Wound Assessment Implementation Guide version 0.1.0 CI Build

Wound Assessment Implementation Guide, published by HL7 International - Clinical Information Modeling Initiative. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/cimi-wound-assessment/ and changes regularly. See the Directory of published versions

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Contents



Introduction

The efforts to standardized clinical assessment data has been ongoing for many years. In 2009, the Office of Nursing Services (ONS) within the Department of Veterans Affairs (VA) initiated an effort to standardize the clinical data documented by VA nurses for wound assessments, eventually expanding that effort to a collaboration chartered by nursing leaders at both VA and Kaiser Permanente. This work resulted in the HL7 Pressure Ulcer Risk domain analysis model (DAM) that passed ballot at HL7 in 2011 (Harris et al, 2015). The Skin and Wound Assessment work was continued in 2016 under the direction of the HL7 Clinical Information Modeling Initiative (CIMI) Workgroup and Logica Health, formerly Health Services Platform Consortrium (HSPC). The content development and modeling work was performed in collaboration with Intermountain Healthcare and the Veteran’s Administration (VA). Wound assessment nurses from the VA and the National Pressure Ulcer Advisory Panel (NPUAP) were the validating subject matter experts. CIMI took on this work in 2017. The Patient Care Workgroup is the primary sponsor for this work. The PSS can be found here.

Formal Veiw of Profile Content

Profile element and extension mappings

The table below represents a set of concepts and elements needed to properly document the presence of a wound. The LOINC and SNOMED code bindings are extensible. It is required that systems using this profile support at least these elements and concepts.

Profile Name LOINC or SNOMED CT code LOINC Name and Comments Or SNOMED CT preferred name UCUM Unit Code (where applicable) Coments about mapping
Wound Assertion Profile
   Present on Admission extension 89251-3 Condition present on admission This is a mapping only. Extension does not contain a definitional identifier.
   Pressure Ulcer Association extension Currently there isn't a LOINC code to associate or map to this extension.
   Wound Assessment Interpretation extension 64110-0 Interpretation This is a mapping only. Extension does not contain a definitional identifier.
   Episode estension 89252-1 Episode of Wound This is a mapping only. Extension does not contain a definitional identifier.
   Trend extension 89253-9 Trend This is a mapping only. Extension does not contain a definitional identifier.
   Periwound Condition extension 72301-5 Description of Periwound This is a mapping only. Extension does not contain a definitional identifier.
   Wound Type Etiology extension 11373-8 Injury cause This is a mapping only. Extension does not contain a definitional identifier.
   Wound Image extension 72170-4 Photographic image This is a mapping only. Extension does not contain a definitional identifier.
   Wound Internal Item or Body Structure Visible extension 89250-5 Device or anatomic structure visible in wound This is a mapping only. Extension does not contain a definitional identifier.
   Wound Gradation extension This is a reference to a choice of different observations that classify the grade of a wound. LOINC mappings will be tied to the individual observations.
      NPUAP Wound Grade 72527-5 Pressure ulcer stage NPUAP
      PEDIS Wound Grade Total Score There isn't a LOINC code to associate this profile to, yet.
      SINBAD Wound Grade Total Score There isn't a LOINC code to associate this profile to, yet.
      University of Texas Wound Grade There isn't a LOINC code to associate this profile to, yet.
      Wagner Wound Grade There isn't a LOINC code to associate this profile to, yet.
   Wound Related Observations Panel extension 39135-9 Wound assessment panel The items in this panel are part of the identified LOINC code. However, not all of the items in the LOINC panel are represented in this extension.
      Wound Bed 89254-7 Wound bed panel
        Wound Bed Appearance 72371-8 Appearance of Wound base
         Wound Bed Appearance Area component 72370-0 Area of identified wound bed appearance/Area of wound bed of Wound base
        Wound Bed Color 39132-6 Color of Wound base
          Wound Bed Color Area 89256-2 Wound bed area identified by color/Area of wound bed
      Wound Edge 89254-7 Wound edge panel
        Wound Edge Color 39133-4 Color of Wound edge
        Wound Edge Description 72304-9 Edge of wound description
      Wound Tunneling 239158009   Tunneling wound This ID is from the Solor extension of SNOMED CT
        Wound Tunneling Direction component 72297-5 Tunneling clock position of Wound
        Wound Tunneling Length component 72296-7 Tunneling [Length] of Wound cm
      Wound Undermining 449752001 Wound tissue undermining
        Wound Undermining Direction component 72294-2 Undermining clock position of Wound
        Wound Undermining Length component 72293-4 Undermining [Length] of Wound cm
      Wound Exudate 239164002 Wound discharge
        Wound Exudate Amount Description component 39116-9 Drainage amount of Wound
        Wound Exudate Appearance component 72290-0 Appearance of Exudate from wound
        Wound Exudate Color component 72289-2 Color of Exudate from wound
        Wound Exudate Odor component 72288-4 Odor of Exudate from wound
        Wound Exudate Volume component No LOINC code to associate this to, yet. mL
      Wound Size 72287-6 Wound size panel
        Wound Length component 39126-8 Length of Wound cm
        Wound Width component 39125-0 Width of Wound cm
        Wound Depth component 39127-6 Depth of Wound cm
        Wound Area component 89260-4 Area of wound cm2
        Wound Volume component No LOINC code to associate this to, yet. mL
        Qualitative Wound Depth component 39114-4 Depth of Wound - nominal
      Wound Shape 94086-6 Wound Shape
   Body Location extension The Body Location used here is a highly structured, complex extension. Currently there is not a LOINC code that describes this structure.
   Recurrence extension This is a two-part extension with a periodicity value and a episode value. Neither have a LOINC code to associate them to.


