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.

TID 3114 Patient Assessment Type: Extensible Order: Significant

NL Relation with Parent Value Type 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”) or DT (PA-00500, SRT, “Observation of Vital Signs”)
2 > HAS PROPERTIES INCLUDE TID (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) $Method = BCID (3560) Blood Pressure Methods
3 > HAS PROPERTIES INCLUDE TID (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)
4 > HAS PROPERTIES INCLUDE TID (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 TID (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 TID (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 TID (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 TID (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 TID (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, “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.