Wound-v3.0(2016EN): verschil tussen versies
(Nieuwe pagina aangemaakt met '==General information== Name: '''nl.zorg.Wound''' link=Wond-v3.0(2016NL)<BR> Version: '''3.0''' <br> HCIM Status:Final<br> Publication: '''20...') |
Geen bewerkingssamenvatting |
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Regel 3: | Regel 3: | ||
Version: '''3.0''' <br> | Version: '''3.0''' <br> | ||
HCIM Status:Final<br> | HCIM Status:Final<br> | ||
Release: '''2016''' <br> | |||
Release status: Published<br> | Release status: Published<br> | ||
Release date: 1-5-2016 | |||
----- | ----- | ||
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2016(EN)]] [[HCIM_Release_2016(EN) |Back to HCIM list ]]</div> | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2016(EN)]] [[HCIM_Release_2016(EN) |Back to HCIM list ]]</div> | ||
Regel 106: | Regel 106: | ||
==Information Model== | ==Information Model== | ||
<BR> | <BR> | ||
<imagemap> Bestand:Wound-v3.0Model(EN).png | center | |||
rect 800 628 920 678 [[#WoundEdgeCodelist]] | |||
rect 81 324 273 374 [[#WoundAnatomicalLocationCodelist]] | |||
rect 82 227 274 277 [[#WoundTypeCodelist]] | |||
rect 461 35 589 105 [[NursingIntervention-v3.0(2016EN)]] | |||
rect 293 400 421 470 [[#10125]] | |||
rect 295 508 423 578 [[#10129]] | |||
rect 624 508 752 578 [[#10130]] | |||
rect 293 126 421 196 [[#10131]] | |||
rect 785 399 934 469 [[#10132]] | |||
rect 466 508 594 578 [[#10133]] | |||
rect 195 629 351 679 [[#WoundTissueWCSCodelist]] | |||
rect 612 629 762 679 [[#WoundMoistureCodelist]] | |||
rect 293 217 421 287 [[#10120]] | |||
rect 292 314 420 384 [[#10117]] | |||
rect 549 184 649 264 [[#10119]] | |||
rect 626 35 754 105 [[PlannedCareActivityForTransfer-v3.0(2016EN)]] | |||
rect 290 35 426 105 [[MedicalDevice-v3.0(2016EN)]] | |||
rect 785 508 933 578 [[#10321]] | |||
rect 226 696 381 746 [[#WoundTissueOncoUlcerCodelist]] | |||
rect 785 35 934 105 [[#10720]] | |||
rect 785 126 934 196 [[#10721]] | |||
rect 785 217 934 287 [[#10722]] | |||
rect 785 308 934 378 [[#10723]] | |||
desc none | |||
</imagemap> | |||
<BR> | <BR> | ||
{| border= "1" width="1500px" style = "font-size: 9.5pt; border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px" | {| border= "1" width="1500px" style = "font-size: 9.5pt; border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px" | ||
Regel 112: | Regel 137: | ||
|style="width:30px;"|Type||style="width:100px;"|Id||colspan="6 " style="width:140px;"|Concept||Card.||style="width: 600px;"|Definition||style="width:200px;"|DefinitionCode||style="width:200px;"|Reference | |style="width:30px;"|Type||style="width:100px;"|Id||colspan="6 " style="width:140px;"|Concept||Card.||style="width: 600px;"|Definition||style="width:200px;"|DefinitionCode||style="width:200px;"|Reference | ||
|-style="vertical-align:top; background-color: #E3E3E3; " | |-style="vertical-align:top; background-color: #E3E3E3; " | ||
|style = "text-align:center" |[[Bestand: block.png| 20px]] | |style = "text-align:center" |[[Bestand: block.png| 20px | link=]] | ||
||NL-CM:19.2.1 | ||NL-CM:19.2.1 | ||
|colspan ="6" style ="padding-left: 0px"|<span Title="NL: Wond">[[Bestand: arrowdown.png | 10px]]Wound</span> | |colspan ="6" style ="padding-left: 0px"|<span Id=10119 Title="NL: Wond">[[Bestand: arrowdown.png | 10px | link=]]Wound</span> | ||
| | | | ||
|Root concept of the Wound information model. This root concept contains all data elements of the Wound information model. | |Root concept of the Wound information model. This root concept contains all data elements of the Wound information model. | ||