Scope and Usage

Scope

The profiles within this wound assessment implementation guide are used to collect a set of standardized and agreed upon data elements for a complete wound assessment. All types of wounds are covered except burns.

Use cases

Use case 1: Stage Four Pressure Injury Peter Pepper is admitted for treatment of a stage four pressure injury with tunneling. The wound is 3 cm X 4 cm and 3 cm deep. There is a 3 cm tunnel in the two o’clock direction. The edge of the wound is boggy.

Wound Assert

FHIR resource path Text Description Code Terminology system
Wound type value set bindings
Condition.code
CIMI Wound Type reference set
Wound Type reference set 201000205104 SNOMED CT Solor Extension
Wound Type value set] 2.16.54.1.113883.1.11.20.2.6 VSAC
Condition.code Coded value: Pressure ulcer Pressure ulcer (disorder) 399912005 SNOMED CT
Wound Gradation extension bindings
Condition.woundGradationExt.woundGradationSystem.woundStageNPUAP
Coded value: Stage IV
Category/Stage IV: Full Thickness tissue loss LA19446-6 LOINC
Body Location extension bindings
Condition.BodyLocationExt.AnatomicLocationExt
Wound Anatomic Location refset
Wound Anatomic Location refset 24191000205108 SNOMED CT Solor extension
Wound Anatomic Location value set 2.16.840.1.113762.1.4.1181.14 VSAC
Condition.BodyLocationExt.AnatomicLocationExt
Coded value: Coccyx
Entire skin of coccygeal region (body structure) 287274001 SNOMED CT
Present on Admission Extension bindings
Condition.PresentOnAdmissionExt
Yes/No Reference Set
Yes/No reference set 361000205105 SNOMED CT Solor extension
Yes/No value set 2.16.840.1.113762.1.4.1181.46 VSAC
Condition.PresentOnAdmissionExt
Coded value: Yes
Yes 373066001 SNOMED CT
Periwound Condition Extension bindings
Condition.PeriwoundConditionext
Periwound Condition value set
Periwound condition refset 91000205108 SNOMED CT Solor extension
Periwound condition value set 2.16.840.1.113762.1.4.1181.2 VSAC
Condition.PeriwoundConditionext
Coded value: Boggy
Boggy periwound skin (finding) 449737008 SNOMED CT
Wound Related Observations Panel
Wound Size panel 72287-6 LOINC
Condition.relalatedObservations.Size.width
Quantitative value: 3 cm
Width of wound 39125-0 LOINC
cm UCUM
258672001 SNOMED CT
Condition.relalatedObservations.Size.length
Quantitative value: 4 cm
Length of Wound 39126-8 LOINC
cm UCUM
258672001 SNOMED CT
Condition.relalatedObservations.Size.depth
Quantitative value: 3 cm
Depth of Wound 39127-6 LOINC
cm UCUM
258672001 SNOMED CT
Wound Undermining Panel 8925-8 LOINC
Condition.relalatedObservations.WoundUnderminingAssert.code Wound tissue undermining (finding) 449752001 SNOMED CT
Condition.relalatedObservations.WoundUnderminingAssert.length
Quantitative value: 1 cm
Undermining [Length] of Wound 72293-4 LOINC
cm UCUM
258672001 SNOMED CT
Condition.relalatedObservations.WoundUnderminingAssert.clockPosition
Clockface Position reference set
Undermining clock position of Wound 72294-2 LOINC
Clock Face Position Solor refset No Solor refset id yet Solor extension
Condition.relalatedObservations.WoundUnderminingAssert.clockPosition
Coded value: 2 O’clock
2 o'clock position (qualifier value) 260328008 SNOMED CT

