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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

AnswerCodeScoreAnswer ID
Relaxed muscles--restful face, neutral expression

Relaxed

LA33694-30LA33694-3
Grimace--tight facial muscles, furrowed brow; chin, and jaw (negative facial expressions - nose, mouth, and brow)

Grimace

LA33695-01LA33695-0

Member of these Panels

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

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Έκφραση προσώπου:Εύρεση:Pt:^Ασθενής:Ord:
Synonyms: - H&P.HX Ord Pt Ασθενής Έκφραση προσώπου Εύρεση
it-ITItalian (Italy)Espressione del viso:Osservazione:Pt:^Paziente:Ord:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
ru-RURussian (Russian Federation)Лица выражение:Находка:ТчкВрм:^Пациент:Пор:
Synonyms: Порядковый Точка во времени;Момент
zh-CNChinese (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

AnswerCodeScoreAnswer ID
No cry

0 = No cry--quiet, not crying

0LA32300-8
Whimper

1 = Whimper--mild moaning, intermittent

1LA32301-6
Vigorous cry

2 = Vigorous Cry--loud scream, rising, shrill, continuous (Note: Silent cry may be scored if baby is intubated as evidence by obvious mouth facial movements)

2LA32302-4

Member of these Panels

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

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Κλάμα:Εύρεση:Pt:^Ασθενής:Ord:
Synonyms: - H&P.HX Ord Pt Ασθενής Εύρεση Κλάμα
it-ITItalian (Italy)Pianto:Osservazione:Pt:^Paziente:Ord:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
zh-CNChinese (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

AnswerCodeScoreAnswer ID
Relaxed

0 = Relaxed--usual pattern for this baby

0LA32283-6
Change in breathing

1 = Change in breathing--Indrawing, irregular, faster than usual, gagging, breath holding

1LA33706-5

Member of these Panels

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

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Αναπνευστικά μοτίβα:Εύρεση:Pt:Αναπνευστικό:Ord:
Synonyms: H&P.HX Ord Pt Αναπνευστικά μοτίβα Αναπνευστικό Αναπνοή Εύρεση
it-ITItalian (Italy)Modelli di respirazione:Osservazione:Pt:Respiratorio:Ord:
Synonyms: Anamnesi Osservazione Punto nel tempo (episodio)
zh-CNChinese (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

AnswerCodeScoreAnswer ID
Sleeping

Score of 0: Sleeping/Awake--Quiet, peaceful, sleeping or alert and settles

0LA11864-8
Awake

0 = Awake--alert and settled

0LA33709-9
Fussy

1 = Fussy--alert, restless, and thrashing

1LA33710-7

Member of these Panels

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

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Κατάσταση διέγερσης:Εύρεση:Pt:^Ασθενής:Ord:
Synonyms: - H&P.HX Ord Pt Ασθενής Εύρεση Κατάσταση Κατάσταση διέγερσης
it-ITItalian (Italy)Stato di eccitazione:Osservazione:Pt:^Paziente:Ord:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
zh-CNChinese (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

AnswerCodeScoreAnswer ID
Restrained

0 = Restrained--no muscular rigidity occasional random movements of arms

0LA32285-1
Relaxed

0 = Relaxed--no muscular rigidity occasional random movements of arms

0LA32283-6
Flexed

1 = Flexed--tense, straight arms, rigid and/or rapid extension, flexion

1LA33707-3
Extended

1 = Extended--tense, straight arms, rigid and/or rapid extension, flexion

1LA33708-1

Member of these Panels

LOINCLong Common Name
101967-8Neonatal 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

AnswerCodeScoreAnswer ID
Relaxed/Restrained

No muscular rigidity occasional random leg movements

0LA33757-8
Flexed/Extended

Tense, straight legs, rigid and/or rapid extension, flexion

1LA33758-6

Member of these Panels

LOINCLong Common Name
101967-8Neonatal 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

AnswerCodeScoreAnswer ID
Sum the scores for the 6 observationsLL6349-6LA33711-5

Member of these Panels

LOINCLong Common Name
101967-8Neonatal 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

AnswerCodeScoreAnswer ID
No pain

0 No pain

LA131-5
Mild pain

1-3 Mild pain

LA15111-0
Moderate pain

4-5 Moderate pain

LA135-6
Severe pain

6-7 Severe pain

LA15109-4

Member of these Panels

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