Regel 120: | Regel 145: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: CD.png| 16px]] | |style = "text-align:center" |[[Bestand: CD.png| 16px | link=]] | ||
||NL-CM:19.2.5 | ||NL-CM:19.2.5 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: WondSoort">[[Bestand: arrowright.png | 10px]]WoundType</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10120 Title="NL: WondSoort">[[Bestand: arrowright.png | 10px | link=]]WoundType</span> | ||
|1 | |1 | ||
|Description of the type of wound. | |Description of the type of wound. | ||
Regel 130: | Regel 155: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#WoundTypeCodelist|WoundTypeCodelist]] | |[[Bestand: List2.png | link=#WoundTypeCodelist]]||[[#WoundTypeCodelist|WoundTypeCodelist]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: CD.png| 16px]] | |style = "text-align:center" |[[Bestand: CD.png| 16px | link=]] | ||
||NL-CM:19.2.4 | ||NL-CM:19.2.4 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: WondWeefsel">[[Bestand: arrowright.png | 10px]]WoundTissue</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10129 Title="NL: WondWeefsel">[[Bestand: arrowright.png | 10px | link=]]WoundTissue</span> | ||
|0..1 | |0..1 | ||
|Description of the tissue of the wound. For this, the WCS model can be used. A different classification is used for oncological ulcers. | |Description of the tissue of the wound. For this, the WCS model can be used. A different classification is used for oncological ulcers. | ||
Regel 143: | Regel 168: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#WoundTissueOncoUlcerCodelist|WoundTissueOncoUlcerCodelist]] | |[[Bestand: List2.png | link=#WoundTissueOncoUlcerCodelist]]||[[#WoundTissueOncoUlcerCodelist|WoundTissueOncoUlcerCodelist]] | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#WoundTissueWCSCodelist|WoundTissueWCSCodelist]] | |[[Bestand: List2.png | link=#WoundTissueWCSCodelist]]||[[#WoundTissueWCSCodelist|WoundTissueWCSCodelist]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: BL.png| 16px]] | |style = "text-align:center" |[[Bestand: BL.png| 16px | link=]] | ||
||NL-CM:19.2.7 | ||NL-CM:19.2.7 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: WondInfectie">[[Bestand: arrowright.png | 10px]]WoundInfection</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10133 Title="NL: WondInfectie">[[Bestand: arrowright.png | 10px | link=]]WoundInfection</span> | ||
|0..1 | |0..1 | ||
|Indication stating whether the wound is infected. | |Indication stating whether the wound is infected. | ||
Regel 161: | Regel 186: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: CD.png| 16px]] | |style = "text-align:center" |[[Bestand: CD.png| 16px | link=]] | ||
||NL-CM:19.2.6 | ||NL-CM:19.2.6 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: WondVochtigheid">[[Bestand: arrowright.png | 10px]]WoundMoisture</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10130 Title="NL: WondVochtigheid">[[Bestand: arrowright.png | 10px | link=]]WoundMoisture</span> | ||
|0..1 | |0..1 | ||
|Description of the moisture in the wound. | |Description of the moisture in the wound. | ||
Regel 175: | Regel 200: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#WoundMoistureCodelist|WoundMoistureCodelist]] | |[[Bestand: List2.png | link=#WoundMoistureCodelist]]||[[#WoundMoistureCodelist|WoundMoistureCodelist]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: CD.png| 16px]] | |style = "text-align:center" |[[Bestand: CD.png| 16px | link=]] | ||
