Standard Health Record FHIR Implementation Guide

Profiles defined as part of this Guide

SHR Namespace Name Based On Definition
Adverse AdverseEvent AdverseEvent Any unfavorable and unintended sign, symptom, disease, or other medical occurrence with a temporal association with the use of a medical product, procedure or other therapy, or in conjunction with a research study, regardless of causal relationship. EXAMPLE(S): back pain, headache, pulmonary embolism, death. The AdverseEvent may also document a causal relationship to an intervention is at least a reasonable possibility i.e., the relationship cannot be ruled out.
Adverse NoAdverseEvent Observation Documentation of a situation where no adverse event has been detected or is known.
Adverse ToxicReaction AdverseEvent A grade 3 or 4 adverse reaction to medication, radiation treatment, or other therapy.
Allergy AllergyIntolerance AllergyIntolerance A finding related to the presence or absence of an individual's risk or sensitivity to a substance or class of substances. A finding can be taken as tantamount to a representation of an allergic condition, allowing it to be tracked over time.
Allergy NoAllergyToSubstance Observation Used to record that a particular substance or class of substances does not pose a known elevated risk to the subject. NoAllergyToSubstance is not an assertion because the value (a code representing a substance) does not carry the complete meaning.
Allergy NoKnownAllergy Observation Express no known allergies to broad classes: anything, animals, drugs, foods, or environmental factors. NoKnownAllergy is an assertion because the code, such as 'No known food allergy' carries the complete meaning.
Base Entry DomainResource Metadata attributes that apply to any item represented in the standard health record. An Entry may not belong exclusively to a single person's health record, but could represent an entity that surfaces in multiple records, such as organizations or practitioners. If the entry belongs to a single person's record, then the identity of the person of record must be recorded.
Behavior AlcoholBingeFrequency Observation How often have you had 6 or more Units if female, or 8 or more if male, on a single occasion in the last year?.
Behavior AlcoholUse Observation The subject's current or past use of alcohol.
Behavior BehavioralFinding Observation A statement about observable responses, actions, or activities of the subject. Can be used to assert or deny behaviors.
Behavior DietFollowed Observation A type of nutritional plan followed by the subject.
Behavior DietNutritionConcern Observation An anxiety or worry about the diet or nutritional intake of the subject.
Behavior ExerciseHoursPerWeek Observation Hours of moderate or vigorous activity per week.
Behavior HasSufficientFood Observation Frequency that the person of record unable to obtain food to stay hunger.
Behavior HoursSleepPerNight Observation Typical hours spent sleeping per night.
Behavior IntravenousDrugUse Observation Records whether the subject injects recreational drugs.
Behavior NicotineUse Observation The subject's current or past use of nicotine.
Behavior ONCSmokingStatus Observation Records the extent of the subject's use of tobacco.
Behavior PhysicalActivityLevel Observation The amount of exercise or other physical activity compared to others of the same age. See BMC Medical Research Methodology 2012 12:20 1471-2288.
Behavior PhysicalActivityLimitation Observation Anything that limits physical activity, including health factors, logistical, monetary, or social restrictions.
Behavior PhysicalActivityPanel Observation Questions related to physical activity.
Behavior Religion Observation The affiliation of the person with a recognized religious group.
Behavior ReligiousCongregation Observation A group of place of religious practice.
Behavior ReligiousPracticeStatus Observation The extent to which the religious practice is actively followed.
Behavior ReligiousRestriction Observation Any restriction on that derives from religion and may impact medical treatment, other than dietary (handled elsewhere).
Behavior SleepQualityCause Observation Reason for poor sleep quality.
Behavior SleepQualityPanel Observation Self-reported sleep quality.
Behavior SubstanceAbuseTreatment Procedure The treatment program used to address a substance abuse problem.
Behavior SubstanceUse Observation Assertion concerning the past or current use of a substance (alcohol, recreational drugs, illegal drugs, or abuse of prescription medication) that could negatively impact the subject's health.
Behavior TroubleFallingAsleep Observation How often the subject has trouble falling asleep.
Behavior TroubleStayingAsleep Observation How often the subject has trouble staying asleep.
Behavior ViolentRiskToOthers Observation Risk or danger posed by the focal subject to others.
Behavior ViolentRiskToSelf Observation Risk or danger posed by the focal subject to his or herself.
