HL7 FHIR Profile: Skin and Wound Assessment, Release 1 [cited 2019 03 18]. Available at: https://cimi.hl7.org/submissions/september_2018/skinwoundig/fullcimi/site/index.html.
http://www.healthcareimprovementscotland.org/our_work/patient_safety/tissue_viability_resources/general_wound_assessment_chart.aspx
https://zibs.nl/wiki/Wound-v3.1(2017EN)
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2019-03-18
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2019-03-18
- 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
- References: https://www.wwwoundcare.ca/Uploads/ContentDocuments/BWAT.pdf HL7 FHIR Profile: Skin and Wound Assessment, Release 1 [cited 2019 03 18]. Available at: https://cimi.hl7.org/submissions/september_2018/skinwoundig/fullcimi/site/index.html. http://www.healthcareimprovementscotland.org/our_work/patient_safety/tissue_viability_resources/general_wound_assessment_chart.aspx https://zibs.nl/wiki/Wound-v3.1(2017EN)
- Current Contact: Heather Leslie, Atomica Informatics
- Original Namespace: org.openehr
- Original Publisher: openEHR Foundation
- Custodian Namespace: org.openehr
- MD5-CAM-1.0.1: 16CFECB52BBBA7A6F3C74F436C7DB908
- Build Uid: d87ba094-4e60-4cb5-93be-4c0eae0839c3
- Revision: 0.0.1-alpha
Choice of:
Text
Coded Text- Abrasion
[LOINC(2.27)::LA7410-9 | Abrasion] - Avulsion
[LOINC(2.27)::LA18220-6 | Avulsion] - Bite
[LOINC(2.27)::LA19023-3 | Bite] - Blister
[LOINC(2.27)::LA19024-1 | Blister] - Burn
- Gunshot wound
- Contusion
- Crush injury
- Erythema
- Fissure
- Laceration
- Maceration
- Pressure ulcer
- Ulcer
- Puncture
- Rash
- Graft
- Surgical incision
- Trauma
- Abrasion
For example: the very generic term "skin", which will likely require additional qualification using one of the 'Body site' data elements, or the complete phrase "skin of right knee". Coding of the system or structure examined with a terminology is preferred, where possible.
For example: "entire body", "face" or "right cheek". If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant.
If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant.
Include:
openEHR-EHR-CLUSTER.anatomical_
openEHR-EHR-CLUSTER.anatomical_
openEHR-EHR-CLUSTER.anatomical_
Property: Length
Units:
- >=0.0 cm
- >=0.0 in
- >=0.0 mm
Property: Length
Units:
- >=0.0 cm
- >=0.0 mm
- >=0.0 in
Property: Length
Units:
- >=0.0 cm
- >=0.0 mm
- >=0.0 in
As per Bates-Jensen wound assessment tool.
- Tissues damaged but no break in skin surface
- Superficial, abrasion, blister or shallow crater [Even with, &/or elevated above skin surface (e.g.,hyperplasia).]
- Deep crater with or without undermining of adjacent tissue
- Visualization of tissue layers not possible due to necrosis
- Supporting structures include tendon, joint capsule
Property: Area
Units:
- >=0.0 cm²
- >=0.0 mm²
- >=0.0 in²
Units:
- >=0.0 mm³
- >=0.0 cc
- >=0.0 in³
Choice of:
- Coded Text
- Round
- Ovoid
- Square
- Rectangular
- Quadrangular [A four sided shape.]
- Club-shaped
- Dumbbell-shaped
- Funnel-shaped
- Horseshoe-shaped
- J-shaped
- Pear-shaped
- Saddle-shaped
- V-shaped
- Wedge-shaped
- Text
Choice of:
- Coded Text
- Red/Healthy
- Red/Hyperemic
- Pink/Pale
- Yellow
- Black
- Brown
- Gray
- Text
- Well-defined [Distinct wound outline.]
- Poorly-defined [Indistinct or diffuse wound outline.]
Choice of:
- Coded Text
- Scabbed
- Rolled [Soft to firm and flexible to touch.]
- Hyperkeratotic [Callous-like tissue formation around wound & at edges.]
- Fibrotic [Scarred, hard, rigid to touch.]
- Text
- Attached [The edge appears flush with the wound base or has a sloping edge.]
- Not attached [The edge has sides or walls present; floor or base of wound is deeper than edge.]
Multiple occurrences allow for the use of coded text to describe various types of skin around the wound.
Choice of:
- Coded Text
- Boggy
- Blanched
- Blistered
- Calloused
- Dry
- Ecchymotic
- Edematous
- Erythematous
- Excoriated
- Fluctuant
- Friable
- Hemorrhagic
- Indurated
- Lacerated
- Macerated
- Moist
- Purpuric
- Rash
- Rupture
- Scarred
- Swollen (inflammed)
- Healthy and intact
- Text
- Present
- Absent
- Present
- Absent
- Normal skin temperature
- Raised skin temperature
For example: a device; a drain tube; or a pressure point.