||NL-CM:19.2.11 | ||NL-CM:19.2.11 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: WondRand">[[Bestand: arrowright.png | 10px]]WoundEdge</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10321 Title="NL: WondRand">[[Bestand: arrowright.png | 10px | link=]]WoundEdge</span> | ||
|0..1 | |0..1 | ||
|Description of the condition of the outer edges of the wound. | |Description of the condition of the outer edges of the wound. | ||
Regel 192: | Regel 217: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#WoundEdgeCodelist|WoundEdgeCodelist]] | |[[Bestand: List2.png | link=#WoundEdgeCodelist]]||[[#WoundEdgeCodelist|WoundEdgeCodelist]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: PQ.png| 16px]] | |style = "text-align:center" |[[Bestand: PQ.png| 16px | link=]] | ||
||NL-CM:19.2.12 | ||NL-CM:19.2.12 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: Wondlengte">[[Bestand: arrowright.png | 10px]]WoundLength</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10720 Title="NL: Wondlengte">[[Bestand: arrowright.png | 10px | link=]]WoundLength</span> | ||
|0..1 | |0..1 | ||
|The length of the wound. | |The length of the wound. | ||
Regel 208: | Regel 233: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: PQ.png| 16px]] | |style = "text-align:center" |[[Bestand: PQ.png| 16px | link=]] | ||
||NL-CM:19.2.13 | ||NL-CM:19.2.13 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: Wondbreedte">[[Bestand: arrowright.png | 10px]]WoundWidth</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10721 Title="NL: Wondbreedte">[[Bestand: arrowright.png | 10px | link=]]WoundWidth</span> | ||
|0..1 | |0..1 | ||
|The width of the wound. | |The width of the wound. | ||
Regel 221: | Regel 246: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: PQ.png| 16px]] | |style = "text-align:center" |[[Bestand: PQ.png| 16px | link=]] | ||
||NL-CM:19.2.14 | ||NL-CM:19.2.14 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: Wonddiepte">[[Bestand: arrowright.png | 10px]]WoundDepth</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10722 Title="NL: Wonddiepte">[[Bestand: arrowright.png | 10px | link=]]WoundDepth</span> | ||
|0..1 | |0..1 | ||
|The depth of the wound. | |The depth of the wound. | ||
Regel 234: | Regel 259: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: CD.png| 16px]] | |style = "text-align:center" |[[Bestand: CD.png| 16px | link=]] | ||
||NL-CM:19.2.8 | ||NL-CM:19.2.8 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: AnatomischeLocatie">[[Bestand: arrowright.png | 10px]]AnatomicalLocation</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10117 Title="NL: AnatomischeLocatie">[[Bestand: arrowright.png | 10px | link=]]AnatomicalLocation</span> | ||
|0..1 | |0..1 | ||
|The location of the wound on the body. | |The location of the wound on the body. | ||
Regel 244: | Regel 269: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: List2.png]]||[[#WoundAnatomicalLocationCodelist|WoundAnatomicalLocationCodelist]] | |[[Bestand: List2.png | link=#WoundAnatomicalLocationCodelist]]||[[#WoundAnatomicalLocationCodelist|WoundAnatomicalLocationCodelist]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: TS.png| 16px]] | |style = "text-align:center" |[[Bestand: TS.png| 16px | link=]] | ||
||NL-CM:19.2.2 | ||NL-CM:19.2.2 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: WondOntstaansdatum">[[Bestand: arrowright.png | 10px]]WoundStartDate</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10131 Title="NL: WondOntstaansdatum">[[Bestand: arrowright.png | 10px | link=]]WoundStartDate</span> | ||
|0..1 | |0..1 | ||
|The date on which the wound appeared. | |The date on which the wound appeared. | ||
