TID 3114 Patient Assessment
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### TID 3114 Patient Assessment

The Patient Assessment Template allows recording of the assessment of the patient's cardiovascular, neurological, and/or respiratory condition. A particular use of this template is for "vital signs", which are a specific subset of mandatory patient assessment measurements.

Type:

  Extensible

Order:

  Significant

Table TID 3114. Patient Assessment

| NL | Rel with Parent | VT | Concept Name | VM | Req Type | Condition | Value Set Constraint
--- | --- | --- | --- | --- | --- | --- | --- | ---
1 |  |  | CODE | EV (121123, DCM, "Patient Status or Event") | 1 | M |  | DT (121165, DCM, "Patient Assessment Performed") DT (PA-00500, SRT, "Observation of Vital Signs")
2 | > | HAS PROPERTIES | INCLUDE | DTID 300 “Measurement” | 1 | MC | IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs") | $Measurement = EV (F-008EC, SRT, "Systolic blood pressure") $Units = DCID 3500 “Pressure Units” $Method = BCID 3560 “Blood Pressure Methods”
3 | > | HAS PROPERTIES | INCLUDE | DTID 300 “Measurement” | 1 | MC | IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs") | $Measurement = EV (F-008ED, SRT, "Diastolic blood pressure") $Units = DCID 3500 “Pressure Units”
4 | > | HAS PROPERTIES | INCLUDE | DTID 300 “Measurement” | 1 | MC | IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs") | $Measurement = EV (8867-4, LN, "Heart rate") $Units = EV ({H.B.}/min, UCUM, "BPM")
5 | > | HAS PROPERTIES | INCLUDE | DTID 300 “Measurement” | 1 | MC | IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs") | $Measurement = EV (8310-5, LN, "Body temperature") $Units = EV (Cel, UCUM, "C")
6 | > | HAS PROPERTIES | INCLUDE | DTID 300 “Measurement” | 1 | MC | IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs") | $Measurement = DCID 3526 “Blood Gas Saturation” $Units = EV (%, UCUM, "%")
7 | > | HAS PROPERTIES | INCLUDE | DTID 300 “Measurement” | 1 | MC | IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs") | $Measurement = EV (F-043E7, SRT, "Respiration rate") $Units = EV (/min, UCUM, "breaths/min")
8 | > | HAS PROPERTIES | INCLUDE | DTID 300 “Measurement” | 1-n | MC | IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs") | $Measurement = EV (122195, DCM, "Pulse Strength") $Method = BCID 3442 “Peripheral Pulse Methods” $TargetSite = BCID 3440 “Peripheral Pulse Locations” $Units = DT ({0:4}, UCUM, "range 0:4")
9 | > | HAS PROPERTIES | INCLUDE | DTID 300 “Measurement” | 1 | MC | IF Row 1 value = (PA-00500, SRT, "Observation of Vital Signs") | $Measurement = EV (F-009EA, SRT, "Pain Score") $Units = DT ({1:10}, UCUM, "range 1:10")
10 | > | HAS PROPERTIES | CODE | DT (8884-9, LN, "Cardiac Rhythm") | 1 | U |  | BCID 3415 “Cardiac Rhythms”
11 | > | HAS PROPERTIES | CODE | DT (9304-7, LN, "Respiration Rhythm") | 1 | U |  | BCID 3416 “Respiration Rhythms”
12 | > | HAS PROPERTIES | CODE | DT (F-043E6, SRT, "Respiration Assessment") | 1 | U |  | BCID 3448 “Airway Assessment”
13 | > | HAS PROPERTIES | CODE | DT (F-046D8, SRT, "Skin condition") | 1-n | U |  | BCID 3446 “Skin Condition”
14 | > | HAS PROPERTIES | CODE | DT (F-04317, SRT, "Patient mental state assessment") | 1 | U |  | No BCID
15 | > | HAS PROPERTIES | TEXT | BCID 3441 “Patient Assessments” | 1-n | U |  |

Content Item Descriptions

Row 8 | Pulse Strength allows the assessment of the patient's pulse at multiple locations using the Topographical concept modifier. It may also be used for a single pulse strength measurement from an unspecified location, as is typical of vital signs assessments.
Row 16 | Allows free text description of patient assessments that are not expressible by coded entries of Rows 10 to 14.

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