- Present [The identified factor is observed.]
- Absent [The identified factor is not observed.]
- Indeterminate [It is not possible to tell if the identified factor is present or absent.]
Multiple occurrences of this Cluster allow for recordings of more than one colour.
For example: red/healthy; red/hyperaemic; pink, yellow; black, brown; or grey.
Choice of:
- Coded Text
- Red/Healthy
- Red/Hyperemic
- Pink/Pale
- Yellow
- Black
- Brown
- Gray
- Text
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.
- Percent
Multiple occurrences of this Cluster allow for recordings of multiple discrete areas of different appearances..
For example: necrotic; sloughing; fibrinous; eschar; or granulation tissue.
Choice of:
- Text
- Coded Text
- White/gray non-viable tissue [May appear prior to wound opening; skin surface is white or grey.]
- Non-adherent, yellow slough [Thin, mucinous substance; scattered throughout wound bed; easily separated from wound tissue.]
- Loosely adherent, yellow slough [Thick, stringy, clumps of debris; attached to wound tissue.]
- Adherent, soft, black eschar [Soggy tissue; strongly attached to tissue in centre or base of wound.]
- Firmly adherent, hard/black eschar [Firm, crusty tissue; strongly attached to wound base and edges (like a hard scab).]
- Non-blanchable erythema
- Epithelialization
- Fibrinous tissue
- Granulation tissue
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.
- Percent
Coding of the visible internal structure if preferred, if possible.
Choice of:
- Text
- Coded Text
- Bone
- Blood vessel
- Cartilage
- Fascia
- Joint capsule
- Mesh
- Muscle
- Musculoskeletal implant
- Pin
- Prosthesis
- Subcutaneous tissue
- Tendon
- Foreign body
- Present [The identified object or structure is observed in the wound.]
- Absent [The identified object or structure is not observed in the wound.]
- Indeterminate [It is not possible to tell if the identified object or structure is present or absent in the wound.]
- Present [Tunnelling is observed in the wound.]
- Absent [Tunnelling is not observed in the wound.]
- Indeterminate [It is not possible to tell if a tunnel is present or absent.]
Multiple occurrences of this cluster will allow recording about each tunnel that leads from the wound.
Property: Length
Units:
- >=0.0 cm
- >=0.0 mm
- >=0.0 in
For example: one o'clock.
Choice of:
- Text
- Coded Text
- One o'clock [The tunnel is located at the one o'clock position relative to the identified reference point.]
- Two o'clock [The tunnel is located at the two o'clock position relative to the identified reference point.]
- Three o'clock [The tunnel is located at the three o'clock position relative to the identified reference point.]
- Four o'clock [The tunnel is located at the four o'clock position relative to the identified reference point.]
- Five o'clock [The tunnel is located at the five o'clock position relative to the identified reference point.]
- Six o'clock [The tunnel is located at the six o'clock position relative to the identified reference point.]
- Seven o'clock [The tunnel is located at the seven o'clock position relative to the identified reference point.]
- Eight o'clock [The tunnel is located at the eight o'clock position relative to the identified reference point.]
- Nine o'clock [The tunnel is located at the nine o'clock position relative to the identified reference point.]
- Ten o'clock [The tunnel is located at the ten o'clock position relative to the identified reference point.]
- Eleven o'clock [The tunnel is located at the eleven o'clock position relative to the identified reference point.]
- Twelve o'clock [The tunnel is located at the twelve o'clock position relative to the identified reference point.]
For example: color; induration; warmth; or oedema.
- Present [Undermining is observed in the wound.]
- Absent [Undermining is not observed in the wound.]
- Indeterminate [It is not possible to tell if undermining is present or absent.]
Multiple occurrences of this cluster will allow recording of the undermining occurring in different parts of the wound.
Property: Length
Units:
- >=0.0 cm
- >=0.0 mm
- >=0.0 in
For example: one o'clock.
- Present [An exudate is observed in the wound.]
- Absent [An exudate is not observed in the wound.]
- Indeterminate [It is not possible to tell if an exudate is present or absent.]
- Scant
- Moderate
- Large
Choice of:
- Coded Text
- Blue
- Green
- Orange
- Pink
- Red
- White
- Yellow
- Brown
- Clay
- Maroon
- Violet
- Tan
- Colorless
- Text
Choice of:
- Coded Text
- Sanguinous
- Serosanguinous
- Serous
- Purulent
- Seropurulent
- Viscous
- Text
- None, undetectable
- Offensive
Include:
All not explicitly excluded archetypes
Include:
openEHR-EHR-CLUSTER.media_
openEHR-EHR-CLUSTER.media_
Coding of the 'Clinical interpretation' with a terminology is preferred, where possible.
Include:
openEHR-EHR-CLUSTER.exclusion_