| TEMPLATE ID | Wound Assessment Panel |
|---|---|
| Concept | Wound Assessment Panel |
| Description | To represent the HL7 FHIR Profile: Skin and Wound Assessment, Release 1 in openEHR |
| Purpose | To represent the HL7 FHIR Profile: Skin and Wound Assessment, Release 1 in openEHR |
| References | |
| Authors | date: 2019-03-18; author: Heather Leslie |
| Other Details Language | date: 2019-03-18; author: Heather Leslie |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1013.26.215 |
| Root archetype id | openEHR-EHR-OBSERVATION.exam.v1 |
| Wound Assessment Panel | Wound Assessment Panel: Findings observed during the physical examination of a subject of care. |
| Data | |
| woundIdentifier | woundIdentifier: A name or alias for the wound, so that it can be distinguished from other wounds. |
| woundLength | woundLength: Length of the wound (longest dimension). >=0; >=0; >=0 Units:
|
| woundWidth | woundWidth: Width of the wound (perpendicular to longest dimension). >=0; >=0; >=0 Units:
|
| woundDepth | woundDepth: Depth of the wound. >=0; >=0; >=0 Units:
|
| woundArea | woundArea: Area of the wound. >=0; >=0; >=0 Units:
|
| woundEdgeDescription | woundEdgeDescription: Description about the edge of the wound. Value set: terminology:SNOMEDCT?subset=%20https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.8/expansion&language=en-GB |
| woundEdgeColor | woundEdgeColor: Colour of the wound edge. Value set: terminology:LOINC?subset=%20LOINC%20Answer%20List%20LL2338-3&language=en-GB |
| woundPeriwoundDescription | woundPeriwoundDescription: Description of the skin surrounding the wound. Multiple occurrences allow for the use of coded text to describe various aspects of the skin around the wound. Value set: terminology:SNOMEDCT?subset=https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.2/expansion&language=en-GB |
| woundPressureUlcerAssociation | woundPressureUlcerAssociation: Details about factors that may be associated with the wound. |
| Factor | Factor: Associated factor that may causing or influencing the healing of the wound. For example: a device; or pressure point.
|
| Present or absent? | Present or absent?: Is the identified factor present?
|
| woundBedColorObservation | woundBedColorObservation: Details about the colour of the base of the wound. Multiple occurrences of this Cluster allow for recordings of more than one colour. |
| woundBedColor | woundBedColor: Description of the colour of the wound base. For example: red/healthy; red/hyperaemic; pink, yellow; black, brown; or grey. Value set: terminology:SNOMEDCT?subset=%20https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.7/expansion&language=en-GB |
| woundBedColorAreaPercentage | woundBedColorAreaPercentage: The proportion of the wound that is the identified colour. This is the the area of the base of the wound that is a specific colour, compared to the total area of the wound bed and represented as a percentage.
|
| woundBedAppearanceObservation | woundBedAppearanceObservation: Details about the appearance of the base of the wound. Multiple occurrences of this Cluster allow for recordings of multiple discrete areas of different appearances.. |
| woundBedAppearance | woundBedAppearance: Description of the appearance of the wound base. For example: necrotic; sloughing; fibrinous; eschar; or granulation tissue. Value set: terminology:SNOMEDCT?subset=%20https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.6/expansion&language=en-GB |
| woundBedAppearancePercentage | woundBedAppearancePercentage: The proportion of the wound that has the identified appearance. This is the the area of the base of the wound that has a specific appearance, compared to the total area of the wound bed and represented as a percentage.
|
| woundVisibleInternalStructure | woundVisibleInternalStructure: Details about the observation of any exposed body structures, devices, and/or foreign bodies visible by the naked eye in a wound. |
| Object/structure | Object/structure: Idnetification of an exposed body structure, device, and/or foreign body visible by the naked eye within the wound. Coding of the visible internal structure if preferred, if possible. Value set: terminology:SNOMEDCT?subset=https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.1/expansion&language=en-GB |
| Present or absent? | Present or absent?: Is the object/structure present?
|
| woundTunnellingPresentOrAbsent | woundTunnellingPresentOrAbsent: Is tunnelling present in the wound?
|
| woundTunnellingObservation | woundTunnellingObservation: Details about tunnelling into other tissues. Multiple occurrences of this cluster will allow recording about each tunnel that leads from the wound. |
| woundTunnelLength | woundTunnelLength: Length of an identified tunnel radiating out from the centre of the wound. >=0; >=0; >=0 Units:
|
| woundTunnelClockDirection | woundTunnelClockDirection: Direction of the tunnel radiating outward from the centre of the wound, as described by a clock-face. For example: one o'clock. Value set: terminology:FHIR?subset=http://hl7.org/fhir/us/sw/ValueSet/shr-core-ClockDirectionVS&language=en-GB |
| woundUnderminingPresentOrAbsent | woundUnderminingPresentOrAbsent: Is undermining present in the wound? For example: color; induration; warmth; or oedema.
|
| woundUnderminingObservation | woundUnderminingObservation: Details about undermining of the wound. Multiple occurrences of this cluster will allow recording of the undermining occurring in different parts of the wound. |
| woundUnderminingLength | woundUnderminingLength: Amount of tissue destruction that extends under the intact wound edge. >=0; >=0; >=0 Units:
|
| woundUnderminingClockDirection | woundUnderminingClockDirection: Direction of the undermining outward from the centre of the wound, as described by a clock-face. For example: one o'clock. Value set: terminology:FHIR?subset=http://hl7.org/fhir/us/sw/ValueSet/shr-core-ClockDirectionVS&language=en-GB |
| woundExudatePresentOrAbsent | woundExudatePresentOrAbsent: Is an exudate present in the wound?
|
| woundExudateAppearance | woundExudateAppearance: Narrative description about the fluid. Value set: terminology:?subset=https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.11/expansion |
| woundExudateAmount | woundExudateAmount: Description of the amount of fluid observed at the identified body site. The intent of this data element is to record either a narrative description of the amount, or to code with a value set such as small/medium/profuse or normal/increased where appropriate in a template. This data element is not intended for quantitative assessment of body fluids - use OBSERVATION.fluid_output for this purpose. Value set: terminology:?subset=https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.10/expansion |
| woundExudateColor | woundExudateColor: Description of the colour of the body fluid. The intent of this data element is to record either a narrative description of the colour, or to code with a value set where appropriate in a template. Value set: terminology:?subset=https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.12/expansion |
| woundExudateOdor | woundExudateOdor: Description of the smell of the body fluid. The intent of this data element is to record either a narrative description of the odour, or to code with a value set where appropriate in a template. Value set: terminology:?subset=https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.13/expansion |
| photographicImage | photographicImage: Multimedia representation of the clinical observation or finding. |
| woundEpisode | woundEpisode: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. Value set: terminology:SNOMEDCT?subset=https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.4/expansion&language=en-GB |
| woundAssessmentInterpretation | woundAssessmentInterpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. Value set: terminology:?subset=%20LOINC%20Answer%20List%20LL3816-7%20(LOINC)%20() |
| woundTrend | woundTrend: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. Value set: terminology:?subset=https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.5/expansion |
| precondition | precondition: Description of any incidental factors that may have contributed to the physical examination findings. |