Skin

SHR implementation of the HL7 Pressure Ulcer Prevention Domain Analysis Model (May, 2011).

CausativeFactor

The cause the irritation or inflammation.

Value:  Choice
         |  CodeableConcept from TBD required A set of codes drawn from different coding systems, representing the same concept.
         |  Device required A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.

ImmersionDepth

Depth of penetration (sinking) into a support surface.

Value:  Quantity Units is cm (cm) A quantity with units.

PressureUlcer [Entry]

A single pressure ulcer, tracked over a period of time. Multiple PressureUlcerAssessments (at different times) may be associated with a single PressureUlcer. C0011127

Based On Problem

Value:  CodeableConcept is TBD A set of codes drawn from different coding systems, representing the same concept.
BodySite must be a PressureUlcerBodySite 0 or more Location on or in the body.
Manifestation must be a PressureUlcerManifestation 0 or more A complaint or observed (subjective) indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.
CausativeFactor 0 or more The cause the irritation or inflammation.
PressureUlcerIntervention (TBD) 0 or more Description TBD
ProblemCategory 0 or more A categorization of the problem using common clinical categories.
NonOccurrenceModifier optional When true, indicates either that the event or action documented in the entry did not occur, or the the thing documented is absent or does not exist.
GeneralizedLikelihood optional Quantitative or qualitative measure of likelihood.
SupportingEvidenceQuality optional An assessment of the quality and/or quantity of the source information that supports judgment.
ClinicalStatus required A flag indicating whether the problem is active or inactive, recurring, in remission, or resolved.
IncludeOnProblemList optional Whether or not to include this problem on the subject's current problem list.
Onset optional The beginning or first appearance of a mental or physical disorder.
WhenClinicallyRecognized optional The time at which a condition or problem was first identified in a healthcare context.
Preexisting optional If the problem or condition existed before the current episode of care.
Abatement optional The end, remission or resolution.
Severity optional Degree of severity of a symptom, disorder, or problem.
Criticality optional A clinical judgment of potential clinical harm, or seriousness, of a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.
GradeOrStage optional The stage or grade of a disease.

PressureUlcerBodySite

The site of a pressure ulcer.

Based On BodySite

Value:  CodeableConcept from PressureUlcerBodySiteVS A set of codes drawn from different coding systems, representing the same concept.
Laterality optional Anatomical location or specimen further detailing the side(s) of interest.
Directionality not used Anatomical location or specimen further detailing directionality.
PortionTotality not used ObservationQualifier for anatomical location or specimen further detailing the portion or totality, which means arrangement of, or apportioning of an entity.
Description optional An account, representation, statement, or explanation of something.

PressureUlcerManifestation [Entry]

Observation regarding the properties and severity of a single pressure ulcer. 54574-9

Based On Manifestation

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 54574-9 required A term from a controlled vocabulary that defines the data element (the question, not the answer) as specifically as possible. The specific code should always align with the concept of the element, but may be more specific. For example, the concept associated with medications is code for 'medication used', but the ObservationCode is the code for the particular medication used. For tests, ObservationCode identifies the specific test being performed, and for observations, the specific question being asked.
ObservationStatus from NonLabObservationStatusVS required A qualifier describing the stage or administrative state of the observation. If not given, it is assumed the status is final.
VisibleInternalStructure 0 or more An internal body structure visible from outside the body, for example, due to injury.
WoundSize optional The estimated or measured dimensions of a wound.
WoundTunnelling optional A discharging blind-ended track that extends from the surface of an organ to an underlying area or abscess cavity. The track is invariably lined with granulation tissue. In chronic cases this may be augmented with epithelial tissue.
WoundUndermining optional Assessment of deep tissue (subcutaneous fat and muscle) damage around the wound margin. Tunneling is just under the skin surface and doesn't involve deep tissue, and sinus tracts are a narrow tract that are away from the wound margins and go downward into the wound.
WoundBedAndEdge optional
WoundExudate optional A mass of cells and fluid that has seeped out of a wound.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Severity optional Degree of severity of a symptom, disorder, or problem.
BodySite optional Location on or in the body.
ObservationCategory 0 or more A categorization of the observation according to how the observation was collected or its clinical area.
ObservationReason optional The reason for making the observation.
ObservationNonOccurrenceModifier optional True if the observation did not occcur, e.g., if a test was not performed or the assessment was not done, when it might otherwise be expected.
ObservationQualifier 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
ObservationMethod optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
ClinicallyRelevantTime optional The time or time period that the observation addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.
Setting 0 or more Description of the place or type of surroundings where something is positioned or where an event takes place.
Location 0 or more A position, site, or point in space where something can be found.

PressureUlcerNotPresent [Entry]

A statement that there is no pressure ulcer at a given body site. If body site is omitted, or if the body site is a coding representing the entire body, then the inference is that no pressure ulcers is present anywhere on the body.

