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. 2018 Apr 6;25(6):730–738. doi: 10.1093/jamia/ocy018

Table 2.

Example Nursing Assessment Data Elements Whose Concepts Mapped onto LOINC

Care component Data element LOINC concepts (ID) Property Time System Scale Method Relation with populating indicator
Reason for encounter Primary diagnosis Primary diagnosis (18630-4) Imp Pt Patient Nom Inclusion criteria
Administrative Length of stay Hospital stay duration (78033-8) Time Pt Patient Qn Patient days
Pathophysiologic disease-related factors Use of anticoagulants/coagulopathy diagnosis/the first day of surgical procedure Bleeding risk [CCC] (81225-5) Find Pt Cardiovascular system Ord Observed.CCC Frequency of nursing assessment of risk factors
Nursing diagnosis: visual impairment Visual alteration [CCC] (28242-6) Find Pt Eye Ord Observed.CCC
Cognitive factors Delirium Delirium [MDSv3] (54626-7) Pt Patient MDSv3
Consciousness Level of consciousness (80288-4) Find Pt Patient Ord
Behavior factors Fall history Fall history on admission [MDSv3] (54849-5) Pt Patient MDSv3
Therapeutic factors IV line Intravenous apparatus (59457-2) Find Pt Patient Ord Morse Fall Scale
Foley catheter Indwelling catheter [MDS] (45628-5) Find Pt Patient Ord MDS
Incident characteristic Injury level Event outcome [MERSTH] (42545-4) Find Pt Patient Ord Observed. MERSTH Frequency of injurious falls

CCC, clinical care classification; MDS, Minimum Data Set; MERSTH, Medical Event Reporting System Total Healthsystem.