TEMPLATE Wound Assert Report (Wound Assert Report)

TEMPLATE IDWound Assert Report
ConceptWound Assert Report
DescriptionTo represent the CIMI HSCP Wound assert FHIR representation in openEHR. Found at http://models.opencimi.org/ig/skin-and-wound-fhir-profiles/StructureDefinition-WoundAssert-definitions.html
PurposeTo represent the CIMI HSCP Wound assert FHIR representation in openEHR. Found at http://models.opencimi.org/ig/skin-and-wound-fhir-profiles/StructureDefinition-WoundAssert-definitions.html
References
Authorsdate: 2019-03-25; author: Heather Leslie
Other Details Languagedate: 2019-03-25; author: Heather Leslie
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr}
Language useden
Citeable Identifier1013.26.218
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  • Left 
  • Right 
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  •  Coded Text
    • Medial 
    • Lateral 
    • Superior 
    • Inferior 
    • Anterior 
    • Posterior 
    • Proximal 
    • Distal 
    • Deep 
    • Superficial 
    • Palmar 
    • Plantar 
    • Dorsal 
    • Mid 
    • Oral 
    • Anal 
  •  Text
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  •  Coded Text
    • Midline 
    • Midaxillary line 
    • Anterior axillary line 
    • Posterior axillary line 
    • Mid-clavicular line 
    • Mid-pupillary line 
    • Mid-scapular line 
  •  Text
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  •  Coded Text
    • One o'clock 
    • Two o'clock 
    • Three o'clock 
    • Four o'clock 
    • Five o'clock 
    • Six o'clock 
    • Seven o'clock 
    • Eight o'clock 
    • Nine o'clock 
    • Ten o'clock 
    • Eleven o'clock 
    • Twelve o'clock 
  •  DurationPT0M..PT12H
    Units:
    • Hour
    • Minute
  •  Quantity
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  • Wound stage one
  • Wound stage two
  • Wound stage three
  • Wound stage four
  • First degree burn
  • Second degree burn
  • Third degree burn
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  • Pressure point of skin 
  • Pressure point of skin related to device 
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  • Within defined limits 
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  • Deterioration of status
  • Deterioration of status
  • Resolved
  • Stabilization of status
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  • New 
  • Ongoing 
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  • Acute 
  • Chronic 
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subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 cm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0039], code=at0039, itemType=ELEMENT, level=3, text=Wound Area, description=Area of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 cm2, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0048], code=at0048, itemType=ELEMENT, level=3, text=Wound Edge Description, description=Description about the edge of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0049], code=at0049, itemType=ELEMENT, level=3, text=Wound Edge Color, description=Colour of the wound edge., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0057], code=at0057, itemType=ELEMENT, level=3, text=Periwound Condition, description=Description of the skin surrounding the wound., comment=Multiple occurrences allow for the use of coded text to describe various aspects of the skin around the wound., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0054], code=at0054, itemType=CLUSTER, level=3, text=Wound bed colour, description=Details about the colour of the base of the wound., comment=Multiple occurrences of this Cluster allow for recordings of more than one colour., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0054]/items[at0055], code=at0055, itemType=ELEMENT, level=4, text=Wound Bed Color, description=Description of the colour of the wound base., comment=For example: red/healthy; red/hyperaemic; pink, yellow; black, brown; or grey., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0054]/items[at0056], code=at0056, itemType=ELEMENT, level=4, text=Proportion, description=The proportion of the wound that is the identified colour., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0051], code=at0051, itemType=CLUSTER, level=3, text=Wound bed appearance, description=Details about the appearance of the base of the wound., comment=Multiple occurrences of this Cluster allow for recordings of multiple discrete areas of different appearances.., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0051]/items[at0052], code=at0052, itemType=ELEMENT, level=4, text=Wound Bed Appearance, description=Description of the appearance of the wound base., comment=For example: necrotic; sloughing; fibrinous; eschar; or granulation tissue., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0051]/items[at0053], code=at0053, itemType=ELEMENT, level=4, text=Proportion, description=The proportion of the wound that has the identified appearance., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0014], code=at0014, itemType=CLUSTER, level=3, text=HSPC Wound Internal Item Or Body Structure Visible, description=Details about the observation of any exposed body structures, devices, and/or foreign bodies visible by the naked eye in a wound., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=4, text=Wound Internal Item or Body Structure Visible, description=Idnetification of an exposed body structure, device, and/or foreign body visible by the naked eye within the wound., comment=Coding of the visible internal structure if preferred, if possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0014]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Present or absent?, description=Is the object/structure present?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Absent 
  • Indeterminate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0045], code=at0045, itemType=CLUSTER, level=3, text=HSPC Wound Tunneling Assert, description=Details about tunnelling into other tissues., comment=Multiple occurrences of this cluster will allow recording about each tunnel that leads from the wound., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0045]/items[at0046], code=at0046, itemType=ELEMENT, level=4, text=WoundTunnelingLength, description=Length of an identified tunnel radiating out from the centre of the wound., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0; >=0
Units:
  • cm
  • mm
  • [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0045]/items[at0047], code=at0047, itemType=ELEMENT, level=4, text=WoundTunnelingDirection, description=Direction of the tunnel radiating outward from the centre of the wound, as described by a clock-face., comment=For example: one o'clock., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0045]/items[at0058], code=at0058, itemType=ELEMENT, level=4, text=Description, description=Narrative description of a tunnel., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0041], code=at0041, itemType=CLUSTER, level=3, text=HSPC Wound Undermining Assert, description=Details about undermining of the wound., comment=Multiple occurrences of this cluster will allow recording of the undermining occurring in different parts of the wound., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0041]/items[at0042], code=at0042, itemType=ELEMENT, level=4, text=WoundUnderminingLength, description=Amount of tissue destruction that extends under the intact wound edge., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0; >=0
Units:
  • cm
  • mm
  • [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[at0041]/items[at0044], code=at0044, itemType=ELEMENT, level=4, text=WoundUnderminingDirectio, description=Direction of the undermining outward from the centre of the wound, as described by a clock-face., comment=For example: one o'clock., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[openEHR-EHR-CLUSTER.exam_body_fluid.v0], code=at0000, itemType=CLUSTER, level=3, text=WoundExudateAssert, description=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., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[openEHR-EHR-CLUSTER.exam_body_fluid.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Wound Exudate Appearance, description=Narrative description about the fluid., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[openEHR-EHR-CLUSTER.exam_body_fluid.v0]/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=WoundExudateAmountDescription, description=Description of the amount of fluid observed at the identified body site., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[openEHR-EHR-CLUSTER.exam_body_fluid.v0]/items[at0018], code=at0018, itemType=ELEMENT, level=4, text=WoundExudateColor, description=Description of the colour of the body fluid., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[openEHR-EHR-CLUSTER.exam_body_fluid.v0]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Viscosity, description=Description of the viscosity or thickness of the body fluid., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[openEHR-EHR-CLUSTER.exam_body_fluid.v0]/items[at0017], code=at0017, itemType=ELEMENT, level=4, text=WoundExudateOdor, description=Description of the smell of the body fluid., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_wound.v0]/items[openEHR-EHR-CLUSTER.multimedia.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=HSPC Wound Image, description=Multimedia representation of the clinical observation or finding., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null]], templateType=normal]