83186-7 Mobility

Fully-Specified Name

Component
Ambulation - functional ability
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Long Common Name

Ambulation - functional ability

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.58
Last Updated
Version 2.73 (MIN)
Change Reason
Release 2.70: COMPONENT: Functional ability was added to the Component to clarify the term meaning and for consistency across terms.; SHORTNAME: Updated for clarity; SCALE_TYP: Updated for accuracy; CLASS: Updated for increased usability;
Order vs. Observation
Observation
Common Test Rank Get Info
8280

Normative Answer List LL6326-4

AnswerCodeScoreAnswer ID
Ambulates with no gait disturbance

The patient is able to ambulate independently and requires no assistance from staff and does not use assistive devices (Ex. cane, walker, wheelchair).

0LA33643-0
Ambulates or transfers with assistive device or assistance

The patient may ambulate independently with the help of an assistive device, or may be able to ambulate or transfer with the help of one or more staff.

1LA33644-8
Ambulates with unsteady gait and no assistance

The patient ambulates independently but displays an unsteady gait, such as shuffling gait, hemiparesis, Parkinsonian gait, etc.

1LA33645-5
Unable to ambulate or transfer

The patient does not ambulate or transfer at all. The patient may be on strict bedrest or is lifted out of bed with either the use of a mechanical device or staff.

0LA33646-3

Member of these Panels

LOINCLong Common Name
96762-0Barthel index panel
101438-0CHAMPS pediatric fall risk assessment
101549-4Schmid fall risk assessment
83180-0Self-care activities - functional ability panel

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Περιπατητική ικανότητα - λειτουργική ικανότητα:Εύρεση:Pt:^Ασθενής:Ord:
Synonyms: - CLIN Ord Pt Ασθενής Εύρεση Περιπατητική ικανότητα - λειτουργική ικανότητα
es-MXSpanish (Mexico)Deambulación - capacidad funcional:Tipo:Punto temporal:^ Paciente:Ordinal:
it-ITItalian (Italy)Deambulazione - abilità funzionale:Osservazione:Pt:^Paziente:Ord:
Synonyms: Clinico Osservazione paziente Punto nel tempo (episodio)
nl-NLDutch (Netherlands)mobiliteit:bevinding:moment:^patiënt:ordinaal:
Synonyms: vermogen tot voortbewegen; lopen
zh-CNChinese (China)步行 - 实用能力:发现:时间点:^患者:序数型:
Synonyms: 下床活动;移动;步行 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 时刻;随机;随意;瞬间 步行(移动、行走、下床活动、下床、上下床) - 实用能力(功能能力、功能性能力、实用自理能力、实用生活能力)

8693-4 Mentation

Fully-Specified Name

Component
Mental status
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
Observed

Long Common Name

Mental status

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.73 (MIN)
Common Test Rank Get Info
2229

Normative Answer List LL6327-2

AnswerCodeScoreAnswer ID
Alert, oriented x3

The patient is oriented to person, place and time at all times.

0LA33647-1
Periodic confusion

The patient is oriented in one or two spheres or only occasionally to three spheres.

1LA33648-9
Confusion at all times

The patient is not oriented to time or place.

1LA33649-7
Comatose/unresponsive

The patient is not arousable to assess orientation.

0LA33650-5

Member of these Panels

LOINCLong Common Name
88677-0German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
101549-4Schmid fall risk assessment

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Ψυχική κατάσταση:Εύρεση:Pt:^Ασθενής:Nom:Παρατηρηθέν
Synonyms: - H&P.PX Nom Pt Ασθενής Εύρεση Κατάσταση Παρατηρηθέν Ψυχική κατάσταση
es-ARSpanish (Argentina)estado mental:hallazgo:punto en el tiempo:^paciente:Nominal:observado
es-MXSpanish (Mexico)Estado mental:Tipo:Punto temporal:^ Paciente:Nominal:Observed
fr-BEFrench (Belgium)Status mental:Observation:Temps ponctuel:^Patient:Nominal:Observé
it-ITItalian (Italy)Stato mentale:Osservazione:Pt:^Paziente:Nom:Osservato
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
pt-BRPortuguese (Brazil)Estado mental:Achado:Pt:^Paciente:Nom:Observado
Synonyms: Finding; Findings; Point in time; Random; Nominal; Observ
ru-RURussian (Russian Federation)Психический статус:Находка:ТчкВрм:^Пациент:Ном:Наблюдённый
Synonyms: Номинальный;Именной Точка во времени;Момент
zh-CNChinese (China)心理状况:发现:时间点:^患者:名义型:观察法
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 时刻;随机;随意;瞬间 状况;情况 病史与体格检查 精神状态;心智状态;心理状态 观测法

83183-4 Elimination

Fully-Specified Name

Component
Toileting - functional ability
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Long Common Name

Toileting - functional ability

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.58
Last Updated
Version 2.73 (MIN)
Change Reason
Release 2.70: COMPONENT: Functional ability was added to the Component to clarify the term meaning and for consistency across terms.; SCALE_TYP: Updated for accuracy; CLASS: Updated for increased usability; SHORTNAME: Updated for clarity;
Order vs. Observation
Observation
Common Test Rank Get Info
3806

Normative Answer List LL6328-0

AnswerCodeScoreAnswer ID
Independent in elimination

The patient is able to ambulate to the bathroom without assistance, or uses a urinal independently.