Regel 256: | Regel 281: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: TS.png| 16px]] | |style = "text-align:center" |[[Bestand: TS.png| 16px | link=]] | ||
||NL-CM:19.2.3 | ||NL-CM:19.2.3 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: DatumLaatsteVerbandwissel">[[Bestand: arrowright.png | 10px]]DateOfLastDressingChange</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10132 Title="NL: DatumLaatsteVerbandwissel">[[Bestand: arrowright.png | 10px | link=]]DateOfLastDressingChange</span> | ||
|0..1 | |0..1 | ||
|Date on which the dressing was last changed. | |Date on which the dressing was last changed. | ||
Regel 265: | Regel 290: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: Verwijzing.png| 20px]] | |style = "text-align:center" |[[Bestand: Verwijzing.png| 20px | link=]] | ||
||NL-CM:19.2.17 | ||NL-CM:19.2.17 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: Drain::MedischHulpmiddel">[[Bestand: arrowright.png | 10px]]Drain::MedicalAid</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10879 Title="NL: Drain::MedischHulpmiddel">[[Bestand: arrowright.png | 10px | link=]]Drain::MedicalAid</span> | ||
|0..1 | |0..1 | ||
|A drain is a medical aid placed to drain blood and exudate from the wound area. | |A drain is a medical aid placed to drain blood and exudate from the wound area. | ||
Regel 279: | Regel 304: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: block.png]]||[[MedicalDevice-v3.0(2016EN) |MedicalDevice]] | |[[Bestand: block.png | link=MedicalDevice-v3.0(2016EN)]]||[[MedicalDevice-v3.0(2016EN) |MedicalDevice]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: Verwijzing.png| 20px]] | |style = "text-align:center" |[[Bestand: Verwijzing.png| 20px | link=]] | ||
||NL-CM:19.2.10 | ||NL-CM:19.2.10 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: Behandeling::VerpleegkundigeActie">[[Bestand: arrowright.png | 10px]]Treatment::NursingProcedure</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10121 Title="NL: Behandeling::VerpleegkundigeActie">[[Bestand: arrowright.png | 10px | link=]]Treatment::NursingProcedure</span> | ||
|0..* | |0..* | ||
|The nursing procedures required to care for the wound, such as cleaning the wound. Things like the used dressing and bandage materials and the frequency of the dressing changes can be described as well. | |The nursing procedures required to care for the wound, such as cleaning the wound. Things like the used dressing and bandage materials and the frequency of the dressing changes can be described as well. | ||
Regel 292: | Regel 317: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: block.png]]||[[NursingIntervention-v3.0(2016EN) |NursingIntervention]] | |[[Bestand: block.png | link=NursingIntervention-v3.0(2016EN)]]||[[NursingIntervention-v3.0(2016EN) |NursingIntervention]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: Verwijzing.png| 20px]] | |style = "text-align:center" |[[Bestand: Verwijzing.png| 20px | link=]] | ||
||NL-CM:19.2.16 | ||NL-CM:19.2.16 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: GeplandeActie::GeplandeZorgActiviteit">[[Bestand: arrowright.png | 10px]]PlannedProcedure::PlannedCareActivity</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10878 Title="NL: GeplandeActie::GeplandeZorgActiviteit">[[Bestand: arrowright.png | 10px | link=]]PlannedProcedure::PlannedCareActivity</span> | ||
|0..* | |0..* | ||
|The planned (nursing) procedure or 'clinical reminder'. This could for example be a reminder for the time at which the wound dressing is to be replaced or at which the drain is to be placed. | |The planned (nursing) procedure or 'clinical reminder'. This could for example be a reminder for the time at which the wound dressing is to be replaced or at which the drain is to be placed. | ||
