Version 2.80

103778-7 Facial expression

Form Coding Instructions

New "Facial expression" that is reusable Score of 0: Relaxed muscles--Restful face, neutral expression Score of 1: Grimace--Tight facial muscles, furrowed brow; chin, and jaw (negative facial expressions - nose, mouth, and brow)

Source: Nursing Knowledge Big Data Science Encoding-Modeling Workgroup

Fully-Specified Name

Component
Facial expression
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.77
Last Updated
Version 2.78 (NAM)
Order vs. Observation
Both

Normative Answer List LL6344-7

Answer Code Score Answer ID
Relaxed muscles--restful face, neutral expression LA33694-3 0 LA33694-3
Grimace--tight facial muscles, furrowed brow; chin, and jaw (negative facial expressions - nose, mouth, and brow) LA33695-0 1 LA33695-0

Member of these Panels

LOINC Long Common Name
101967-8 Neonatal infant pain scale panel (NIPS)
103780-3 Pain assessment in advanced dementia PAINAD

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Έκφραση προσώπου:Εύρεση:Pt:^Ασθενής:Ord:
Synonyms: Εύρεση
it-IT Italian (Italy) Espressione del viso:Osservazione:Pt:^Paziente:Ord:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Лица выражение:Находка:ТчкВрм:^Пациент:Пор:
Synonyms: Порядковый Точка во времени;Момент
zh-CN Chinese (China) 面部表情: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 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.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 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 病史与体格检查 脸部表情;表情

101971-0 Cry

Fully-Specified Name

Component
Cry
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.75
Last Updated
Version 2.76 (MAJ)
Order vs. Observation
Observation

Normative Answer List LL6345-4

Answer Code Score Answer ID
No cry 0 LA32300-8
Whimper 1 LA32301-6
Vigorous cry 2 LA32302-4

Member of these Panels

LOINC Long Common Name
101967-8 Neonatal infant pain scale panel (NIPS)

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Κλάμα:Εύρεση:Pt:^Ασθενής:Ord:
Synonyms: Εύρεση
it-IT Italian (Italy) Pianto:Osservazione:Pt:^Paziente:Ord:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 哭啼: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 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.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 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 病史与体格检查

101970-2 Breathing patterns

Term Description

New "Breathing Pattern" that is reusable Score of 0: Relaxed--Usual pattern for this baby
Score of 1: Change in breathing--Indrawing, irregular, faster than usual, gagging, breath holding

Fully-Specified Name

Component
Breathing patterns
Property
Find
Time
Pt
System
Respiratory
Scale
Ord
Method

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.75
Last Updated
Version 2.76 (MAJ)
Order vs. Observation
Observation

Normative Answer List LL5947-8

Answer Code Score Answer ID
Relaxed 0 LA32283-6
Change in breathing 1 LA33706-5

Member of these Panels

LOINC Long Common Name
101967-8 Neonatal infant pain scale panel (NIPS)

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Αναπνευστικά μοτίβα:Εύρεση:Pt:Αναπνευστικό:Ord:
Synonyms: Εύρεση
it-IT Italian (Italy) Modelli di respirazione:Osservazione:Pt:Respiratorio:Ord:
Synonyms: Anamnesi Osservazione Punto nel tempo (episodio)
zh-CN Chinese (China) 呼吸模式:发现:时间点:呼吸道: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 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 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 呼吸道标本（样品、样本）;呼吸系统标本（样品、样本） 时刻;随机;随意;瞬间 病史与体格检查

101972-8 State of arousal

Term Description

Score of 0: Sleeping/Awake--Quiet, peaceful, sleeping or alert and settles
Score of 1: Fussy--Alert, restless, and thrashing

Fully-Specified Name

Component
State of arousal
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.75
Last Updated
Version 2.76 (MAJ)
Order vs. Observation
Observation

Normative Answer List LL5952-8

Answer Code Score Answer ID
Sleeping 0 LA11864-8
Awake 0 LA33709-9
Fussy 1 LA33710-7

Member of these Panels

LOINC Long Common Name
101967-8 Neonatal infant pain scale panel (NIPS)

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Κατάσταση διέγερσης:Εύρεση:Pt:^Ασθενής:Ord:
Synonyms: Εύρεση
it-IT Italian (Italy) Stato di eccitazione:Osservazione:Pt:^Paziente:Ord:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 觉醒状态: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 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.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 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 州;邦;政府;国家;状况;情况 时刻;随机;随意;瞬间 病史与体格检查

101974-4 Arms

Term Description

Score of 0: Relaxed/Restrained--No muscular rigidity occasional random movements of arms
Score of 1: Flexed/Extended--Tense, straight arms, rigid and/or rapid extension, flexion

Fully-Specified Name

Component
Arms
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
NIPS

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.75
Last Updated
Version 2.76 (MAJ)
Order vs. Observation
Observation

Normative Answer List LL6348-8

Answer Code Score Answer ID
Restrained 0 LA32285-1
Relaxed 0 LA32283-6
Flexed 1 LA33707-3
Extended 1 LA33708-1

Member of these Panels

LOINC Long Common Name
101967-8 Neonatal infant pain scale panel (NIPS)

101975-1 Legs

Fully-Specified Name

Component
Legs
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
NIPS

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.75
Last Updated
Version 2.76 (MAJ)
Order vs. Observation
Observation

Normative Answer List LL6342-1

Answer Code Score Answer ID
Relaxed/Restrained 0 LA33757-8
Flexed/Extended 1 LA33758-6

Member of these Panels

LOINC Long Common Name
101967-8 Neonatal infant pain scale panel (NIPS)

101973-6 Total score (0 to 7)

Term Description

Total score is the sum of points for the 6 parameters; the sum will be a minimum of zero (0) and a maximum of seven (7).

Fully-Specified Name

Component
Total score (0 to 7)
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.75
Last Updated
Version 2.76 (MAJ)
Order vs. Observation
Observation

Normative Answer List LL6349-6

Answer Code Score Answer ID
Sum the scores for the 6 observations LL6349-6 LA33711-5

Member of these Panels

LOINC Long Common Name
101967-8 Neonatal infant pain scale panel (NIPS)

101951-2 NIPS assessment (interpretation)

Term Description

Interpretation of the total score:
Score 0 = no pain.
Score 1-3 = mild pain
Score 4-5 = moderate pain
Score 6-7 = severe pain
Limitation: A falsely low score may be seen in an infant who is too premature, ill to respond, or who is vented and receiving a paralyzing agent.

Fully-Specified Name

Component
NIPS Assessment
Property
Imp
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.75
Last Updated
Version 2.76 (NAM)
Order vs. Observation
Observation

Normative Answer List LL5953-6

Answer Code Score Answer ID
No pain LA131-5
Mild pain LA15111-0
Moderate pain LA135-6
Severe pain LA15109-4

Member of these Panels

LOINC Long Common Name
101967-8 Neonatal infant pain scale panel (NIPS)