Based On PressureUlcer

Value:  CodeableConcept is TBD A set of codes drawn from different coding systems, representing the same concept.
NonOccurrenceModifier is true optional When true, indicates either that the event or action documented in the entry did not occur, or the the thing documented is absent or does not exist.
GeneralizedLikelihood optional Quantitative or qualitative measure of likelihood.
SupportingEvidenceQuality optional An assessment of the quality and/or quantity of the source information that supports judgment.
ClinicalStatus required A flag indicating whether the problem is active or inactive, recurring, in remission, or resolved.
IncludeOnProblemList not used Whether or not to include this problem on the subject's current problem list.
Onset not used The beginning or first appearance of a mental or physical disorder.
WhenClinicallyRecognized not used The time at which a condition or problem was first identified in a healthcare context.
Preexisting not used If the problem or condition existed before the current episode of care.
Abatement not used The end, remission or resolution.
Severity not used Degree of severity of a symptom, disorder, or problem.
Criticality not used A clinical judgment of potential clinical harm, or seriousness, of a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.
GradeOrStage not used The stage or grade of a disease.
Manifestation not used A complaint or observed (subjective) indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.
BodySite must be a PressureUlcerBodySite 0 or more Location on or in the body.
CausativeFactor 0 or more The cause the irritation or inflammation.
PressureUlcerIntervention (TBD) 0 or more Description TBD
ProblemCategory 0 or more A categorization of the problem using common clinical categories.

SupportSurface

A specific instance of a support surface used to distribute pressure and support a patient. The value is coding of the type of support surface. 272243001

Based On Device

Value:  CodeableConcept from SupportSurfaceVS A set of codes drawn from different coding systems, representing the same concept.
SupportSurfaceCategory optional The category of support surface.
SupportSurfaceBodyPosition optional What body positions the surface can be used for, specifically, sitting or lying.
SupportSurfaceComponent 0 or more A physical material, structure, or system used alone or in combination with other components to fashion a support surface.
DeviceUdi 0 or more Unique Device Identifier (UDI) Barcode string number for a device, assigned by the organization using the device.
VendorModelNumber optional The model number of the device, assigned by the manufacturer or vendor.

SupportSurfaceBodyPosition

What body positions the surface can be used for, specifically, sitting or lying.

Value:  CodeableConcept from SupportSurfaceBodyPositionVS A set of codes drawn from different coding systems, representing the same concept.

SupportSurfaceCategory

The category of support surface.

Value:  CodeableConcept from SupportSurfaceCategoryVS A set of codes drawn from different coding systems, representing the same concept.

SupportSurfaceComponent

A physical material, structure, or system used alone or in combination with other components to fashion a support surface.

Value:  CodeableConcept from SupportSurfaceComponentVS A set of codes drawn from different coding systems, representing the same concept.

SupportSurfaceEmployed

A paricular instance of the use of a support surface in patient care.

Based On DeviceUse

Value:  Device must be a SupportSurface A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Implanted is false optional Whether this device is implanted in the body.
ImmersionDepth optional Depth of penetration (sinking) into a support surface.
Device required A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
DeviceUseStatus required A code representing the patient or other source's judgment about the state of the device used that this statement is about. Generally this will be active or completed.
NonOccurrenceModifier optional When true, indicates either that the event or action documented in the entry did not occur, or the the thing documented is absent or does not exist.
Reason 0 or more The justification for an action or non-action, conclusion, opinion, etc.
PeriodOfUse optional A period of time when a device, medication, or other therapy is used.

VisibleInternalStructure

An internal body structure visible from outside the body, for example, due to injury.

Value:  CodeableConcept from VisibleInternalStructureVS A set of codes drawn from different coding systems, representing the same concept.

WoundBedAndEdge

No Description

WoundBaseAppearance (TBD) required Description TBD
WoundBaseColor (TBD) required Description TBD
WoundEdgeAppearance required Evaluation of the state of the tissue at the edge of the wound.
WoundEdgeColor (TBD) required Description TBD
WoundClosureType (TBD) optional Description TBD

WoundEdgeAppearance

Evaluation of the state of the tissue at the edge of the wound. 723204-9

Value:  CodeableConcept from WoundEdgeAppearanceVS A set of codes drawn from different coding systems, representing the same concept.

WoundExudate

A mass of cells and fluid that has seeped out of a wound.

Value:  boolean
WoundExudateOdor (TBD) required Description TBD
WoundExudateColor (TBD) required Description TBD
DrainageAmount (TBD) required Description TBD
WoundExudateAppearance (TBD) required Description TBD

WoundSize

The estimated or measured dimensions of a wound. C3496620

Area optional The extent of a 2-dimensional surface enclosed within a boundary.
Circumference optional The length of such a boundary line of a figure, area, or object.
Volume optional The amount of three dimensional space occupied by an object or the capacity of a space or container.
Width required The measurement or extent of something from side to side.
Depth required The extent downward or inward; the perpendicular measurement from the surface downward to determine deepness.
Length required The measurement or linear extent of something from end to end; the greater of two or the greatest of three dimensions of a body.

WoundTunnelling

A discharging blind-ended track that extends from the surface of an organ to an underlying area or abscess cavity. The track is invariably lined with granulation tissue. In chronic cases this may be augmented with epithelial tissue. C0406830

Value:  boolean
ClockDirection required A direction indicated by an angle relative to 12 o'clock.
Length required The measurement or linear extent of something from end to end; the greater of two or the greatest of three dimensions of a body.

WoundUndermining

Assessment of deep tissue (subcutaneous fat and muscle) damage around the wound margin. Tunneling is just under the skin surface and doesn't involve deep tissue, and sinus tracts are a narrow tract that are away from the wound margins and go downward into the wound.

Value:  boolean
ClockDirection required A direction indicated by an angle relative to 12 o'clock.
WoundUnderminingLength (TBD) required Description TBD