Regel 305: | Regel 330: | ||
{| | {| | ||
|- | |- | ||
|[[Bestand: block.png]]||[[PlannedCareActivityForTransfer-v3.0(2016EN) |PlannedCareActivityForTransfer]] | |[[Bestand: block.png | link=PlannedCareActivityForTransfer-v3.0(2016EN)]]||[[PlannedCareActivityForTransfer-v3.0(2016EN) |PlannedCareActivityForTransfer]] | ||
|} | |} | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: ED.png| 16px]] | |style = "text-align:center" |[[Bestand: ED.png| 16px | link=]] | ||
||NL-CM:19.2.15 | ||NL-CM:19.2.15 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: WondFoto">[[Bestand: arrowright.png | 10px]]WoundImage</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10723 Title="NL: WondFoto">[[Bestand: arrowright.png | 10px | link=]]WoundImage</span> | ||
|0..1 | |0..1 | ||
|A photo of the wound. | |A photo of the wound. | ||
Regel 317: | Regel 342: | ||
| | | | ||
|-style="vertical-align:top; background-color: transparent; " | |-style="vertical-align:top; background-color: transparent; " | ||
|style = "text-align:center" |[[Bestand: ST.png| 16px]] | |style = "text-align:center" |[[Bestand: ST.png| 16px | link=]] | ||
||NL-CM:19.2.9 | ||NL-CM:19.2.9 | ||
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | |style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" | | ||
|colspan ="5" style ="padding-left: 0px"|<span Title="NL: Toelichting">[[Bestand: arrowright.png | 10px]]Explanation</span> | |colspan ="5" style ="padding-left: 0px"|<span Id=10125 Title="NL: Toelichting">[[Bestand: arrowright.png | 10px | link=]]Explanation</span> | ||
|0..1 | |0..1 | ||
|Explanation of the wound. | |Explanation of the wound. | ||
Regel 338: | Regel 363: | ||
{|class="wikitable" width="621px" style= "font-size: 9.5pt;" | {|class="wikitable" width="621px" style= "font-size: 9.5pt;" | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="2" style="background-color: #1F497D; width: 100%; color | |colspan="2" style="background-color: #1F497D; width: 100%; "|<font color=#FFFFFF><b>Wond</b></font> | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="width: 42%; "|WondSoort | | style="width: 42%; "|WondSoort | ||
Regel 373: | Regel 398: | ||
| style="width: 58%; "|18-10-2014 | | style="width: 58%; "|18-10-2014 | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
|colspan="2" style="background-color: #4F81BD; width: 100%; color | |colspan="2" style="background-color: #4F81BD; width: 100%; "|<font color=#FFFFFF><b>Behandeling</b></font> | ||
|-style=vertical-align:top; | |-style=vertical-align:top; | ||
| style="width: 42%; "|Activiteit | | style="width: 42%; "|Activiteit | ||
Regel 613: | Regel 638: | ||
==This information model in other releases== | |||
<ul> | |||
<li>[[Wound-v1.0(2015EN) | Release 2015, (Version 1.0)]]</li> | |||
<li>[[Wound-v3.1(2017EN) | Release 2017, (Version 3.1)]]</li> | |||
</ul> | |||
==More on this information model== | ==More on this information model== | ||
To exchange information based on health and care information models, additional, more technical specifications are required.<BR> | |||
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications: | |||
<ul> | |||
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2016bbr-?id=2.16.840.1.113883.2.4.3.11.60.6.4.2.19.2&effectiveDate=2016-05-01T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li> | |||
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR [https://simplifier.net/NictizSTU3/~resources?text=zib&category=StructureDefinition [[File:fhir.png|link=]]]</li> | |||
