Score and Assessment Systems |
Author: | Null |
Address: | |
Original Work: | Null |
Coypright: |
unknown |
Trademark: |
unknown |
Explanation: | |
HL7 v2.x datatype: | |
HL7 V3 datatype: |
Interpretation must be defined!
Comp. | Decription | Bezeichnung | Code System: Codes/ Score Value |
Details / Score Range |
/ Units |
HL7 DT v2 + V3 | / Snomed CT |
---|---|---|---|---|---|---|---|
1 | Age |
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1 | <60 - | NM + INT | |||||
2 | 70 - 61 | NM + INT | |||||
4 | - >71 | NM + INT | |||||
2 | cardiac signs |
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no failure | 1 | - | NM + INT | ||||
diuretic, digoxin, anti-anginal or anti- hypertensive | 2 | - | NM + INT | ||||
periphereal oedema, borderline cardiomegaly | 4 | - | NM + INT | ||||
raised jugular venous pressure or cardiomegaly | 8 | - | NM + INT | ||||
3 | Physical Findings |
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no dyspnoea | 1 | - | NM + INT | ||||
dyspnoea on exertion | 2 | - | NM + INT | ||||
limiting dyspnoea, moderate COPD | 4 | - | NM + INT | ||||
dyspnoea at rest, (F>30%) or fibrosis or consilidation | 8 | - | NM + INT | ||||
4 | intravascular systolic |
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1 | 130 - 110 | NM + INT | |||||
100-109 | 2 | - | NM + INT | ||||
90-99 | 4 | - | NM + INT | ||||
8 | <90 - | NM + INT | |||||
131-170 | - | NM + INT | |||||
>171 | - | NM + INT | |||||
5 | heart rate |
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1 | 80 - 50 | NM + INT | |||||
40-49 | 2 | - | NM + INT | ||||
4 | 120 - 101 | NM + INT | |||||
<40 | 8 | - | NM + INT | ||||
81-100 | - | NM + INT | |||||
>121 | - | NM + INT | |||||
6 | Glasgow coma scale |
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1 | 15 - 15 | NM + INT | |||||
2 | 14 - 12 | NM + INT | |||||
4 | 11 - 9 | NM + INT | |||||
8 | <8 - | NM + INT | |||||
7 | Hemoglobin |
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1 | 16 - 13 | NM + INT | |||||
16,1- 17 | 2 | - | NM + INT | ||||
17,1- 18 | 4 | - | NM + INT | ||||
>18,1 | 8 | - | NM + INT | ||||
11,5- 12,9 | - | NM + INT | |||||
10- 11,4 | - | NM + INT | |||||
<9,9 | - | NM + INT | |||||
8 | Leukocytes |
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4-10 | 1 | - | NM + INT | ||||
3,1- 4 | 2 | - | NM + INT | ||||
<3 | 4 | - | NM + INT | ||||
10,1- 20 | - | NM + INT | |||||
>20,1 | - | NM + INT | |||||
9 | Urea |
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<7,5 | 1 | - | NM + INT | ||||
7,6- 10 | 2 | - | NM + INT | ||||
10,1- 15 | 4 | - | NM + INT | ||||
>15 | 8 | - | NM + INT | ||||
10 | Sodium | ||||||
>136 | 1 | - | NM + INT | ||||
131-135 | 2 | - | NM + INT | ||||
126-130 | 4 | - | NM + INT | ||||
<125 | 8 | - | NM + INT | ||||
11 | Potassium | ||||||
3,5-5 | 1 | - | NM + INT | ||||
5,1-5,3 | 2 | - | NM + INT | ||||
5,4- 5,9 | 4 | - | NM + INT | ||||
>6 | 8 | - | NM + INT | ||||
3,2- 3,4 | - | NM + INT | |||||
2,9- 3,1 | - | NM + INT | |||||
<2,8 | - | NM + INT | |||||
12 | ECG | ||||||
normal | 1 | - | NM + INT | ||||
atrial fibrillation (rate 60-90/min) | 4 | - | NM + INT | ||||
any abnormal rhythm, >ectopics/min, Q waves or ST/T wave changes | 8 | - | NM + INT | ||||
13 | Possum score.physiological |
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14 | operative severity |
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minor | 1 | - | NM + INT | ||||
moderate (cholecystectomy, appendectoma, mastectomy, transurethral resection of prostate | 2 | - | NM + INT | ||||
major (any labarotomy, bowel resection, cholecystectomy with choledochotomy, peripheral vascular procedure or major amputation) | 4 | - | NM + INT | ||||
major+ (any aortic procedure, abdominoperineal resection pancreatic or liver resection, oesophagogastrectomy) | 8 | - | NM + INT | ||||
15 | procedures |
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1 | 1 - 1 | NM + INT | |||||
4 | 2 - 2 | NM + INT | |||||
8 | - >2 | NM + INT | |||||
16 | Blood loss.total |
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1 | <100 - | NM + INT | |||||
2 | 500 - 101 | NM + INT | |||||
4 | 999 - 501 | NM + INT | |||||
8 | - >999 | NM + INT | |||||
17 | Contamination |
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none | 1 | - | NM + INT | ||||
minor (serous fluid) | 2 | - | NM + INT | ||||
local plus | 4 | - | NM + INT | ||||
free bowl content, pus or blood | 8 | - | NM + INT | ||||
18 | metastatic cancer |
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none | 1 | - | NM + INT | ||||
primary only | 2 | - | NM + INT | ||||
nodal metastases | 4 | - | NM + INT | ||||
distant metastases | 8 | - | NM + INT | ||||
19 | Type of surgery |
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elective | 1 | - | NM + INT | ||||
emergenvy resus >2h or possible op <24h after admission | 4 | - | NM + INT | ||||
emergency surgery <2h needed | 8 | - | NM + INT | ||||
20 | possum score.operativ |
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21 | possum score.total |
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TOTAL SCORE |
The primary purpose of the information provided above is to enhance interoperability. The primary focus lies on the assigned codes.
Therefore, no guarantee can be given whether the use of the score or assessment system is allowed or not.
It is highly recommended to check with the author directly.
We are aware that the presented information may be not enough in order to work with it.
The authors have done their best to ensure copyright and other jurisdictional requirements.