Version 2.80

103776-1 Breathing independent of vocalization

Fully-Specified Name

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

Long Common Name

Breathing

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.77
Last Updated
Version 2.78 (NAM)
Change Reason
Release 2.78: METHOD_TYP: Per nursing request;
Order vs. Observation
Both

Normative Answer List LL6337-1

Answer Code Score Answer ID
Normal breathing 0 LA30814-0
Occasional labored breathing 1 LA33667-9
Short period of hyperventilation 1 LA33668-7
Noisy labored breathing 2 LA33669-5
Long period of hyperventilation 2 LA33672-9
Cheyne-Stokes Copyright http://snomed.info/sct ID:309155007 Cheyne-Stokes respiration (finding) 2 LA25231-4

Member of these Panels

LOINC Long Common Name
103780-3 Pain assessment in advanced dementia PAINAD

Language Variants Get Info

Tag Language Translation
it-IT Italian (Italy) Respirazione:Osservazione:Pt:^Paziente:Ord:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 呼吸: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

103777-9 Negative vocalization

Term Description

1. None is characterized by speech or vocalization that has a neutral or pleasant quality.
2. Occasional moan or groan is characterized by mournful or murmuring sounds, wails, or laments. Groaning is characterized by louder than usual inarticulate involuntary sounds, often abruptly beginning and ending.
3. Low level speech with a negative or disapproving quality is characterized by muttering, mumbling, whining, grumbling, or swearing in a low volume with a complaining, sarcastic, or caustic tone.
4. Repeated troubled calling out is characterized by phrases or words being used over and over in a tone that suggests anxiety, uneasiness, or distress.
5. Loud moaning or groaning is characterized by mournful or murmuring sounds, wails, or laments in much louder
than usual volume. Loud groaning is characterized by louder than usual inarticulate involuntary sounds, often abruptly beginning and ending.
6. Crying is characterized by an utterance of emotion accompanied by tears. There may be sobbing or quiet weeping.

Fully-Specified Name

Component
Negative vocalization
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 LL6340-5

Answer Code Score Answer ID
None Copyright http://snomed.info/sct ID:260413007 None (qualifier value) 0 LA137-2
Occasional moan or groan 1 LA33673-7
Low level of speech with a negative or disapproving quality 1 LA33674-5
Repeated troubled calling out 2 LA33675-2
Loud moaning or groaning 2 LA33676-0
Crying 2 LA29193-2

Member of these Panels

LOINC Long Common Name
103780-3 Pain assessment in advanced dementia PAINAD

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) PAINAD.Αρνητική φώνηση:Εύρεση:Pt:^Ασθενής:Ord:
Synonyms: Εύρεση
it-IT Italian (Italy) PAINAD.Vocalizzazione negativa:Osservazione:Pt:^Paziente:Ord:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 负面发声:发现:时间点:^患者:序数型:
Synonyms: Neg 不存在的 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 反面的 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 否定的 否认的 时刻;随机;随意;瞬间 消极发声;负向发声 消极的 病史与体格检查 负性的 负的 负面的 阴 阴性（Negative，Neg）

103778-7 Facial expression

Form Coding Instructions

1. Smiling or inexpressive. Smiling is characterized by upturned corners of the mouth, brightening of the eyes, and a look of pleasure or contentment. Inexpressive refers to a neutral, at ease, relaxed, or blank look. 2. Sad is characterized by an unhappy, lonesome, sorrowful, or dejected look. There may be tears in the eyes. 3. Frightened is characterized by a look of fear, alarm, or heightened anxiety. Eyes appear wide open. 4. Frown is characterized by a downward turn of the corners of the mouth. Increased facial wrinkling in the forehead and around the mouth may appear. 5. Facial grimacing is characterized by a distorted, distressed look. The brow is more wrinkled, as is the area around the mouth. Eyes may be squeezed shut.

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 LL6341-3

Answer Code Score Answer ID
Smiling or inexpressive 0 LA33677-8
Feeling sad 1 LA33685-1
Frightened 1 LA16653-0
Frown 1 LA33691-9
Facial grimacing 2 LA33692-7

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

103779-5 Body language

Term Description

1. Relaxed is characterized by a calm, restful, mellow appearance. The person seems to be taking it easy.
2. Tense is characterized by a strained, apprehensive, or worried appearance. The jaw may be clenched. (Exclude any contractures.)
3. Distressed pacing is characterized by activity that seems unsettled. There may be a fearful, worried, or disturbed element present. The rate may be faster or slower.
4. Fidgeting is characterized by restless movement. Squirming about or wiggling in the chair may occur. The person might be hitching a chair across the room. Repetitive touching, tugging, or rubbing body parts can also be observed.
5. Rigid is characterized by stiffening of the body. The arms and/or legs are tight and inflexible. The trunk may appear straight and unyielding. (Exclude any contractures.)
6. Fists clenched is characterized by tightly closed hands. They may be opened and closed repeatedly or held tightly shut.
7. Knees pulled up is characterized by flexing the legs and drawing the knees up toward the chest. An overall troubled appearance. (Exclude any contractures.)
8. Pulling or pushing away is characterized by resistiveness upon approach or to care. The person is trying to escape by yanking or wrenching him- or herself free or shoving you away.
9. Striking out is characterized by hitting, kicking, grabbing, punching, biting, or other form of personal assault.