</ul> | |||
This information model is also available as [[Media:nl.zorg.Wound-v3.0(2016EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.Wound-v3.0(2016EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]] | This information model is also available as [[Media:nl.zorg.Wound-v3.0(2016EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.Wound-v3.0(2016EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]] | ||
==About this information== | ==About this information== | ||
The information in this wikipage is based on Release summer 2016 <BR> | The information in this wikipage is based on Release summer 2016 <BR> | ||
Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR> | Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR> | ||
This page is generated on | This page is generated on 24/01/2018 23:44:58 <BR> | ||
----- | ----- | ||
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Versie van 25 jan 2018 00:13
General information
Name: nl.zorg.Wound
Version: 3.0
HCIM Status:Final
Release: 2016
Release status: Published
Release date: 1-5-2016
Metadata
DCM::CoderList | Werkgroep RadB Verpleegkundige Gegevens |
DCM::ContactInformation.Address | * |
DCM::ContactInformation.Name | * |
DCM::ContactInformation.Telecom | * |
DCM::ContentAuthorList | Werkgroep RadB Verpleegkundige Gegevens |
DCM::CreationDate | 7-7-2014 |
DCM::DeprecatedDate | |
DCM::DescriptionLanguage | nl |
DCM::EndorsingAuthority.Address | |
DCM::EndorsingAuthority.Name | PM |
DCM::EndorsingAuthority.Telecom | |
DCM::Id | 2.16.840.1.113883.2.4.3.11.60.40.3.19.2 |
DCM::KeywordList | Wond, wondzorg, WCS,TIME, ulcus |
DCM::LifecycleStatus | Final |
DCM::ModelerList | Werkgroep RadB Verpleegkundige Gegevens |
DCM::Name | nl.zorg.Wond |
DCM::PublicationDate | 1-5-2016 |
DCM::PublicationStatus | Published |
DCM::ReviewerList | Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron |
DCM::RevisionDate | 8-9-2015 |
DCM::Superseeds | nl.nfu.Wond-v1.0 |
DCM::Version | 3.0 |
HCIM::PublicationLanguage | EN |
Revision History
Only available in Dutch
Publicatieversie 1.0 (01-07-2015)
Publicatieversie 3.0 (01-05-2016)
ZIB-453 | Wijziging naamgeving ZIB's en logo's door andere opzet van beheer |
Concept
A wound is an interruption of the continuity of the skin, often caused by external influences.
A commonly used model for documenting the wound properties is the TIME (‘Tissue’, ‘Infection’, ‘Moisture’, ‘Edge’) model, which can be used to systematically describe the wound. For wound tissue (T in the TIME model), the structure of the WCS model (Woundcare Consultant Society, WCS Kenniscentrum Wondzorg) is used. The WCS model is not suited for describing oncological ulcers. There is a separate classification for that.
Oncological ulcers are skin defects which result from the tumor process. They are different from wounds resulting from cancer treatment, such as radiotherapy, chemotherapy or surgery.
The concept does not describe decubitus wounds and burn wounds. For these, the relevant information models can be used.
Purpose
Information on the wound is recorded to share this information with other healthcare providers. This information can be used to monitor the wound’s healing process and provide insight into the implemented policy. In a transfer situation, it facilitates continuation of the treatment.
Evidence Base
Though the TIME model can be applied to all types of wounds in the list of wound types, the wound tissue classification (T in the TIME model) is different for different types.
