date2026-10-02T07:33:51+00:00
NameSGHIClinicalScoreCodeSystem
TitleSGHI Clinical Score Code System
DescriptionThe answers to the scored instruments used on inpatient assessments: the Braden pressure ulcer scale, the Morse falls score, MUST nutrition screening and the Glasgow Coma Scale. Each answer is a concept so a response records what was observed rather than a bare number. Codes are namespaced instrument-item-weight; the weight is in the code because within an item it is what tells one answer from another, and because two items in an instrument can share a label. The extraction maps rely on that: they read the weight off the tail of the code when a client submits no calculated total.
Contentcomplete

Resources that use this resource

ValueSet
silfhirprofileig#currentbraden-scale-answerSGHI Braden Scale Answer
silfhirprofileig#currentgcs-eye-openingSGHI GCS Eye Opening
silfhirprofileig#currentgcs-motor-responseSGHI GCS Motor Response
silfhirprofileig#currentgcs-verbal-responseSGHI GCS Verbal Response
silfhirprofileig#currentglasgow-coma-scale-answerSGHI Glasgow Coma Scale Answer
silfhirprofileig#currentmalnutrition-screening-answerSGHI Malnutrition Screening (MUST) Answer
silfhirprofileig#currentmorse-fall-scale-answerSGHI Morse Fall Scale Answer

Resources that this resource uses

No resources found


Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: CodeSystem clinical-score-codesystem

This case-sensitive code system https://fhir.slade360.co.ke/fhir/CodeSystem/clinical-score-codesystem defines the following codes:

CodeDisplayDefinition
braden-sensory-1 Completely limitedBraden sensory perception: unresponsive to painful stimuli, or limited ability to feel pain over most of the body.
braden-sensory-2 Very limitedBraden sensory perception: responds only to painful stimuli, or a sensory impairment over half the body.
braden-sensory-3 Slightly limitedBraden sensory perception: responds to verbal commands but cannot always communicate discomfort.
braden-sensory-4 No impairmentBraden sensory perception: responds to verbal commands, no sensory deficit.
braden-moisture-1 Constantly moistBraden moisture: skin kept moist almost constantly by perspiration or urine.
braden-moisture-2 Often moistBraden moisture: skin often but not always moist; linen changed at least once a shift.
braden-moisture-3 Occasionally moistBraden moisture: skin occasionally moist, requiring an extra linen change about once a day.
braden-moisture-4 Rarely moistBraden moisture: skin usually dry; linen changed at routine intervals.
braden-activity-1 BedfastBraden activity: confined to bed.
braden-activity-2 ChairfastBraden activity: ability to walk severely limited or non-existent; cannot bear own weight.
braden-activity-3 Walks occasionallyBraden activity: walks short distances during the day, with or without assistance.
braden-activity-4 Walks frequentlyBraden activity: walks outside the room at least twice a day and inside it every two hours while awake.
braden-mobility-1 Completely immobileBraden mobility: makes no change in body or extremity position without assistance.
braden-mobility-2 Very limitedBraden mobility: makes occasional slight changes in position but cannot make frequent or significant changes independently.
braden-mobility-3 Slightly limitedBraden mobility: makes frequent though slight changes in position independently.
braden-mobility-4 No limitationBraden mobility: makes major and frequent changes in position without assistance.
braden-nutrition-1 Very poorBraden nutrition: never eats a complete meal, or is nil by mouth or on clear fluids for more than five days.
braden-nutrition-2 Probably inadequateBraden nutrition: rarely eats a complete meal; generally eats about half of what is offered.
braden-nutrition-3 AdequateBraden nutrition: eats over half of most meals, or is fed by tube or parenterally to meet most needs.
braden-nutrition-4 ExcellentBraden nutrition: eats most of every meal and never refuses one.
braden-friction-1 ProblemBraden friction and shear: requires moderate to maximum assistance to move; slides against sheets and cannot lift clear of them.
braden-friction-2 Potential problemBraden friction and shear: moves feebly or requires minimum assistance; skin probably slides against sheets to some extent.
braden-friction-3 No apparent problemBraden friction and shear: moves independently in bed and chair, with enough muscle strength to lift clear of the sheets.
falls-history-0 No fall in the last 12 monthsFalls risk history: no fall recorded in the last twelve months.
falls-history-25 Fall in the last 12 monthsFalls risk history: at least one fall recorded in the last twelve months.
falls-diagnoses-0 One active diagnosis or noneFalls risk: no more than one active diagnosis on the problem list.
falls-diagnoses-15 More than one active diagnosisFalls risk: more than one active diagnosis on the problem list.
falls-aid-0 No walking aid, or bedrestFalls risk walking aid: none needed, on bedrest, or assisted by a nurse.
falls-aid-15 Crutch, stick or walkerFalls risk walking aid: mobilises with a crutch, stick or walking frame.
falls-aid-30 Holds onto furnitureFalls risk walking aid: mobilises by holding onto furniture.
falls-iv-0 No intravenous accessFalls risk: no cannula, line or heparin lock in place.
falls-iv-20 Intravenous access in placeFalls risk: a cannula, line or heparin lock is in place.
falls-gait-0 Normal gait, or bedrestFalls risk gait: normal gait, or immobile.
falls-gait-10 Weak gaitFalls risk gait: short steps, possibly shuffling, seeks support from furniture but not leaning on it.
falls-gait-20 Impaired gaitFalls risk gait: short steps with difficulty rising, head down, grasps furniture for support.
falls-mental-0 Oriented to own abilityFalls risk awareness: the patient's account of what they can manage matches what the nursing team observes.
falls-mental-15 Overestimates or forgets limitsFalls risk awareness: the patient overestimates what they can manage, or forgets their limits.
must-bmi-0 BMI 20 or overMUST body mass index step: 20 kg/m2 or above.
must-bmi-1 BMI 18.5 to 20MUST body mass index step: 18.5 to 20 kg/m2.
must-bmi-2 BMI under 18.5MUST body mass index step: below 18.5 kg/m2.
must-loss-0 Weight loss under 5%MUST weight loss step: unplanned loss of less than 5% of body weight in the last three to six months.
must-loss-1 Weight loss 5 to 10%MUST weight loss step: unplanned loss of 5 to 10% of body weight in the last three to six months.
must-loss-2 Weight loss over 10%MUST weight loss step: unplanned loss of more than 10% of body weight in the last three to six months.
must-acute-0 Eating normallyMUST acute disease effect step: the patient is eating, or a break in intake of five days or more is not expected.
must-acute-2 No nutritional intake for 5 days or moreMUST acute disease effect step: acutely ill with no nutritional intake for five days or more, or none expected for that long.
gcs-eye-1 No eye openingGCS eye opening: none.
gcs-eye-2 Eye opening to pressureGCS eye opening: to pressure.
gcs-eye-3 Eye opening to soundGCS eye opening: to sound.
gcs-eye-4 Spontaneous eye openingGCS eye opening: spontaneous.
gcs-verbal-1 No verbal responseGCS verbal response: none.
gcs-verbal-2 SoundsGCS verbal response: sounds only, no recognisable words.
gcs-verbal-3 WordsGCS verbal response: recognisable words, not conversation.
gcs-verbal-4 ConfusedGCS verbal response: converses but is disoriented.
gcs-verbal-5 OrientedGCS verbal response: oriented conversation.
gcs-motor-1 No motor responseGCS motor response: none.
gcs-motor-2 ExtensionGCS motor response: extension to pain.
gcs-motor-3 Abnormal flexionGCS motor response: abnormal flexion to pain.
gcs-motor-4 Normal flexionGCS motor response: normal flexion, withdraws from pain.
gcs-motor-5 LocalisingGCS motor response: localises to pain.
gcs-motor-6 Obeys commandsGCS motor response: obeys commands.