Fully-Specified Name

Component
Body language
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 LL6393-4

Answer Code Score Answer ID
Relaxed 0 LA32283-6
Tense 1 LA33837-8
Distressed pacing 1 LA33838-6
Fidgeting 1 LA33839-4
Rigid 2 LA25043-3
Fists clenched 2 LA33840-2
Knees pulled up 2 LA33841-0
Pulling or pushing away 2 LA33843-6
Striking out 2 LA33844-4

Member of these Panels

LOINC Long Common Name
103780-3 Pain assessment in advanced dementia PAINAD

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) PAINAD.Γλώσσα του σώματος:Εύρεση:Pt:^Ασθενής:Ord:
Synonyms: Εύρεση
it-IT Italian (Italy) PAINAD.Linguaggio del corpo:Osservazione:Pt:^Paziente:Ord:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 身体语言: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 物体 病史与体格检查 语种 身势语;肢体语言;体态语;体语

103775-3 Consolability

Term Description

1. No need to console is characterized by a sense of well-being. The person appears content.
2. Distracted or reassured by voice or touch is characterized by a disruption in the behavior when the person is
spoken to or touched. The behavior stops during the period of interaction, with no indication that the person is at all
distressed.
3. Unable to console, distract, or reassure is characterized by the inability to soothe the person or stop a behavior with
words or actions. No amount of comforting, verbal or physical, will alleviate the behavior.

Fully-Specified Name

Component
Consolability
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 2.79 (MIN)
Change Reason
Release 2.79: EXTERNAL_COPYRIGHT_LINK: Removed invalid copyright - term does not need copyright;
Order vs. Observation
Both

Normative Answer List LL6394-2

Answer Code Score Answer ID
No need to console 0 LA33845-1
Distracted or reassured by voice or touch 1 LA33846-9
Unable to console, distract, or reassure 2 LA33847-7

Member of these Panels

LOINC Long Common Name
103780-3 Pain assessment in advanced dementia PAINAD

103781-1 Total Score (0 to 10)

Fully-Specified Name

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

Long Common Name

Total score PAINAD

Basic Attributes

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

Member of these Panels

LOINC Long Common Name
103780-3 Pain assessment in advanced dementia PAINAD

Language Variants Get Info

Tag Language Translation
it-IT Italian (Italy) Punteggio totale:Punteggio:Pt:^Paziente:Qn:PAINAD
Synonyms: Anamnesi paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 总评分:评分:时间点:^患者:定量型:PAINAD
Synonyms: Pain assessment in advanced dementia;晚期老年痴呆疼痛评估;晚期老年痴呆疼痛评估量表;晚期老年痴呆症疼痛评估量表 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 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 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 病史与体格检查

Example Units

Unit Source
{score} Example UCUM Units

104532-7 Pain score interpretation

Term Description

Developers of standardized pain assessment scales often use a total score between zero and ten (0 - 10) to assess pain level. The clinician's interpretation of the score is rarely included in the standardized assessment scale. This reusable pain scale score interpretation can be used in conjunction with the developer's pain assessment scale when the developer (or designated clinical subject matter expert) validates the answer list meaning is an exact match.

Fully-Specified Name

Component
Pain score interpretation
Property
Imp
Time
Pt
System
^Patient
Scale
Nom
Method
PAINAD

Long Common Name

Pain score interpretation PAINAD

Basic Attributes

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

Example Answer List LL6562-4

Answer Code Score Answer ID
No pain 0 LA131-5
Mild pain 1-3 LA15111-0
Moderate pain 4-6 LA135-6
Severe pain 7-10 LA15109-4

Member of these Panels

LOINC Long Common Name
103780-3 Pain assessment in advanced dementia PAINAD

Language Variants Get Info

Tag Language Translation
it-IT Italian (Italy) Punteggio del dolore, interpretazione:Imp:Pt:^Paziente:Nom:PAINAD
Synonyms: Anamnesi Impressione/interpretazione di studio Interpretazione del punteggio del dolore paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 疼痛评分解释:印象:时间点:^患者:名义型:PAINAD
Synonyms: Pain assessment in advanced dementia;晚期老年痴呆疼痛评估;晚期老年痴呆疼痛评估量表;晚期老年痴呆症疼痛评估量表 分值;分数;得分 分值解释;分数解释;得分解释;总分解释;总评分解释;总分值解释;总分数解释;总得分解释;评分总体解释 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 判读;解释说明;说明;释义;阐明 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 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 时刻;随机;随意;瞬间 疼;痛;痛苦;悲痛;苦恼 疼痛评分（分值、得分、分数） 疼痛评分（分值、得分、分数、打分）解释（说明） 病史与体格检查