Toward a National Health Information Infrastructure: A Key Strategy for Improving Quality in Long-Term Care. APPENDIX G. Terms Provided by Domain Experts, Partial or No Matches

Terms From Domain Experts, Partial Match or No Match to MDS
Terms from Domain Experts Partial Match
MDS
No Match
MDS
Pressure Ulcer Terms
Adequacy of treatment   Adequacy of treatment
Air-fluidized bed Pressure relieving device for bed  
Avoid positioning directly on the trochanter   Avoid positioning directly on the trochanter
Body control   Body control
Bony prominences   Bony prominence
Braden scale   Braden scale
Cellulitis   Cellulitis
Characteristics of support surfaces   Characteristics of support surfaces
Clean dressings Application of dressings  
Complete history   Complete history
Complete physical examination   Complete physical examination
Debridement (sharp, mechanical, enzymatic, or autolytic) Ulcer care  
Dietary intake of protein   Dietary intake of protein
Depression score   Depression score
Dietary intake of calories Calories received through parenteral or tube feedings in last 7 days  
Dynamic support surface Pressure relieving device for bed  
Educational program for prevention of pressure ulcers Nursing rehabilitation/restoration "other"  
Electrical stimulation therapy Ulcer care  
Eschar   Eschar
Exudate   Exudate
Film dressing Ulcer care  
Friction   Friction
Friction injuries   Friction injuries
Hydrocolloid dressing Ulcer care  
Hydrotherapy Ulcer care  
Hyperbaric oxygen Ulcer care  
Inspect skin at least once a day, if early treatment   Inspect skin at least once a day, if early treatment
Irrigation pressure   Irrigation pressure
Lifting devices   Lifting devices
Low air-loss bed Pressure relieving device for bed  
Lubricants to reduce friction injuries   Lubricants to reduce friction injuries
Modular products   Modular products
Moisture exposure on intact skin   Moisture exposure on intact skin
Mineral supplements   Mineral supplements
Normal saline for cleansing Ulcer care  
Norton scale   Norton scale
Oral intake goals   Oral intake goals
Periodic reassessment (at least weekly)   Periodic reassessment
Poor meal intake   Poor meal intake
Positioning devices   Positioning devices
Positioning techniques   Positioning techniques
Postural alignment   Postural alignment
Protective films   Protective films
Protective dressings   Protective dressings
Protective padding   Protective padding
Range of motion   Range of motion
Risk for delayed healing   Risk for delayed healing
Risk for moisture exposure   Risk for moisture exposure
Risk for pressure ulcers   Risk for pressure ulcers
Shearing   Shearing
Sepsis    
Severity of illness   Severity of illness
Shift weight every 15 minutes Nursing rehabilitation/restoration "other"  
Skin cleansed at routine intervals   Skin cleansed at routine intervals
Skin cleansed at time of soiling   Skin cleansed at time of soiling
Static support surface   Static support surface
Stryker frame   Stryker frame
Tissue viability of the surgical site (if operative repair of pressure ulcer)   Tissue viability of surgical site
Topical treatment with iodine containing agents Application of ointments/medications  
Transferring support Modes of transfer  
Treatment goals   Treatment goals
Ulcer care plan evaluated   Ulcer care plan evaluated
Vitamin supplements Number of medications  
Whirlpool treatment Ulcer care  
Chronic Pain Terms
Contractures   Contractures
Drawing of pain location   Drawing of pain location
Energy/fatigue   Energy/fatigue
Faces pain scale   Faces pain scale
Facial expressions (wrinkled forehead, tightly closed eyes, grimacing, frowning) Sad, pained, worried facial expression  
Fibromyalgia   Fibromyalgia
Grunting Making self understood  
Headaches   Headaches
Impact of pain on (quality of life outcomes, physical function, sleep, appetite, interpersonal relationships/interactions with others, mood, mental staus)   Impact of pain on (quality of life outcomes)
Irritability Verbal expressions of distress (e.g., repetitive anxious complaints/concerns)  
Knees pulled up   Knees pulled up
Lasting minutes or hours   Lasting minutes or hours
Low back pain   Low back pain
McGill pain questionnaire   McGill pain questionnaire
Monitoring pain intensity Pain intensity  
Myofascial pain syndromes   Myofascial pain syndromes
Non-pharmacologic interventions   Non-pharmacologic interventions
Nonverbal behaviors (bracing, rubbing, guarding)   Nonverbal behaviors (bracing, rubbing, guarding)
Numbness   Numbness
Osteoarthritis Arthritis  
Pain behaviors   Pain behaviors
Pain intensity Pain intensity  
Pain map   Pain map
Patient satisfaction associated with pain management   Patient satisfaction associated with pain management
Pattern of pain   Pattern of pain
Peripheral neuropathy   Peripheral neuropathy
Phantom limb pain   Phantom limb pain
Post-herpetic neuralgia   Post-herpetic neuralgia
Radiating pain   Radiating pain
Rheumatoid arthritis Arthritis  
Risk of unrecognized and thus untreated pain   Risk of unrecognized and thus untreated pain
Screening procedures   Screening procedures
Spinal stenosis   Spinal stenosis
Stabbing pain Pain symptom  
Throbbing pain Pain symptom  
Tingling   Tingling
Vasculitic pain syndromes   Vasculitic pain syndromes
Vasogenic claudication   Vasogenic claudication
Verbal descriptors scale   Verbal descriptors scale
What starts pain   What starts pain
What makes pain better   What makes pain better
What makes pain worse   What makes pain worse
When pain starts   When pain starts
Urinary Incontinence Terms
Ability to toilet Toilet use  
Characteristics of voiding and non-invasive bladder diagnosis   Characteristics of voiding and non-invasive bladder diagnosis
Factors associated with UI   Factors associated with UI
Genital system exam to identify physical abnormalities that may explain incontinence (e.g., pelvic prolapse)   Genital system exam to identify physical abnormalities that may explain incontinence (e.g., pelvic prolapse)
How often person voids when prompted on a routine basis   How often person voids when prompted on a routine basis
Importance of problem to resident   Importance of problem to resident
Lab reports   Lab reports
Non-invasive diagnoses of bladder function   Non-invasive diagnoses of bladder function
Primary care provider notes   Primary care provider notes
Prior treatment for incontinence   Prior treatment for incontinence
Prompted toileting Any scheduled toileting plan  
Prompted void    
Rectal exam to exclude fecal impaction   Rectal exam to exclude fecal impaction
Skin exam to evaluate skin problems associated with uninary incontinence   Skin exam to evaluate skin problems associated with uninary incontinence
Status of incontinence: day and night Bladder continence  
Symptoms on urination   Symptoms on urination
Symptoms to distinguish between urge incontinence (short interval between sensation to void and bladder contraction) and stress incontinence (urine loss during physical movements)   Symptoms to distinguish between urge incontinence (short interval between sensation to void and bladder contraction) and stress incontinence (urine loss during physical movements)
Targeted history   Targeted history
Targeted physical   Targeted physical
Toileting responsiveness assessments   Toileting responsiveness assessments
Urodynamic analyses of bladder functioning   Urodynamic analyses of bladder functioning
Voiding record Any scheduled toileting plan Voiding record