Source1

{
  "resourceType": "CodeSystem",
  "id": "clinical-score-codesystem",
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "url": "https://fhir.slade360.co.ke/fhir/CodeSystem/clinical-score-codesystem",
  "version": "0.1.0",
  "name": "SGHIClinicalScoreCodeSystem",
  "title": "SGHI Clinical Score Code System",
  "status": "active",
  "experimental": false,
  "date": "2026-10-02T07:33:51+00:00",
  "publisher": "Kathurima Kimathi",
  "contact": [
    {
      "name": "Kathurima Kimathi",
      "telecom": [
        {
          "system": "url",
          "value": "https://www.linkedin.com/in/kathurima-kimathi/"
        },
        {
          "system": "email",
          "value": "kathurimakimathi415@gmail.com"
        }
      ]
    },
    {
      "name": "Oscar John",
      "telecom": [
        {
          "system": "email",
          "value": "oscarjohnotieno@gmail.com",
          "use": "work"
        }
      ]
    },
    {
      "name": "Kennedy Omondi",
      "telecom": [
        {
          "system": "email",
          "value": "kennankole@gmail.com",
          "use": "work"
        }
      ]
    }
  ],
  "description": "The answers to the scored instruments used on inpatient assessments: the Braden pressure ulcer scale, the Morse falls score, MUST nutrition screening and the Glasgow Coma Scale. Each answer is a concept so a response records what was observed rather than a bare number. Codes are namespaced instrument-item-weight; the weight is in the code because within an item it is what tells one answer from another, and because two items in an instrument can share a label. The extraction maps rely on that: they read the weight off the tail of the code when a client submits no calculated total.",
  "caseSensitive": true,
  "content": "complete",
  "count": 60,
  "concept": [
    {
      "code": "braden-sensory-1",
      "display": "Completely limited",
      "definition": "Braden sensory perception: unresponsive to painful stimuli, or limited ability to feel pain over most of the body."
    },
    {
      "code": "braden-sensory-2",
      "display": "Very limited",
      "definition": "Braden sensory perception: responds only to painful stimuli, or a sensory impairment over half the body."
    },
    {
      "code": "braden-sensory-3",
      "display": "Slightly limited",
      "definition": "Braden sensory perception: responds to verbal commands but cannot always communicate discomfort."
    },
    {
      "code": "braden-sensory-4",
      "display": "No impairment",
      "definition": "Braden sensory perception: responds to verbal commands, no sensory deficit."
    },
    {
      "code": "braden-moisture-1",
      "display": "Constantly moist",
      "definition": "Braden moisture: skin kept moist almost constantly by perspiration or urine."
    },
    {
      "code": "braden-moisture-2",
      "display": "Often moist",
      "definition": "Braden moisture: skin often but not always moist; linen changed at least once a shift."
    },
    {
      "code": "braden-moisture-3",
      "display": "Occasionally moist",
      "definition": "Braden moisture: skin occasionally moist, requiring an extra linen change about once a day."
    },
    {
      "code": "braden-moisture-4",
      "display": "Rarely moist",
      "definition": "Braden moisture: skin usually dry; linen changed at routine intervals."
    },
    {
      "code": "braden-activity-1",
      "display": "Bedfast",
      "definition": "Braden activity: confined to bed."
    },
    {
      "code": "braden-activity-2",
      "display": "Chairfast",
      "definition": "Braden activity: ability to walk severely limited or non-existent; cannot bear own weight."
    },
    {
      "code": "braden-activity-3",
      "display": "Walks occasionally",
      "definition": "Braden activity: walks short distances during the day, with or without assistance."
    },
    {
      "code": "braden-activity-4",
      "display": "Walks frequently",
      "definition": "Braden activity: walks outside the room at least twice a day and inside it every two hours while awake."
    },
    {
      "code": "braden-mobility-1",
      "display": "Completely immobile",