Behavior WakeFeelingRested Observation How often the subject feels rested when they wake up.
Careplan CarePlan Basic Describes how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.
Careplan CareTeam Basic Planned participants in the coordination and delivery of care for a patient or group.
Careplan Goal Basic A broad statement about what should be accomplished for or by a patient or other subject. It represents the intended long-term outcome toward which an individual or a group aspires, and toward which, effort is directed, in the form of activities.
Condition AcademicProblem Condition A problem with learning or behavior in a learning environment.
Condition Condition Condition A disorder, abnormality, problem, injury, complaint, risk, functionality, concern, illness, disease, ailment, sickness, affliction, upset, difficulty, disorder, symptom, worry, or trouble. A ConditionPresent finding implies the existence of a condition as an entity. 'Condition' is interpreted broadly to cover states of existence - things the patient is or has.
Condition ConditionAbsent Observation A finding that a condition is or was not present in the subject at a certain time, not necessarily the time the information is gathered.
Condition DiseaseProgression Observation A finding related to the current trend of a disease. This concept is most often used for chronic and incurable diseases where the status and trendline of the disease is an important determinant of therapy and prognosis. The specific disorder being evaluated must be cited in the AssessmentFocus as a reference to a Condition.
Condition Injury Condition Damage inflicted on the body by an external force.
Condition MentalHealthCondition Condition A condition relating to a person’s psychological and emotional well-being.
Core Address Address An address expressed using postal conventions (as opposed to GPS or other location definition formats). This data type may be used to convey addresses for use in delivering mail as well as for visiting locations and which might not be valid for mail delivery. There are a variety of postal address formats defined around the world. (Source: HL7 FHIR).
Core Age Age How long something has existed in time.
Core Annotation Annotation An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
Core ContactDetail ContactDetail Describes an individual and how to reach them.
Core ContactPoint ContactPoint An electronic means of contacting an organization or individual.
Core Distance Distance The measure of space separating two objects or points.
Core Duration Duration The length of time that something continues.
Core Frequency Ratio How many occurrences of an event per unit of time.
Core Geoposition Location The location on the surface of the Earth, described by a latitude and longitude (and optional altitude).
Core GestationalAge Age The age of the embryo or fetus. This may be assessed by medical history, physical examination, early immunologic pregnancy tests, radiography, ultrasonography, and amniotic fluid analysis.
Core HumanName HumanName A name used by a human being, written as it would be typically expressed. May include a breakdown of the various elements of the name (family name, given name, etc.).
Core Identifier Identifier A unique string that identifies a specific person or thing.
Core IntegerQuantity Quantity A Quantity that is an integer.
Core Money Money Representation of an amount of currency or monetary value.
Core OrganizationalIdentifier Identifier A code identifying a specific organization. The NPI should be provided, if available. Other business identifiers, such employer tax ID, or MVX code for vaccine manufacturers, should also be provided.
Core Qount Count The whole number of items, as a unit-bearing quantity.
Core Quantity Quantity A quantity with units, whose value may be bounded from above or below, as defined in FHIR
Core Range Range An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
Core Ratio Ratio A unit of measurement for the quotient of the amount of one entity to another.
Core SampledData SampledData Data that comes from a series of measurements taken by a device, which may have upper and lower limits. The data type also supports more than one dimension in the data.
Core Signature Signature A digital Signature - XML DigSig, JWT, Graphical image of signature, etc.
Core SimpleQuantity Quantity A quantity where the comparator is not used, as defined in FHIR
Core Statistic Quantity A quantity that represents a statistic, e.g. maximum, minimum, mean, median, etc.
Core Timing Timing A timing schedule that specifies an event that may occur multiple times. Timing offers a choice of multiple OccurrenceTime (used is used to specify specific times), or recurrence patterns.
Core UnitedStatesAddress Address An address for a place in the USA, conforming to US mail postal conventions. (Source: HL7 FHIR).
Device Device Device A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Device DeviceNotUsed Basic A record of a device not used by a patient, for example, no stent implanted.
Device DeviceUsed Basic A record of the use of a device by a patient.
Encounter Encounter Basic A description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient, independent of the context of requested, planned, performed, etc.