 

Terms From Domain Experts, Partial Match or No Match to SNOMED CT
Terms from Domain Experts Partial Match
SNOMED CT
No Match
SNOMED CT
Pressure Ulcer Terms
Activity Type of activity Activity
Adequacy of treatment   Adequacy of treatment
Awareness Consciousness (SNOMED term "state of awareness" is a retired concept)
Bed bound Bed ridden  
Bony prominences   Bony prominences
Braden scale   Braden scale
Can request help Request for
Ability to ask questions (specific types of help)
Help
Chair bound Confined to chair  
Characteristics of support surfaces   Characteristics of support surfaces
Condition factors   Condition factors
Difficulty with repositioning Repositioning Difficulty with repositioning
Distracted Easily distracted Distracted without modifier
Friction injuries   Friction injuries
Locomotion   Locomotion
Modular products   Modular products
Moisture   Moisture exposure
Motion of: neck, arm, hand, leg, foot Motion
Ability to move arm
Ability to move hand
Ability to move leg
Ability to move foot
Motion
Norton scale   Norton scale
Periodic reassessment   Periodic reassessment
Poor meal intake Food intake Meal
Skin pliability Skin assessment Pliability
Ulcer care plan evaluated Care plan
Evaluation
Ulcer care plan
Verbal responses Uses verbal communication  
Viability of the surgical site   (SNOMED term "surgical site" has been retired)
Chronic Pain Terms
Description Symptom description NOS Description
Drawing   Drawing
Faces pain scale Finding of present pain intensity Faces pain scale
Facial expressions (wrinkled forehead, tightly closed eyes, grimacing, frowning) Grimaces Wrinkled forehead
Tightly closed eyes
Frowning
Grunting Vocalization (SNOMED includes term grunting but "is_a" animal vocalization)
Impact of pain on quality of life outcomes Pain
Determination of outcome
Impact
Quality of life
Lasting minutes or hours Time frame
Intervals of minutes
Intervals of hours
Lasting
Negative vocalization Negative
Vocalization
Negative vocalization
Nonverbal behavior (bracing, rubbing, guarding)   Nonverbal behavior (bracing, rubbing, guarding)
Nonverbal indicators of discomfort Discomfort Nonverbal indicators
Pain map   Map
Physical function   Physical function
Risk of unrecognized and thus untreated pain Risk of
Pain
Unrecognized
Untreated
Vasculitic pain syndomes Pain Vasculitic pain syndomes
Withdrawal from activities of interest Loss of interest Withdrawal from activities
Urinary Incontinence Terms
Importance of problem to resident Problem Importance
Resident
Targeted history History taking
Has focus
Targeted
Targeted physical Physical exam
Limited
Targeted

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