Value sets

This table shows the terminology bindings used in the profile.

Value Set VSAC OID Solor SNOMED CT ID Purpose
Body Landmark Description value set No SNOMD CT or Solor refset ID A set of codes the refer to a body structure used as a reference point for other body locations.
Body Location Orientation value set No SNOMD CT or Solor refset ID A set of codes used to identify the orientation of an identified body location.
Body Location Qualifier value set No SNOMD CT or Solor refset ID A set of codes that add further qualifying data to a body location.
Body Side Refset 2.16.840.1.113762.1.4.1181.30 191000205101 This reference set is used to document a position to the left, right, or bilateral of an object from a center reference point. Resulting LOINC code 20228-3 "Anatomic part Laterality"
Clock Face Position Value Set No SNOMD CT or Solor refset ID A set of codes that describe a direction based on the face of a radial clock.
National Pressure Ulcer Advisory Panel Pressure Injury Classification System value set This is a temporary value set. Solor extension SNOMED CT codes requested. A set of codes for the NPUAP pressure injury grades.
Qualitative Wound Depth value set No SNOMD CT or Solor refset ID A set of codes that describe the depth of a wound.
Recurrence value set No SNOMD CT or Solor refset ID A seto of codes that describe how often an event re-occurs.
Surface Orientation value set No SNOMD CT or Solor refset ID A set of codes that describe where in reference to the skin surface (shallow, deep, etc.) a body location is.
Underlying Anatomical Structure value set No SNOMD CT or Solor refset ID A set of codes that identify any body structure that is beneath an identified body location.
University of Texas Diabetic Foot Ulcer Grade Classification System value set This is a temporary value set. Solor extension SNOMED CT codes requested. A set of codes describing the diabetic foot ulcer grades developed by the University of Texas.
University of Texas Diabetic Foot Ulcer Grade Stage Classification System value set This is a temporary value set. Solor extension SNOMED CT codes requested. A set of codes describing the stages that can be ascribed to wound grades developed by the University of Texas.
Wagner Diabetic Foot Ulcer Classification System value set This is a temporary value set. Solor extension SNOMED CT codes requested. A set of codes describing diabetic wound ulcer grades developed by the Wagner system.
National Pressure Ulcer Advisory Panel pressure injury staging system This is a temporary value set. Solor extension SNOMED CT codes requested. A set of codes that describe the stage for a pressure injury.
Exudate odor refset 2.16.840.1.113762.1.4.1181.13 341000205109 This refset is to record and retrieve data related to exudate odor.
Periwound condition refset 2.16.840.1.113762.1.4.1181.2 91000205108 The purpose of this refset is to describe the skin surrounding the wound
Presence absence refset 2.16.840.1.113762.1.4.1181.9 371000205102 This refset provides values for recording and retrieving information about the presence or absence of a clinical observation
Pressure ulcer association refset VSAC OID not create yet 611000205100 This reference set contains bony prominences (such as sacrum) and medical devices (such as wheel chair) which may contribute to the cause of a pressure injury.