Encounter EncounterNotPerformed Basic
Encounter EncounterPerformed Encounter
Encounter EncounterRequested Basic
Entity BodySite BodySite A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
Entity Facility Location Services and space and equipment provided for a particular purpose; a building or place that provides a particular service or is used for a particular industry. Could be a clinical site, community site, or a mobile facility.
Entity Group Group A set of entities (personnel, material, or places) to be considered together. May be a pool of like-type resources, a team, or combination of personnel, material and places.
Entity Medication Medication A type of prescription drug or over-the-counter drug that is used to prevent, treat, or relieve symptoms of a disease or abnormal condition, but excluding vaccines.
Entity NationalProviderIdentifier Identifier A unique 10-digit number to allow US healthcare providers to identify themselves in a standard way throughout the healthcare industry.
Entity Organization Organization A social or legal structure formed by human beings.
Entity OrganizationIdentifier Identifier An identifier of the organization. An NPI preferred, tax id is allowed, and a local id is allowed in addition to ‘authoritative’ identifier
Entity Patient Patient A person in the role of a patient, including extended demographic information about the subject of this health record.
Entity Person Basic A person relevant to the health or social situation of the subject (including the person of record him or herself).
Entity Practitioner Practitioner A person who practices a healing art.
Entity RelatedPerson RelatedPerson A person in a role defined in relationship to a patient
Entity RelationshipType Basic The relationship of the subject to another person in the same extended family or extended family. May or may not be a blood relative.
Entity Specimen Specimen Sample for analysis
Entity SpecimenContainer Basic Direct container of specimen (tube/slide, etc.)
Entity SpecimenTreatment Procedure Treatment performed on the specimen.
Entity Substance Substance Any matter of defined composition that has discrete existence, whose origin may be biological, mineral or chemical.
Environment AnimalExposure Observation The type of animals or pets the subject is exposed to.
Environment AnnualIncome Observation The amount of earnings made by a family unit in one year, estimated or self-reported.
Environment CanAffordChildCare Observation How often can the subject afford child care?
Environment CanAffordClothing Observation How often can the subject afford clothing?
Environment CanAffordDentalCare Observation How often can the subject afford dental care?
Environment CanAffordFood Observation How often can the subject afford food?
Environment CanAffordHousing Observation How often can the subject afford housing?
Environment CanAffordMedication Observation How often can the subject afford medications?
Environment CanAffordTransportation Observation How often can the subject afford transportation?
Environment CanAffordUtilities Observation How often can the subject afford utilities?
Environment Coinhabitant Observation A person living with the subject.
Environment DomesticViolence Observation Whether the subject experiences domestic violence.
Environment EmotionalSafety Observation Whether the subject feels physically safe in the subject's home environment.
Environment ExposureToAgent Observation Documentation of exposure to a substance, type of substance, or disease vector potentially affecting health, including blood products, farm animals or pets, recreational drugs, sexual transmitted diseases, foods, toxins, pathogens, noise, radiation, pollutants, or prenatal exposures to teratogens. Can be used to deny such exposures via the NegationFlag.
Environment FinancialSituationPanel Observation Measures of the ability of the subject to obtain and pay for the necessities of life.
Environment HomeEnvironmentRisk Observation A risk experienced in the home environment.
Environment HouseholdSituationPanel Observation Information about the makeup of the household of the subject.
Environment HouseholdSize Observation The number of people living together with mutual financial dependency. Besides the subject, the household size may include spouse or partner, dependent children including adopted and foster children, dependent parents, dependent siblings and other relatives, but not roommates, ex-spouses, non-dependent children, and unborn children. If the subject lives alone, the household size is 1.
Environment HousingSecurity Observation Whether the subject is at-risk of losing their housing or in a stable housing situation.
Environment IncomeSource Observation Where the household income comes from.
Environment IncomeStability Observation Whether the subject regards his or her source of income as dependable.
Environment NonCashBenefit Observation Government benefits received by the focal subject, other than cash benefits.
Environment NumberOfDependents Observation The number of dependents supported by the subject.
Environment PhysicalSafety Observation How often the subject feels physically safe in the subject's home environment.
Environment SocialEnvironment Observation Factors affecting the health of the subject in their daily living environment.
Environment TransportationAvailability Observation Whether the subject has reliable transportation to bring him or her to medical appointments and to get medications.
Familyhistory FamilyMemberCondition Condition A condition of a person related to the person of record.