      "definition": "Braden mobility: makes no change in body or extremity position without assistance."
    },
    {
      "code": "braden-mobility-2",
      "display": "Very limited",
      "definition": "Braden mobility: makes occasional slight changes in position but cannot make frequent or significant changes independently."
    },
    {
      "code": "braden-mobility-3",
      "display": "Slightly limited",
      "definition": "Braden mobility: makes frequent though slight changes in position independently."
    },
    {
      "code": "braden-mobility-4",
      "display": "No limitation",
      "definition": "Braden mobility: makes major and frequent changes in position without assistance."
    },
    {
      "code": "braden-nutrition-1",
      "display": "Very poor",
      "definition": "Braden nutrition: never eats a complete meal, or is nil by mouth or on clear fluids for more than five days."
    },
    {
      "code": "braden-nutrition-2",
      "display": "Probably inadequate",
      "definition": "Braden nutrition: rarely eats a complete meal; generally eats about half of what is offered."
    },
    {
      "code": "braden-nutrition-3",
      "display": "Adequate",
      "definition": "Braden nutrition: eats over half of most meals, or is fed by tube or parenterally to meet most needs."
    },
    {
      "code": "braden-nutrition-4",
      "display": "Excellent",
      "definition": "Braden nutrition: eats most of every meal and never refuses one."
    },
    {
      "code": "braden-friction-1",
      "display": "Problem",
      "definition": "Braden friction and shear: requires moderate to maximum assistance to move; slides against sheets and cannot lift clear of them."
    },
    {
      "code": "braden-friction-2",
      "display": "Potential problem",
      "definition": "Braden friction and shear: moves feebly or requires minimum assistance; skin probably slides against sheets to some extent."
    },
    {
      "code": "braden-friction-3",
      "display": "No apparent problem",
      "definition": "Braden friction and shear: moves independently in bed and chair, with enough muscle strength to lift clear of the sheets."
    },
    {
      "code": "falls-history-0",
      "display": "No fall in the last 12 months",
      "definition": "Falls risk history: no fall recorded in the last twelve months."
    },
    {
      "code": "falls-history-25",
      "display": "Fall in the last 12 months",
      "definition": "Falls risk history: at least one fall recorded in the last twelve months."
    },
    {
      "code": "falls-diagnoses-0",
      "display": "One active diagnosis or none",
      "definition": "Falls risk: no more than one active diagnosis on the problem list."
    },
    {
      "code": "falls-diagnoses-15",
      "display": "More than one active diagnosis",
      "definition": "Falls risk: more than one active diagnosis on the problem list."
    },
    {
      "code": "falls-aid-0",
      "display": "No walking aid, or bedrest",
      "definition": "Falls risk walking aid: none needed, on bedrest, or assisted by a nurse."
    },
    {
      "code": "falls-aid-15",
      "display": "Crutch, stick or walker",
      "definition": "Falls risk walking aid: mobilises with a crutch, stick or walking frame."
    },
    {
      "code": "falls-aid-30",
      "display": "Holds onto furniture",
      "definition": "Falls risk walking aid: mobilises by holding onto furniture."
    },
    {
      "code": "falls-iv-0",
      "display": "No intravenous access",
      "definition": "Falls risk: no cannula, line or heparin lock in place."
    },
    {
      "code": "falls-iv-20",
      "display": "Intravenous access in place",
      "definition": "Falls risk: a cannula, line or heparin lock is in place."
    },
    {
      "code": "falls-gait-0",
      "display": "Normal gait, or bedrest",
      "definition": "Falls risk gait: normal gait, or immobile."
    },
    {
      "code": "falls-gait-10",
      "display": "Weak gait",
      "definition": "Falls risk gait: short steps, possibly shuffling, seeks support from furniture but not leaning on it."
    },
    {
      "code": "falls-gait-20",
