| TEMPLATE ID | Wound related observations Panel |
|---|---|
| Concept | Wound related observations Panel |
| Description | Not Specified |
| Purpose | Not Specified |
| References | |
| Authors | date: 2019-03-25 |
| Other Details Language | date: 2019-03-25 |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1013.26.217 |
| Root archetype id | openEHR-EHR-OBSERVATION.exam.v1 |
| Wound related observations panel | Wound related observations panel: Findings observed during the physical examination of a subject of care. |
| Wound Length | Wound Length: Length of the wound (longest dimension). >=0 cm |
| Wound Width | Wound Width: Width of the wound (perpendicular to longest dimension). >=0 cm |
| Wound Depth | Wound Depth: Depth of the wound. >=0 cm |
| Wound Area | Wound Area: Area of the wound. >=0 cm² |
| Wound Edge Description | Wound Edge Description: Description about the edge of the wound. |
| Wound Edge Color | Wound Edge Color: Colour of the wound edge. |
| Periwound Condition | Periwound Condition: 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. |
| Wound bed colour | Wound bed colour: Details about the colour of the base of the wound. Multiple occurrences of this Cluster allow for recordings of more than one colour. |
| Wound Bed Color | Wound Bed Color: Description of the colour of the wound base. For example: red/healthy; red/hyperaemic; pink, yellow; black, brown; or grey. |
| Proportion | Proportion: 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.
|
| Wound bed appearance | Wound bed appearance: 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.. |
| Wound Bed Appearance | Wound Bed Appearance: Description of the appearance of the wound base. For example: necrotic; sloughing; fibrinous; eschar; or granulation tissue. |
| Proportion | Proportion: 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.
|
| HSPC Wound Internal Item Or Body Structure Visible | HSPC Wound Internal Item Or Body Structure Visible: Details about the observation of any exposed body structures, devices, and/or foreign bodies visible by the naked eye in a wound. |
| Wound Internal Item or Body Structure Visible | Wound Internal Item or Body Structure Visible: 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. |
| Present or absent? | Present or absent?: Is the object/structure present?
|
| HSPC Wound Tunneling Assert | HSPC Wound Tunneling Assert: Details about tunnelling into other tissues. Multiple occurrences of this cluster will allow recording about each tunnel that leads from the wound. |
| WoundTunnelingLength | WoundTunnelingLength: Length of an identified tunnel radiating out from the centre of the wound. >=0; >=0; >=0 Units:
|
| WoundTunnelingDirection | WoundTunnelingDirection: Direction of the tunnel radiating outward from the centre of the wound, as described by a clock-face. For example: one o'clock. |
| Description | Description: Narrative description of a tunnel. |
| HSPC Wound Undermining Assert | HSPC Wound Undermining Assert: 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:
|
| WoundUnderminingDirectio | WoundUnderminingDirectio: Direction of the undermining outward from the centre of the wound, as described by a clock-face. For example: one o'clock. |
| WoundExudateAssert | WoundExudateAssert: Findings observed during the examination of body fluid at a body site or from an identified body source, usually as part of a physical examination by a clinician. |
| Wound Exudate Appearance | Wound Exudate Appearance: Narrative description about the fluid. |
| WoundExudateAmountDescription | WoundExudateAmountDescription: 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. |
| 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. |
| Viscosity | Viscosity: Description of the viscosity or thickness of the body fluid. The intent of this data element is to record either a narrative description of the viscosity, or to code with a value set where appropriate in a template. |
| 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. |
| HSPC Wound Image | HSPC Wound Image: Multimedia representation of the clinical observation or finding. |