Familyhistory FamilyMemberConditionAbsent Observation A condition of a person related to the person of record.
Financial Coverage Coverage Health insurance coverage available (even if not used for payment for a given encounter).
Finding Assertion Observation A unary observation, also known as an assertion, is an observation that takes the form of a single code, without an explicit question or property. Examples include reported symptoms such as 'chest pain' and facts such as 'patient bed in low position'. Assertions may be negated setting the NegationFlag to true. The ObservationCode is defaulted to 'assertion' since assertions have no explicit question. Assertions cannot have a ValueAbsentReason, because Assertions without the asserted value are meaningless.
Finding BodyStructureAbsent Observation Absence of distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. The observation has a body site that allows the the structure to be located in the body. The observation identifier allows other observations of the same body structure to be related to QualitativeValueScaleVSthis observation and tracked over time.
Finding BodyStructurePresent Observation Presence of a distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. Body structures are continuants that allow observations of the same body structure to be related to be tracked over time.
Finding Observation Observation Base class for observations (measurements, tests, or questions) and a value containing the result (answer). The subject of a finding can be the entire patient, or an entity such as a location body structure, intervention, or condition. Things observed about the subject can include social and behavioral factors, subjective and objective observations, and assessments.
Finding QuestionAnswer Observation A simplified observation consisting of a question-answer pair. The question is identified by the ObservationCode, and the answer (if given) is in Value. If the answer is missing, the ValueAbsentReason must be provided.
Immunization ImmunizationGiven Immunization A vaccination that was administered to the subject.
Immunization ImmunizationNotGiven Immunization An immunization that was not given to the subject.
Immunization ImmunizationRequested Basic An immunization that is proposed or planned for the subject.
Immunization ImmunizationRequestedAgainst Basic An immunization that is specifically not recommended, perhaps contraindicated for the individual.
Lifehistory CongenitalAbnormality Condition Any abnormality, genetic, anatomical, biochemical, evident at birth or during the neonatal period. Includes malformations, deformations, and chromosomal abnormalities.
Lifehistory EducationalAttainment Observation Educational attainment or level of education of individuals.
Lifehistory Employment Observation Engagement in an activity or service for profit, wages, salary, or as a service to others.
Lifehistory EmploymentStatus Observation Condition of employment including full- or part-time, temporary or permanent, and unemployment.
Lifehistory MilitaryBranch Observation The branch of the US military that the subject has served.
Lifehistory MilitaryService Observation History of service in the US military.
Lifehistory MilitaryServiceDischargeStatus Observation How the subject was formally discharged from the US Military.
Lifehistory MilitaryServiceEra Observation The time period of US military service.
Lifehistory MilitaryStatus Observation The current connection to the US military.
Lifehistory Occupation Observation The principal activity that a person does to earn money, specifying the job performed by the subject, for example, accountant, programmer analyst, patient care associate, staff nurse, etc.
Lifehistory PrenatalExposure Observation Fetal contact with a dangerous substance via the mother.
Lifehistory ServiceConnectedDisability Observation Percentage disability resulting from US Military Service.
Lifehistory Travel Observation Trip to a foreign country or an area, particularly when a health risk is involved.
Medication Adherence Observation The degree (frequency) that the stated treatment plan, prescription, or protocol was followed. A statement of the ability and cooperation of the patient in taking medicine or supplement as recommended or prescribed. This includes correct timing, dosage, and frequency.
Medication Dosage Dosage The dosage of the medication, prescribed or taken.
Medication MedicationChange Basic Description of a modification or change of a medication or dosage.
Medication MedicationDispenseAction Basic The action of ordering and deliving a medication to the party responsible for administering the medication.
Medication MedicationNotRequested Basic A record of a medication NOT prescribed. Recorded only when deviating from the normal expectation, care plan, or standard of care.
Medication MedicationNotUsed MedicationStatement A record of a medication NOT used. Although usually not required, a medication not used is sometimes reported when deviating from normal expectation or care plan.
Medication MedicationRequested MedicationRequest An order for a medication to be dispensed and instructions for use.
Medication MedicationUsed MedicationStatement A record of the use of a medication.
Oncology BRCA1Variant Observation Whether the patient has a mutation in the BRCA1 gene.
Oncology BRCA2Variant Observation Whether the patient has a mutation in the BRCA2 gene.