Wound anatomic location refset 2.16.840.1.113762.1.4.1181.14 551000205100 This refset provides a set of anatomic locations to be used in recording and retrieving data about the location(s) of a patient wound(s) associate with physical exam and other patient care.
Wound bed appearance refset 2.16.840.1.113762.1.4.1181.6 121000205104 This refset provides values for recording and retrieving clinical observations obtained in examination of a wound bed or wound base.
Wound bed color refset 2.16.840.1.113762.1.4.1181.7 151000205105 The purpose of this refset is to document the colors within the base of the wound. The mobile app "Tissue Analytics" color and texture to determine color.
Wound edge description refset 2.16.840.1.113762.1.4.1181.8 161000205108 This refset provides values for recording and retrieving descriptions of a wound edge.
Wound episode refset 2.16.840.1.113762.1.4.1181.4 551000205100 This refset provides the values for documenting the period of the wound, an incident in the course of a wound.
Wound exudate appearance refset 2.16.840.1.113762.1.4.1181.11 181000205103 This refset provides values to describe the consistency of exudate that is present in a wound. The values will be used for recording and retrieving the consistency of exudate.
Wound exudate color refset 2.16.840.1.113762.1.4.1181.12 191000205101 The purpose of this RefSet is to describe the color of exudate that is present in a wound. The values will be used in conjunction with the values from the Wound exudate amount ordinal refset and the Wound exudate appearance refset to document and retrieve values that describe wound exudate.
Wound exudate qualitative amount refset 2.16.840.1.113762.1.4.1181.10 281000205105 Provide values for recording and retrieving clinical observations / findings / phenomena that come about from a clinician examining a patient with a wound.
Wound internal item and/or body structure visible refset 2.16.840.1.113762.1.4.1181.1 111000205106 This reference set contains values for recording exposed body structures or devices visible in a wound.
Wound Shape refset VSAC OID not create yet 24511000205105 The purpose of this reference set is to characterize the outline of a wound. Referencing LOINC code XXX (requested).
Wound trend refset VSAC OID not create yet 561000205102 This refset provides values to document a measure of improvement or deterioration in wound healing.
Wound type etiology refset 2.16.840.1.113762.1.4.1181.3 521000205106 The purpose of this refset is to provide a limited set of causes for a wound.
Wound type refset 2.16.840.1.113883.1.11.20.2.6 201000205104 The purpose of this Refset is to describe types of wounds and skin injuries. Differentiating pressure ulcers and other types of wounds is important for an accurate count of their number and for identifying appropriate wound treatment.
Yes/No refset 2.16.840.1.113762.1.4.1181.46 361000205105 A clinician wants to record a 'yes' or 'no' value; e.g. Wound associated with device – yes"

References

Harris M, Heerman-Langford L, Miller H, Hook M, Dykes P, Matney SA.(2015) Harmonizing and Extending Standards from a Domain-Specific and Bottom-Up Approach: An Example from Development through Use in Clinical Applications. Journal of the American Medical Informatics Association. 22(3), 545-52.

Acknowledgements

This Implementation Guide was made possible by contributions from the following people and organizations:

The Clinical Information Modeling Initiative (CIMI) Workgroup

  • Nathan Davis, Intermountain Healthcare
  • Susan Matney, Intermountain Healthcare
  • Patrick Langford, Intermountain Healthcare