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Skin

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

ImmersionDepth

Depth of penetration (sinking) into a support surface.

Value:  Quantity Units is cm (cm) A quantity with units, whose value may be bounded from above or below, as defined in FHIR

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 must be 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.
Type must be from DeviceVS required The most specific code (lowest level term) describing the kind or sort of thing being represented.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

SupportSurfaceBodyPosition

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

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

SupportSurfaceCategory

The category of support surface.

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

SupportSurfaceUsed

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

Based On DeviceUsed

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 no optional Whether this device is implanted in the body.
ImmersionDepth optional Depth of penetration (sinking) into a support surface.
ActionContext must be a PerformedContext must be from http://hl7.org/fhir/ValueSet/device-statement-status required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
         where  Participant not used An object (usually a Person, Party, or Organization but potentially a device or other Object) that participates in a task or activity.
         where  Status must be from http://hl7.org/fhir/ValueSet/device-statement-status must be from http://hl7.org/fhir/ValueSet/medication-request-status required Position in workflow.
         where  Status must be from http://hl7.org/fhir/ValueSet/device-statement-status must be from http://hl7.org/fhir/ValueSet/medication-request-status must be from http://hl7.org/fhir/ValueSet/device-statement-status required Position in workflow.
Subject required The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
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.
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
Type optional The most specific code (lowest level term) describing the kind or sort of thing being represented.
Category 0 or more A class or division of people or things having particular shared characteristics
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

VisibleInternalStructure

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

Based On ObservationComponent

Value:  CodeableConcept must be from VisibleInternalStructureVS A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.

WoundAbsent [Entry]

Documents the absence of wounds at a given body site.

Based On Assertion

Value:  Value is Wound (416462003)
ObservationCode is TBD required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
NegationFlag is true required A flag that indicates the meaning to be conveyed is the logical opposite of the current assertion. The assertion is negated only when the NegationIndicator is true. If absent or false, the assertion is not negated.
ValueAbsentReason not used Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Specimen not used Sample for analysis
Device not used 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.
ReferenceRange not used The usual or acceptable range for a test result.
ClinicallyRelevantTime optional The time or time period that the finding 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).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category (if covered) 0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
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.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

WoundAssessment [Entry]

Group of observations regarding the properties and severity of a wound. 54574-9

Based On Observation

Value:  Value
ObservationCode is 54574-9 required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ClinicallyRelevantTime optional The time or time period that the finding 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).
FindingStatus required Indicates whether the finding is preliminary, amended, final, etc..
Category from http://hl7.org/fhir/ValueSet/observation-category (if covered) 0 or more A class or division of people or things having particular shared characteristics
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
Specimen optional Sample for analysis
Device optional 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.
ReferenceRange 0 or more The usual or acceptable range for a test result.
ChangeFlag optional Indicator of significant change (delta) from the last or previous measurement.
Details optional An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Interpretation optional A clinical interpretation of a finding.
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.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.
Subject optional The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical or assessment vehicle.
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

WoundBedAndEdge

Description of the periphery and base of a wound.

Based On ObservationComponent

Value:  Choice
         |  Quantity required A quantity with units, whose value may be bounded from above or below, as defined in FHIR
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.
         |  string required
         |  Range required An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
         |  Ratio required A unit of measurement for the quotient of the amount of one entity to another.
         |  Attachment required A file that contains audio, video, image, or similar content.
         |  time required
         |  dateTime required
         |  TimePeriod required A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
         |  IntegerQuantity required A Quantity that is an integer.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.

WoundEdgeAppearance

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

Based On ObservationComponent

Value:  CodeableConcept must be from WoundEdgeAppearanceVS A set of codes drawn from different coding systems, representing the same concept.
ObservationCode is 723204-9 required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.

WoundExudate

Description of the fluid produced by a wound.

Based On ObservationComponent

Value:  Value
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.

WoundPresent [Entry]

A determination that a wound that exists at a particular body site, implicitly, the wound itself. Multiple wound assessments can be associated with a single wound.

Based On Condition

Value:  CodeableConcept must be from WoundTypeVS A set of codes drawn from different coding systems, representing the same concept.
Category must be from ConditionCategoryVS 1 or more A class or division of people or things having particular shared characteristics
Subject required The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
ClinicalStatus must be from http://hl7.org/fhir/ValueSet/condition-clinical required A flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).
BodySiteOrCode 0 or more A body site entity or a body site code.
Onset optional The beginning or first appearance of a mental or physical disorder.
Abatement optional The end, remission or resolution.
WhenClinicallyRecognized optional The time at which a condition or condition was first identified in a healthcare context.
Preexisting optional If the problem or condition existed before the current episode of care.
Severity must be from http://hl7.org/fhir/ValueSet/condition-severity optional Degree of harshness or extent of a symptom, disorder, or condition.
Criticality must be from http://hl7.org/fhir/ValueSet/allergy-intolerance-criticality optional The potential clinical harm associated with 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.
Stage optional The relative advancement in the course of a disease.
FocalSubject optional For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FindingMethod optional The technique used to create the finding, for example, the specific imaging technical or assessment vehicle.
FindingStatus optional Indicates whether the finding is preliminary, amended, final, etc..
Evidence 0 or more A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

WoundSize

The estimated or measured dimensions of a wound. C3496620

Based On ObservationComponent

Value:  Choice
         |  Quantity required A quantity with units, whose value may be bounded from above or below, as defined in FHIR
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.
         |  string required
         |  Range required An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
         |  Ratio required A unit of measurement for the quotient of the amount of one entity to another.
         |  Attachment required A file that contains audio, video, image, or similar content.
         |  time required
         |  dateTime required
         |  TimePeriod required A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
         |  IntegerQuantity required A Quantity that is an integer.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.

WoundTunneling

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

Based On ObservationComponent

Value:  CodeableConcept must be from YesNoUnknownVS A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.

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.

Based On ObservationComponent

Value:  CodeableConcept must be from YesNoUnknownVS A set of codes drawn from different coding systems, representing the same concept.
ValueAbsentReason optional Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
ObservationCode required A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Interpretation optional A clinical interpretation of a finding.
ReferenceRange 0 or more The usual or acceptable range for a test result.
Components optional Components are parts of the parent observation. Component observations share the same attributes (such as Specimen) as the primary observation and are not separable. However, the reference range may be different for each component observation.