Lower Extremity Skin Wound Assessment Implementation Guide STU1 CI Build

Lower Extremity Skin Wound Assessment - IG, published by HL7 International - Electronic Health Records Work Group. 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/fhir-skin-wound-ig/ and changes regularly. See the Directory of published versions

StructureDefinition-WoundAssert

Scope and Usage

Wound Assert is an assertion model used when the condition exists. Wound is a kind of skin alteration including breaks in skin or injury under or to skin wounds (e.g., pressure injury by stage)

Examples

The following examples are provided to illustrate conformant resource content to this profile.

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundAssert

Published on Wed Jun 19 00:00:00 UTC 2019 as a draft by HSPC.

This profile builds on USCoreCondition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*USCoreConditionWound Assert
... presentonadmission 0..1CodeableConceptPresent On Admission
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PresentOnAdmissionExt
Binding: YesNoValueSet (preferred)
... pressureulcerassociation 0..1CodeableConceptPressure Ulcer Association
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PressureUlcerAssociationExt
Binding: PressureUlcerAssociationvalueset (preferred)
... woundAssessmentInterpretation 0..1CodeableConceptWound Assessment Interpretation
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundAssessmentInterpretationExt
Binding: WoundAssessmentInterpretationvalueset (preferred)
... woundEpisode 0..1CodeableConceptWound Episode
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/EpisodeExt
Binding: Episodevalueset (preferred)
... woundTrend 0..1CodeableConceptWound Trend
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/TrendExt
Binding: Trendvalueset (preferred)
... PeriwoundCondition 0..1CodeableConceptPeriwound Condition
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PeriwoundConditionExt
Binding: ReriwoundConditionvalueset (preferred)
... WoundTypeEtiology 0..1CodeableConceptWound Type Etiology
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundTypeEtiologyExt
Binding: WoundTypeEtiologyvalueset (preferred)
... WoundImage 0..1AttachmentWound Image
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundImageExtension
... WoundInternalItemOrBodyStructureVisible 0..1CodeableConceptWound Internal Item Or Body Structure Visible
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundInternalItemOrBodyStructureVisibleExt
Binding: WoundInternalItemOrBodyStructureVisiblevalueset (preferred)
... WoundGradation 0..1CodeableConceptWound Gradation
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundGradationExt
Binding: WoundGradationValueSet (preferred)
... woundRelatedObservationsPanel 0..1Reference(WoundRelatedObservationsPanel)Wound Related Observations Panel
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundRelatedObservationsPanelExt
... BodyLocation 0..1(Complex)Body Location
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/BodyLocationExt
... WoundRecurrence 0..1(Complex)Wound Recurrence
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundRecurrenceExt
... identifier 0..*IdentifierTo be used for the wound ID
... code 1..1CodeableConceptwoundType
Binding: CIMIWoundTypevalueset (preferred)
... bodySite 0..0
... onset[x] 0..1dateTimeOnset Date
... abatement[x] 0..1dateTimeAbatement Date

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*USCoreConditionWound Assert
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... presentonadmission 0..1CodeableConceptPresent On Admission
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PresentOnAdmissionExt
Binding: YesNoValueSet (preferred)
... pressureulcerassociation 0..1CodeableConceptPressure Ulcer Association
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PressureUlcerAssociationExt
Binding: PressureUlcerAssociationvalueset (preferred)
... woundAssessmentInterpretation 0..1CodeableConceptWound Assessment Interpretation
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundAssessmentInterpretationExt
Binding: WoundAssessmentInterpretationvalueset (preferred)
... woundEpisode 0..1CodeableConceptWound Episode
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/EpisodeExt
Binding: Episodevalueset (preferred)
... woundTrend 0..1CodeableConceptWound Trend
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/TrendExt
Binding: Trendvalueset (preferred)
... PeriwoundCondition 0..1CodeableConceptPeriwound Condition
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PeriwoundConditionExt
Binding: ReriwoundConditionvalueset (preferred)
... WoundTypeEtiology 0..1CodeableConceptWound Type Etiology
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundTypeEtiologyExt
Binding: WoundTypeEtiologyvalueset (preferred)
... WoundImage 0..1AttachmentWound Image
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundImageExtension
... WoundInternalItemOrBodyStructureVisible 0..1CodeableConceptWound Internal Item Or Body Structure Visible
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundInternalItemOrBodyStructureVisibleExt
Binding: WoundInternalItemOrBodyStructureVisiblevalueset (preferred)
... WoundGradation 0..1CodeableConceptWound Gradation
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundGradationExt
Binding: WoundGradationValueSet (preferred)
... woundRelatedObservationsPanel 0..1Reference(WoundRelatedObservationsPanel)Wound Related Observations Panel
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundRelatedObservationsPanelExt
... BodyLocation 0..1(Complex)Body Location
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/BodyLocationExt
... WoundRecurrence 0..1(Complex)Wound Recurrence
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundRecurrenceExt
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierTo be used for the wound ID
... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... category SC1..*CodeableConceptproblem-list-item | encounter-diagnosis | health-concern
Binding: US Core Condition Category Codes (extensible)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ1..1CodeableConceptwoundType
Binding: CIMIWoundTypevalueset (preferred)
... subject SΣ1..1Reference(US Core Patient Profile)Who has the condition?
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... onset[x] Σ0..1dateTimeOnset Date
... abatement[x] C0..1dateTimeAbatement Date
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
... asserter Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Person who asserts this condition
... stage C0..*BackboneElementStage/grade, usually assessed formally
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary C0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C0..*BackboneElementSupporting evidence
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣC0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition 0..*USCoreConditionWound Assert
... presentonadmission 0..1CodeableConceptPresent On Admission
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PresentOnAdmissionExt
Binding: YesNoValueSet (preferred)
... pressureulcerassociation 0..1CodeableConceptPressure Ulcer Association
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PressureUlcerAssociationExt
Binding: PressureUlcerAssociationvalueset (preferred)
... woundAssessmentInterpretation 0..1CodeableConceptWound Assessment Interpretation
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundAssessmentInterpretationExt
Binding: WoundAssessmentInterpretationvalueset (preferred)
... woundEpisode 0..1CodeableConceptWound Episode
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/EpisodeExt
Binding: Episodevalueset (preferred)
... woundTrend 0..1CodeableConceptWound Trend
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/TrendExt
Binding: Trendvalueset (preferred)
... PeriwoundCondition 0..1CodeableConceptPeriwound Condition
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PeriwoundConditionExt
Binding: ReriwoundConditionvalueset (preferred)
... WoundTypeEtiology 0..1CodeableConceptWound Type Etiology
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundTypeEtiologyExt
Binding: WoundTypeEtiologyvalueset (preferred)
... WoundImage 0..1AttachmentWound Image
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundImageExtension
... WoundInternalItemOrBodyStructureVisible 0..1CodeableConceptWound Internal Item Or Body Structure Visible
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundInternalItemOrBodyStructureVisibleExt
Binding: WoundInternalItemOrBodyStructureVisiblevalueset (preferred)
... WoundGradation 0..1CodeableConceptWound Gradation
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundGradationExt
Binding: WoundGradationValueSet (preferred)
... woundRelatedObservationsPanel 0..1Reference(WoundRelatedObservationsPanel)Wound Related Observations Panel
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundRelatedObservationsPanelExt
... BodyLocation 0..1(Complex)Body Location
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/BodyLocationExt
... WoundRecurrence 0..1(Complex)Wound Recurrence
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundRecurrenceExt
... identifier 0..*IdentifierTo be used for the wound ID
... code 1..1CodeableConceptwoundType
Binding: CIMIWoundTypevalueset (preferred)
... bodySite 0..0
... onset[x] 0..1dateTimeOnset Date
... abatement[x] 0..1dateTimeAbatement Date

