Functional impairments |
Electronic health records (EHRs): electronic nursing charts (NANDA) |
Chronic constipation
Feeling tired
Problems with falling/staying asleep
Problems with sleep–awake cycle
Urinary incontinence
Help getting on/off bed
Help going to the toilet
Help walking
History of falls
Inability to walk stairs
Irregular gait pattern
Patient using walking equipment/aid
Problems getting dressed
Problems with bathing
Clouding or delirium
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Yes=1, no=0 impaired=1, normal=0 |
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16. Food intake |
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Comorbidities |
EHRs: diagnosis list medication use |
Active malignancy
Hearing impairment
History of osteoporosis
Cardiac arrhythmias
Coronary heart disease
Pressure sores (decubital ulcers)
Diabetes mellitus
History of seizures
History of stroke
Memory impairment
Chronic obstructive lung disease
Use of anticoagulation medication
Use of antiplatelet medication
Polypharmacy (>5 drugs)
Use of sedative, hypnotic and/or neuroleptic drugs
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Presence (yes)=1, absence (no)=0 |
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32. Haematocrit |
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Laboratory results |
Primary laboratory System |
Haemoglobin
Platelet count
Red cell volume (MCV)
Creatinine
Urea
Thyrotropin
C-reactive protein
Lymphocyte total count
High-density lipoprotein)
Potassium
Sodium
Albumin
Blood glucose
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<35%=1,≥35%=0 Serum concentration above or below reference range=1, within=0 <3.9 or>15 mmol/L=1, other=0 >7 or<3.5 mmol/L=1, other=0 |
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46. Cholesterol |
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Vital signs |
EHRs |
Body temperature
Diastolic blood pressure
Heart rate (pulse)
Systolic blood pressure
Oxygen saturation (SpO2)
Patient requires supplemental oxygen
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<36,3°C=1,≥36,3°C=0 >90mmHg=1,≤90 mmHg=0 <60 or>99 BPM=1, other=0 >140mmHg=1,≤140 mmHg=0 <90%=1,≥90%=0 yes=1, no=0 |
Other |
EHRs |
Age
Body mass index
Patient reports being in pain
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>80=1,≤80=0 <18.5 or≥30=1;>25 and<30=0.5, other=0 yes=1, no=0 |