      "display": "Impaired gait",
      "definition": "Falls risk gait: short steps with difficulty rising, head down, grasps furniture for support."
    },
    {
      "code": "falls-mental-0",
      "display": "Oriented to own ability",
      "definition": "Falls risk awareness: the patient's account of what they can manage matches what the nursing team observes."
    },
    {
      "code": "falls-mental-15",
      "display": "Overestimates or forgets limits",
      "definition": "Falls risk awareness: the patient overestimates what they can manage, or forgets their limits."
    },
    {
      "code": "must-bmi-0",
      "display": "BMI 20 or over",
      "definition": "MUST body mass index step: 20 kg/m2 or above."
    },
    {
      "code": "must-bmi-1",
      "display": "BMI 18.5 to 20",
      "definition": "MUST body mass index step: 18.5 to 20 kg/m2."
    },
    {
      "code": "must-bmi-2",
      "display": "BMI under 18.5",
      "definition": "MUST body mass index step: below 18.5 kg/m2."
    },
    {
      "code": "must-loss-0",
      "display": "Weight loss under 5%",
      "definition": "MUST weight loss step: unplanned loss of less than 5% of body weight in the last three to six months."
    },
    {
      "code": "must-loss-1",
      "display": "Weight loss 5 to 10%",
      "definition": "MUST weight loss step: unplanned loss of 5 to 10% of body weight in the last three to six months."
    },
    {
      "code": "must-loss-2",
      "display": "Weight loss over 10%",
      "definition": "MUST weight loss step: unplanned loss of more than 10% of body weight in the last three to six months."
    },
    {
      "code": "must-acute-0",
      "display": "Eating normally",
      "definition": "MUST acute disease effect step: the patient is eating, or a break in intake of five days or more is not expected."
    },
    {
      "code": "must-acute-2",
      "display": "No nutritional intake for 5 days or more",
      "definition": "MUST acute disease effect step: acutely ill with no nutritional intake for five days or more, or none expected for that long."
    },
    {
      "code": "gcs-eye-1",
      "display": "No eye opening",
      "definition": "GCS eye opening: none."
    },
    {
      "code": "gcs-eye-2",
      "display": "Eye opening to pressure",
      "definition": "GCS eye opening: to pressure."
    },
    {
      "code": "gcs-eye-3",
      "display": "Eye opening to sound",
      "definition": "GCS eye opening: to sound."
    },
    {
      "code": "gcs-eye-4",
      "display": "Spontaneous eye opening",
      "definition": "GCS eye opening: spontaneous."
    },
    {
      "code": "gcs-verbal-1",
      "display": "No verbal response",
      "definition": "GCS verbal response: none."
    },
    {
      "code": "gcs-verbal-2",
      "display": "Sounds",
      "definition": "GCS verbal response: sounds only, no recognisable words."
    },
    {
      "code": "gcs-verbal-3",
      "display": "Words",
      "definition": "GCS verbal response: recognisable words, not conversation."
    },
    {
      "code": "gcs-verbal-4",
      "display": "Confused",
      "definition": "GCS verbal response: converses but is disoriented."
    },
    {
      "code": "gcs-verbal-5",
      "display": "Oriented",
      "definition": "GCS verbal response: oriented conversation."
    },
    {
      "code": "gcs-motor-1",
      "display": "No motor response",
      "definition": "GCS motor response: none."
    },
    {
      "code": "gcs-motor-2",
      "display": "Extension",
      "definition": "GCS motor response: extension to pain."
    },
    {
      "code": "gcs-motor-3",
      "display": "Abnormal flexion",
      "definition": "GCS motor response: abnormal flexion to pain."
    },
    {
      "code": "gcs-motor-4",
      "display": "Normal flexion",
      "definition": "GCS motor response: normal flexion, withdraws from pain."
    },
    {
      "code": "gcs-motor-5",
      "display": "Localising",
      "definition": "GCS motor response: localises to pain."
    },
    {
      "code": "gcs-motor-6",
      "display": "Obeys commands",
      "definition": "GCS motor response: obeys commands."
    }
  ]
}