The WCS classification is used for surgical wounds, trauma wounds, diabetic foot and venous ulcers. The following values are used:
- Red wound: granulation tissue
- Yellow wound: signs of infection or fibrin layer
- Black wound: with necrosis
(Source: www.wcs.nl)
Tissue in oncological ulcers is classified as follows:
- Degree I: intact epidermis with imminent damage to the skin through underlying tumor tissue
- Degree II: beginning damage to the subcutis
- Degree III: deep continued growth with damaged subcutis
- Degree IV: dry and/or liquefactive necrosis of up to 30% of the wound surface
- Degree V: dry and/or liquefactive necrosis of more than 30% of the wound surface
(Source: www.oncoline.nl)
Information Model
Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | |||||||||
NL-CM:19.2.1 | Wound | Root concept of the Wound information model. This root concept contains all data elements of the Wound information model. | |||||||||||||
NL-CM:19.2.5 | WoundType | 1 | Description of the type of wound. |
| |||||||||||
NL-CM:19.2.4 | WoundTissue | 0..1 | Description of the tissue of the wound. For this, the WCS model can be used. A different classification is used for oncological ulcers. |
| |||||||||||
NL-CM:19.2.7 | WoundInfection | 0..1 | Indication stating whether the wound is infected. |
|
|||||||||||
NL-CM:19.2.6 | WoundMoisture | 0..1 | Description of the moisture in the wound. |
|
| ||||||||||
NL-CM:19.2.11 | WoundEdge | 0..1 | Description of the condition of the outer edges of the wound. |
|
| ||||||||||
NL-CM:19.2.12 | WoundLength | 0..1 | The length of the wound. |
|
|||||||||||
NL-CM:19.2.13 | WoundWidth | 0..1 | The width of the wound. |
|
|||||||||||
NL-CM:19.2.14 | WoundDepth | 0..1 | The depth of the wound. |
|
|||||||||||
NL-CM:19.2.8 | AnatomicalLocation | 0..1 | The location of the wound on the body. |
| |||||||||||
NL-CM:19.2.2 | WoundStartDate | 0..1 | The date on which the wound appeared. | ||||||||||||
NL-CM:19.2.3 | DateOfLastDressingChange | 0..1 | Date on which the dressing was last changed. | ||||||||||||
NL-CM:19.2.17 | Drain::MedicalAid | 0..1 | A drain is a medical aid placed to drain blood and exudate from the wound area. |
|
| ||||||||||
NL-CM:19.2.10 | Treatment::NursingProcedure | 0..* | The nursing procedures required to care for the wound, such as cleaning the wound. Things like the used dressing and bandage materials and the frequency of the dressing changes can be described as well. |
| |||||||||||
NL-CM:19.2.16 | PlannedProcedure::PlannedCareActivity | 0..* | The planned (nursing) procedure or 'clinical reminder'. This could for example be a reminder for the time at which the wound dressing is to be replaced or at which the drain is to be placed. |
| |||||||||||
NL-CM:19.2.15 | WoundImage | 0..1 | A photo of the wound. | ||||||||||||
NL-CM:19.2.9 | Explanation | 0..1 | Explanation of the wound. |
|
Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page
Example Instances
Only available in Dutch
Wond | |
WondSoort | Chirurgische wond |
AnatomischeLocatie | Bovenbuik rechts |
WondOntstaansdatum | 10-10-2014 |
WondWeefsel | Gele wond |
WondInfectie | Nee |
WondVochtigheid | Vochtige wond |
WondRand | Ondermijning |
Wondlengte | 5 cm |
Wondbreedte | 2 cm |
Wonddiepte | 1 cm |
DatumLaatsteVerbandwissel | 18-10-2014 |
Behandeling | |
Activiteit | Dagelijks behandelen met jodium, niet klevend gaasverband en hydrofyber. |
Toelichting | Wond lekt steeds minder. |
References
1. Richtlijn Wondzorg (Nederlandse Vereniging voor Heelkunde, 2013) [Online] Beschikbaar op:http://www.heelkunde.nl/uploads/o1/hI/o1hIRR2oR4QDojTm5pGjGA/Richtlijn-Wondzorg-final.pdf [Geraadpleegd: 13 februari 2015]
2. Richtlijn Oncologische ulcera (2010) [Online] Beschikbaar op:http://www.oncoline.nl/index.php?pagina=/richtlijn/item/pagina.php&id=32570&richtlijn_id=769 [Geraadpleegd: 13 februari 2015]