0LA33651-3
Independent with frequency or diarrhea

The patient independently meets his elimination needs as stated above, but is currently experiencing diarrhea or urinary frequency, not controlled by medication.

1LA33652-1
Needs assistance with toileting

The patient requires assistance to get to a bathroom, uses a commode chair, or requires assistance with bedpan or urinal.

1LA33653-9
Incontinence Copyright http://snomed.info/sct ID:48340000 incontinence (finding)

The patient is usually incontinent of urine and/or stool.

1LA7445-5

Member of these Panels

LOINCLong Common Name
96762-0Barthel index panel
101549-4Schmid fall risk assessment
83180-0Self-care activities - functional ability panel

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Χρήση της τουαλέτας - λειτουργική ικανότητα:Εύρεση:Pt:^Ασθενής:Ord:
Synonyms: - CLIN Ord Pt Ασθενής Εύρεση Χρήση της τουαλέτας - λειτουργική ικανότητα
es-MXSpanish (Mexico)Ir al baño - capacidad funcional:Tipo:Punto temporal:^ Paciente:Ordinal:
it-ITItalian (Italy)Andare in bagno - abilità funzionale:Osservazione:Pt:^Paziente:Ord:
Synonyms: Clinico Osservazione paziente Punto nel tempo (episodio)
nl-NLDutch (Netherlands)vermogen tot toiletgang:bevinding:moment:^patiënt:ordinaal:
Synonyms: toiletgebruik
zh-CNChinese (China)如厕 - 实用能力:发现:时间点:^患者:序数型:
Synonyms: 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 入厕;上厕所;使用厕所;使用马桶;使用冲水马桶 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 如厕(上厕所、上茅厕、上茅房、上卫生间、上洗手间、上盥洗室、括约肌控制) - 实用能力(功能能力、功能性能力、实用自理能力、实用生活能力) 时刻;随机;随意;瞬间

101440-6 Prior Fall History

Fully-Specified Name

Component
Falls
Property
Hx
Time
Pt
System
^Patient
Scale
Ord
Method

Long Common Name

History of Falls

Basic Attributes

Class
CLIN.RISK
Type
Clinical
First Released
Version 2.74
Last Updated
Version 2.74 (ADD)
Order vs. Observation
Observation

Normative Answer List LL6329-8

AnswerCodeScoreAnswer ID
Yes, Before admission (Home or previous inpatient care)

The patient has had a previous fall either in the home setting or during a previous hospitalization within the past 3 months.

1LA33655-4
Yes, During this admission

The patient has fallen during the current length of stay.

2LA33656-2
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value)

The patient has not fallen previously either at home or while hospitalized within the past 3 months.

0LA32-8
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value)

The nurse is unable to assess the patient's previous fall history.

0LA4489-6

Member of these Panels

LOINCLong Common Name
101438-0CHAMPS pediatric fall risk assessment
101549-4Schmid fall risk assessment

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Πτώσεις:Ιστορικό:Pt:^Ασθενής:Ord:
Synonyms: - CLIN CLIN.RISK Ord Pt Ασθενής Ιστορικό Πτώσεις
it-ITItalian (Italy)Cadute:Hx,Storia,Anamnesi:Pt:^Paziente:Ord:
Synonyms: Clinico paziente Punto nel tempo (episodio) Rischio Clinico
zh-CNChinese (China)跌倒:历史记录:时间点:^患者:序数型:
Synonyms: 临床.风险(危险);临床风险;临床危险 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 时刻;随机;随意;瞬间 跌倒(摔倒、摔跤、跌跤);跌倒情况

66423-5 Current Medications

Fully-Specified Name

Component
Medications
Property
Find
Time
Pt
System
Medication.current
Scale
Nom
Method

Long Common Name

Medications Current medication

Basic Attributes

Class
PHENX
Type
Clinical
First Released
Version 2.36
Last Updated
Version 2.74 (MAJ)
Change Reason
Release 2.74: METHOD_TYP: Removed Method as this concept is not specific to PhenX; Status: Moved from Trial to Active for increased usability; Previous Releases: Updated the PhenX ID from "PhenX.<ID>" to "PX<ID>" in Survey Question Source field to align with the variable identifier used in the PhenX Toolkit.
Order vs. Observation
Observation

Normative Answer List LL6330-6

AnswerCodeScoreAnswer ID
Anti-convulsants/tranquilizers or psychotropics/hypnotics

The nurse checks all medications the patient has received within eight hours or for which the patient is currently scheduled to receive which fall into categories of anticonvulsants, sedatives, psychotropics, and/or hypnotics.