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition C0..*USCoreConditionWound Assert
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... presentonadmission 0..1CodeableConceptPresent On Admission
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PresentOnAdmissionExt
Binding: YesNoValueSet (preferred)
... pressureulcerassociation 0..1CodeableConceptPressure Ulcer Association
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PressureUlcerAssociationExt
Binding: PressureUlcerAssociationvalueset (preferred)
... woundAssessmentInterpretation 0..1CodeableConceptWound Assessment Interpretation
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundAssessmentInterpretationExt
Binding: WoundAssessmentInterpretationvalueset (preferred)
... woundEpisode 0..1CodeableConceptWound Episode
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/EpisodeExt
Binding: Episodevalueset (preferred)
... woundTrend 0..1CodeableConceptWound Trend
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/TrendExt
Binding: Trendvalueset (preferred)
... PeriwoundCondition 0..1CodeableConceptPeriwound Condition
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/PeriwoundConditionExt
Binding: ReriwoundConditionvalueset (preferred)
... WoundTypeEtiology 0..1CodeableConceptWound Type Etiology
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundTypeEtiologyExt
Binding: WoundTypeEtiologyvalueset (preferred)
... WoundImage 0..1AttachmentWound Image
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundImageExtension
... WoundInternalItemOrBodyStructureVisible 0..1CodeableConceptWound Internal Item Or Body Structure Visible
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundInternalItemOrBodyStructureVisibleExt
Binding: WoundInternalItemOrBodyStructureVisiblevalueset (preferred)
... WoundGradation 0..1CodeableConceptWound Gradation
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundGradationExt
Binding: WoundGradationValueSet (preferred)
... woundRelatedObservationsPanel 0..1Reference(WoundRelatedObservationsPanel)Wound Related Observations Panel
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundRelatedObservationsPanelExt
... BodyLocation 0..1(Complex)Body Location
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/BodyLocationExt
... WoundRecurrence 0..1(Complex)Wound Recurrence
URL: http://hl7.org/fhir/us/lower-extremity-skin-wound-assessment/StructureDefinition/WoundRecurrenceExt
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierTo be used for the wound ID
... clinicalStatus ?!SΣC0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣC0..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... category SC1..*CodeableConceptproblem-list-item | encounter-diagnosis | health-concern
Binding: US Core Condition Category Codes (extensible)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.

... code SΣ1..1CodeableConceptwoundType
Binding: CIMIWoundTypevalueset (preferred)
... subject SΣ1..1Reference(US Core Patient Profile)Who has the condition?
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... onset[x] Σ0..1dateTimeOnset Date
... abatement[x] C0..1dateTimeAbatement Date
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Who recorded the condition
... asserter Σ0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)Person who asserts this condition
... stage C0..*BackboneElementStage/grade, usually assessed formally
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary C0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).

.... assessment C0..*Reference(ClinicalImpression | DiagnosticReport | Observation)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).

... evidence C0..*BackboneElementSupporting evidence
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣC0..*CodeableConceptManifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.


.... detail ΣC0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

Terminology Bindings

PathConformanceValueSet
Condition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleUSCoreConditionCategoryCodes
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codepreferredCIMIWoundTypevalueset
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleManifestationAndSymptomCodes

Constraints

IdGradePath(s)DetailsRequirements
con-1errorCondition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
con-2errorCondition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()