3. WCS [Online] Beschikbaar op:www.wcs.nl [Geraadpleegd: 13 februari 2015]
4. Oncoline [Online] Beschikbaar op:www.oncoline.nl [Geraadpleegd: 13 februari 2015]
Valuesets
WoundAnatomicalLocationCodelist
Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.6 |
Conceptname | Codesystem name | Codesystem OID |
SNOMED CT: <<91723000 | anatomical structure | | SNOMED CT | 2.16.840.1.113883.6.96 |
WoundEdgeCodelist
Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.5 |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Wound epithelialisation | 449743005 | SNOMED CT | 2.16.840.1.113883.6.96 | Epithelisatie |
Skin irritation | 367466007 | SNOMED CT | 2.16.840.1.113883.6.96 | Irritatie |
Wound tissue undermining | 449752001 | SNOMED CT | 2.16.840.1.113883.6.96 | Ondermijning |
Macerated skin | 3644009 | SNOMED CT | 2.16.840.1.113883.6.96 | Verweking |
Other | OTH | NullFlavor | 2.16.840.1.113883.5.1008 | Anders |
WoundMoistureCodelist
Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.3 |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Droge wond | DROOG | WondVochtigheid | 2.16.840.1.113883.2.4.3.11.60.40.4.7.3 | Droge wond |
Vochtige wond | VOCHTIG | WondVochtigheid | 2.16.840.1.113883.2.4.3.11.60.40.4.7.3 | Vochtige wond |
Natte wond | NAT | WondVochtigheid | 2.16.840.1.113883.2.4.3.11.60.40.4.7.3 | Natte wond |
WoundTissueOncoUlcerCodelist
Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.2 |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Graad I | GRAAD1 | OncoUlcerWeefsel | 2.16.840.1.113883.2.4.3.11.60.40.4.7.1 | Graad I |
Graad II | GRAAD2 | OncoUlcerWeefsel | 2.16.840.1.113883.2.4.3.11.60.40.4.7.1 | Graad II |
Graad III | GRAAD3 | OncoUlcerWeefsel | 2.16.840.1.113883.2.4.3.11.60.40.4.7.1 | Graad III |
Graad IV | GRAAD4 | OncoUlcerWeefsel | 2.16.840.1.113883.2.4.3.11.60.40.4.7.1 | Graad IV |
Graad V | GRAAD5 | OncoUlcerWeefsel | 2.16.840.1.113883.2.4.3.11.60.40.4.7.1 | Graad V |
WoundTissueWCSCodelist
Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.1 |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Rode wond | ROOD | WondWeefselWCS | 2.16.840.1.113883.2.4.3.11.60.40.4.7.2 | granulerend weefsel |
Gele wond | GEEL | WondWeefselWCS | 2.16.840.1.113883.2.4.3.11.60.40.4.7.2 | met infectieverschijnselen of fibrinebeslag |
Zwarte wond | ZWART | WondWeefselWCS | 2.16.840.1.113883.2.4.3.11.60.40.4.7.2 | met necrose |
WoundTypeCodelist
Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.4 |
Conceptname | Conceptcode | Codesystem name | Codesystem OID | Description |
Surgical wound | 112633009 | SNOMED CT | 2.16.840.1.113883.6.96 | Chirurgische wond |
Wound | 416462003 | SNOMED CT | 2.16.840.1.113883.6.96 | Traumatische wond |
Ulcer of lower extremity | 95344007 | SNOMED CT | 2.16.840.1.113883.6.96 | Ulcus cruris |
Secondary malignant neoplasm of skin | 94579000 | SNOMED CT | 2.16.840.1.113883.6.96 | Oncologische ulcer |
Radiation ulcer | 403722002 | SNOMED CT | 2.16.840.1.113883.6.96 | Stralingswond |
Diabetic foot ulcer | 371087003 | SNOMED CT | 2.16.840.1.113883.6.96 | Ulcus van diabetische voet |
Other | OTH | NullFlavor | 2.16.840.1.113883.5.1008 | Anders |
This information model in other releases
More on this information model
To exchange information based on health and care information models, additional, more technical specifications are required.
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:
- HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment
- HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR
This information model is also available as pdf file or as spreadsheet
About this information
The information in this wikipage is based on Release summer 2016
Conditions for use are located on the mainpage
This page is generated on 24/01/2018 23:44:58