Table 1.
Scheme of Inpatient Fall Data Dictionary and Data Examples
| Field | Example of assessment | Example of intervention |
|---|---|---|
| Care component | Cognitive factors | Impaired mobility |
| Care type | Assessment | Intervention |
| Care activity | Observe (assess or evaluate) delirium/confusional state/altered mental status/ reversible dementia/organic brain syndrome | Regularly scheduled assistance with toileting |
| Data element | Delirium | Aid of toileting |
| Definition | Confusional state | Regularly scheduled assistance with toileting for patients with impaired mobility |
| Terminology | LOINC | ICNP Intervention |
| Concept(s) | Delirium [MDSv3] | Assisting with toileting |
| Terminology code | 54626-7 | 10023531 |
| Local facility ID | Hospital A | Hospital B |
| Local EHR ID.version | eChart.2.0 | SmartCare.3.0 |
| Local screen-item name | Nursing notes | Nursing notes |
| Local expression | Observed delirium symptom(degreea: disorganized) | Provide regularly assistance with toileting |
| Local data type | Assessment statement | Intervention statement |
| Local code | S03745 | A05595 |
aAttribute and value of the nursing statement.