Oncology BreastCancer Condition Finding or diagnosis of cancer originating in the tissues of the breast, and potentially spread to other organs of the body.
Oncology BreastCancerBiomarkerPanel Observation Immunohistochemistry (IHC) assessment for estrogen receptor (ER) and progesterone receptor (PR) as well as IHC or in situ hybridization (ISH) determination of human epidermal growth factor receptor 2 (HER2) status
Oncology BreastCancerGeneticAnalysisPanel Observation The status of genes known or suspected to play a role in breast cancer risk, for example, the tumor suppressor genes, BRCA1 and BRCA2.
Oncology EstrogenReceptorStatus Observation Estrogen receptor alpha is the predominant estrogen receptor expressed in breast tissue and is overexpressed in around 50% of breast carcinomas. ER status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.
Oncology GeneticVariant Observation Whether a subject carries a mutation in a particular gene.
Oncology HER2ReceptorStatus Observation HER2 receptor status. HER2 is a member of the human epidermal growth factor receptor family of proteins and is encoded by the ERBB2 oncogene. HER2 is overexpressed in 20-30% of breast tumors,10 and is associated with an aggressive clinical course and poor prognosis. HER2 status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.
Oncology HER2byImmunohistochemistry Observation HER2 status as determined by Immunohistochemistry (IHC)
Oncology HER2byInSituHybridization Observation HER2 status as determined by In Situ HybridizationISH.
Oncology HistologicGrade Observation The Elston Grade/Nottingham Score, representative of the aggressive potential of the tumor. Well differentiated (Grade 1) look similar to normal cells and are usually slow growing, while poorly differentiated cells (Grade 3) look very different than normal and are fast-growing.
Oncology Ki Ki-67LabelingIndex Observation Ki-67 is a protein phosphatase whose expression is strongly associated with cell proliferation and encoded by the MKI67 gene. The Ki67 labeling index is the fraction of Ki-67-positive cells to total cells in a tumor specimen and may be useful for determining prognosis with respect to survival and disease recurrence. The more positive cells there are, the more quickly they are dividing and forming new cells. ReferenceRange: Low <10, Intermediate 10-20, >20 High
Oncology LymphaticInvolvement Observation Description of lymph nodes contain cancer cells.
Oncology ProgesteroneReceptorStatus Observation Progesterone receptor is expressed in 65% of breast carcinomas. PR status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.
Oncology S S-PhaseFraction Observation An expression of the number of mitoses found in a stated number of cells. The S-phase fraction number tells you what percentage of cells in the tissue sample are in the process of copying their genetic information (DNA). This S-phase, short for synthesis phase, happens just before a cell divides into two new cells. ReferenceRange: Low <6, Intermediate 6-10, >10 High.
Oncology TNMStage Observation The stage of a cancer, assessed according to the standard established by American Joint Committee on Cancer (AJCC). TNM Stage Grouping categorizes the progression of cancer using the Roman Numeral system. See Table 140 in HL7 CDA® R2 Implementation Guide: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm
Oncology TumorDimensions Observation
Oncology TumorMargins Observation The edge or border of the tissue removed in cancer surgery. The margin is described as negative or clean when the pathologist finds no cancer cells at the edge of the tissue, suggesting that all of the cancer has been removed. The margin is described as positive or involved when the pathologist finds cancer cells at the edge of the tissue, suggesting that all of the cancer has not been removed.
Procedure HIVScreeningTestPerformed Basic The performance of a HIV Screening Test. Results will be in an accompanying observation.
Procedure HIVScreeningTestRequested Basic A request for a rapid HIV screening test.
Procedure HIVSupplementalTestPerformed Basic The performance of supplement HIV test, following up an initial screening. Results are in the form of an observation.
Procedure HIVSupplementalTestRequested Basic A request for a confirmatory or additional test for HIV infection.
Procedure ImagingProcedurePerformed Basic
Procedure ImagingProcedureRequested Basic
Procedure LaboratoryProcedurePerformed Basic
Procedure LaboratoryProcedureRequested Basic
Procedure ProcedureNotPerformed Procedure
Procedure ProcedurePerformed Procedure
Procedure ProcedureRequested ProcedureRequest
Procedure ProcedureRequestedAgainst Basic
Procedure SpecimenCollectionPerformed Basic
Procedure SpecimenCollectionRequested Basic
Procedure SurgicalProcedureNotPerformed Basic
Procedure SurgicalProcedurePerformed Procedure
Procedure SurgicalProcedureRequested Basic
Procedure SurgicalProcedureRequestedAgainst Basic
Research ResearchSubject ResearchSubject Record of a subject's enrollment and participation in a research study.
