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.
Extensible
Significant
Table TID 3114. Patient Assessment
|
NL |
Rel with Parent |
VT |
Concept Name |
VM |
Req Type |
Condition |
Value Set Constraint |
|
|---|---|---|---|---|---|---|---|---|
|
1 |
CODE |
1 |
M |
DT (121165, DCM, "Patient Assessment Performed") DT (PA-00500, SRT, "Observation of Vital Signs") |
||||
|
2 |
> |
HAS PROPERTIES |
INCLUDE |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
1 |
U |
|||
|
11 |
> |
HAS PROPERTIES |
CODE |
1 |
U |
|||
|
12 |
> |
HAS PROPERTIES |
CODE |
DT (F-043E6, SRT, "Respiration Assessment") |
1 |
U |
||
|
13 |
> |
HAS PROPERTIES |
CODE |
DT (F-046D8, SRT, "Skin condition") |
1-n |
U |
||
|
14 |
> |
HAS PROPERTIES |
CODE |
DT (F-04317, SRT, "Patient mental state assessment") |
1 |
U |
No BCID |
|
|
15 |
> |
HAS PROPERTIES |
TEXT |
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. |