1LA33657-0

Member of these Panels

LOINCLong Common Name
62787-7PhenX domain - Diabetes
101549-4Schmid fall risk assessment

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Φαρμακευτική αγωγή:Εύρεση:Pt:Φαρμακευτική αγωγή.παρούσα:Nom:
Synonyms: Nom PHENX Pt Εύρεση Φαρμακευτική αγωγή Φαρμακευτική αγωγή.παρούσα
es-MXSpanish (Mexico)Medicamentos:Tipo:Punto temporal:Medicación actual:Nominal:PhenX
it-ITItalian (Italy)Farmaci:Osservazione:Pt:Farmaco.attuale:Nom:
Synonyms: Farmaco attuale Medicazione Osservazione PhenX Punto nel tempo (episodio)
ru-RURussian (Russian Federation)Лекарственные препараты:Находка:ТчкВрм:Лекарственный препарат.текущий:Ном:
Synonyms: Лекарства Номинальный;Именной Точка во времени;Момент
zh-CNChinese (China)药物:发现:时间点:药物.当前:名义型:
Synonyms: Consensus measures for Phenotypes and eXposures;PhenX;暴露;接触;表型与暴露共识指标;表现型与暴露共识指标;表型与暴露公认指标 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 处理用药.当前;处理用药物.当前;处理药物.当前;当前的处理用药;当前的处理用药物;当前的处理药物;当前的治疗用药;当前的治疗用药物;当前的治疗药物;当前的药物;治疗用药.当前;治疗用药物.当前;治疗药物.当前 处理用药;处理用药物;处理药物;治疗用药;治疗用药物;用药;药物处理;药物治疗;治疗药物 时刻;随机;随意;瞬间 药物类;处理用药;处理用药物;处理药物;治疗用药;治疗用药物;用药;药物处理;药物治疗;治疗药物

101550-2 Total score Schmid fall risk assessment

Term Description

Total score calculated ranging from 0 to 6.

Fully-Specified Name

Component
Total Score
Property
Score
Time
Pt
System
^Patient
Scale
Qn
Method
Schmid

Basic Attributes

Class
CLIN.RISK
Type
Clinical
First Released
Version 2.74
Last Updated
Version 2.74 (ADD)
Order vs. Observation
Observation

Member of these Panels

LOINCLong Common Name
101549-4Schmid fall risk assessment

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Συνολική βαθμολογία:Βαθμολογία:Pt:^Ασθενής:Qn:Schmid
Synonyms: - CLIN CLIN.RISK Pt Qn Schmid Ασθενής Βαθμολογία Συνολική βαθμολογία
it-ITItalian (Italy)Punteggio totale:Punteggio:Pt:^Paziente:Qn:Schmid
Synonyms: Clinico paziente Punto nel tempo (episodio) Rischio Clinico Valutazione del rischio di caduta Schmid
zh-CNChinese (China)总评分:评分:时间点:^患者:定量型:Schmid
Synonyms: Schmid(施密德、史密德)跌倒风险评估;Schmid 法 临床.风险(危险);临床风险;临床危险 全体数量 全部 共计 分值;分数;得分 分值;得分;分数 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 总 总分;总分值;总分数;总得分 总和 总数 总量 总额 时刻;随机;随意;瞬间 汇总

Example Units

UnitSource
{score}Example UCUM Units

101551-0 Schmid fall risk assessment [Interpretation]

Term Description

Total score values of 3 or above indicate patient at risk for falls and total score values of less than 3 indicate lower risk of falls.

Fully-Specified Name

Component
Schmid fall risk assessment
Property
Imp
Time
Pt
System
^Patient
Scale
Ord
Method
Schmid

Basic Attributes

Class
CLIN.RISK
Type
Clinical
First Released
Version 2.74
Last Updated
Version 2.77 (MIN)
Change Reason
Release 2.77: LONG_COMMON_NAME: removed double space;
Order vs. Observation
Observation

Normative Answer List LL6321-5

AnswerCodeScoreAnswer ID
Score of 3 or above

Patient at risk for falls

LA33633-1
Score of less than 3

Lower risk of falls

LA33634-9

Member of these Panels

LOINCLong Common Name
101549-4Schmid fall risk assessment