Research Study ResearchStudy A clinical trial or similar research study. Reference: list of FDA data elements describing a research study:
Sex ContraceptiveMethodRequested Basic The contraceptive method(s) proposed, recommended or prescribed by a provider, after counseling and assessment.
Sex ContraceptiveMethodRequestedAgainst Basic The contraceptive method(s) recommended or prescribed by a provider, after counseling and assessment.
Sex ContraceptiveMethodUsed Observation A method contraception used (or not) by the subject.
Sex ContraceptivesUsed Observation How frequently the subject and partner uses contraceptives, and if so, what contraceptive methods used.
Sex CurrentPregnancyStatus Observation Whether or not the subject is currently pregnant.
Sex GenderIdentity Observation Subjective personal perception of one's own gender, which can be male, female, a blend of both, or neither.
Sex IntercourseDifficulty Observation Condition affecting sexual intercourse.
Sex NumberOfLivingChildren Observation Number of living children.
Sex NumberOfPreviousPregnancies Observation Number of previous pregnancies.
Sex NumberOfSexualPartnersPastYear Observation Number of sexual partners in past year.
Sex PregnancyHistory Observation Information about current and past pregnancies.
Sex PregnancyIntention Observation Whether the subject or his/her partner has a plan or desire to either become pregnant or have a child in the next year/near future.
Sex SexualActivity Observation Characterization of the sexual activity of the subject.
Sex SexualBehavior Observation Experience with sexual intercourse.
Sex SexualIdentity Observation Information on gender identity and sexual orientation.
Sex SexualOrientation Observation An inherent and enduring emotional, romantic or sexual attraction to other people.
Skin SupportSurface Device A specific instance of a support surface used to distribute pressure and support a patient. The value is coding of the type of support surface.
Skin VisibleInternalStructure Observation An internal body structure visible from outside the body, for example, due to injury.
Skin Wound Condition A determination that a wound that exists at a particular body site, implicitly, the wound itself. Multiple wound assessments can be associated with a single wound.
Skin WoundAbsent Observation Documents the absence of a wounds of a particular type at a given body site. if the Value is SCT#416462003 (Wound) then there is no wound of any type at the site.
Skin WoundAssessmentPanel Observation Group of observations regarding the properties and severity of a wound.
Skin WoundBedAndEdge Observation Description of the periphery and base of a wound.
Skin WoundExudate Observation Description of the fluid produced by a wound.
Skin WoundSize Observation The estimated or measured dimensions of a wound.
Skin WoundTunneling Observation A discharging blind-ended track that extends from the surface of an organ to an underlying area or abscess cavity. The track is invariably lined with granulation tissue. In chronic cases this may be augmented with epithelial tissue.
Skin WoundUndermining Observation Assessment of deep tissue (subcutaneous fat and muscle) damage around the wound margin. Tunneling is just under the skin surface and doesn't involve deep tissue, and sinus tracts are a narrow tract that are away from the wound margins and go downward into the wound.
Vital BloodPressure Observation The force of circulating blood on the walls of the arteries.
Vital BodyHeight Observation The distance from the sole to the crown of the head.
Vital BodyLength Observation The distance from the sole of the foot to the crown of the head, lying down (typically 0-2 years).
Vital BodyMassIndex Observation A general indicator of the body fat an individual is carrying based upon the ratio of weight to height.
Vital BodyTemperature Observation The measure of the level of heat in a human or animal.
Vital BodyWeight Observation The mass or quantity of heaviness of an individual. Does not include estimates of fetal bodyweight.
Vital HeadCircumference Observation Circumference of the head (typically 0-2 years).
Vital HeartRate Observation The number of times the heart ventricles contract per unit of time, usually per minute.
Vital OxygenSaturation Observation Oxygen saturation in Arterial blood by Pulse oximetry.
Vital RespiratoryRate Observation The rate of breathing (inhalation and exhalation) measured within in a unit time, expressed as breaths per minute.
Vital VitalSign Observation