Wound-v1.0(2015EN): verschil tussen versies

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The information in this wikipage is based on<!--ftInfoBase--> ''Registratie aan de bron'' publication 2015 including errata dd. 16-07-2015 <BR>
The information in this wikipage is based on<!--ftInfoBase--> ''Registratie aan de bron'' publication 2015 including errata dd. 16-07-2015 <BR>
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Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
This page is generated on 20/12/2018 12:43:54 with ZibExtraction v. 3.0.6928.22723<!--ftDate--> <BR>
This page is generated on 20/12/2018 16:37:08 with ZibExtraction v. 3.0.6928.28729<!--ftDate--> <BR>
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Versie van 20 dec 2018 16:23


Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.nfu.Wound NL.png
Version: 1.0
HCIM Status:Final
Release: 2015
Release status: Published
Release date: 8-9-2015

Back 16.png Back to HCIM list

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 NFU & V&VN
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.nfu.Wond
DCM::PublicationDate 8-9-2015
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 8-9-2015
DCM::Superseeds
DCM::Version 1.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-07-2015).

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 building blocks 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


#WoundEdgeCodelist#WoundAnatomicalLocationCodelist#WoundTypeCodelistNursingIntervention-v1.0(2015EN)#10125#10129#10130#10131#10132#10133#WoundTissueWCSCodelist#WoundMoistureCodelist#10120#10117#10119PlannedCareActivityForTransfer-v1.2.1(2015EN)MedicalDevice-v1.2(2015EN)#10321#WoundTissueOncoUlcerCodelist#10720#10721#10722#10723Wound-v1.0Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:19.2.1 Arrowdown.pngWound Root concept of the Wound building block. This root concept contains all data elements of the Wound building block.
CD.png NL-CM:19.2.5 Arrowright.pngWoundType 1 Description of the type of wound.
List2.png WoundTypeCodelist
CD.png NL-CM:19.2.4 Arrowright.pngWoundTissue 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.
List2.png WoundTissueOncoUlcerCodelist
List2.png WoundTissueWCSCodelist
BL.png NL-CM:19.2.7 Arrowright.pngWoundInfection 0..1 Indication stating whether the wound is infected.
405009004 Infection status
CD.png NL-CM:19.2.6 Arrowright.pngWoundMoisture 0..1 Description of the moisture in the wound.
298007001 Moistness of wound
List2.png WoundMoistureCodelist
CD.png NL-CM:19.2.11 Arrowright.pngWoundEdge 0..1 Description of the condition of the outer edges of the wound.
449747006 Wound edge finding
List2.png WoundEdgeCodelist
PQ.png NL-CM:19.2.12 Arrowright.pngWoundLength 0..1 The length of the wound.
401238003 Length of wound
PQ.png NL-CM:19.2.13 Arrowright.pngWoundWidth 0..1 The width of the wound.
401239006 Width of wound
PQ.png NL-CM:19.2.14 Arrowright.pngWoundDepth 0..1 The depth of the wound.
425094009 Depth of wound
CD.png NL-CM:19.2.8 Arrowright.pngAnatomicalLocation 0..1 The location of the wound on the body.
List2.png WoundAnatomicalLocationCodelist
TS.png NL-CM:19.2.2 Arrowright.pngWoundStartDate 0..1 The date on which the wound appeared.
TS.png NL-CM:19.2.3 Arrowright.pngDateOfLastDressingChange 0..1 Date on which the dressing was last changed.
Verwijzing.png NL-CM:19.2.17 Arrowright.pngDrain::MedicalAid 0..1 A drain is a medical aid placed to drain blood and exudate from the wound area.
258646005 Wound drain
Block.png MedicalDevice
Verwijzing.png NL-CM:19.2.10 Arrowright.pngTreatment::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.
Block.png NursingIntervention
Verwijzing.png NL-CM:19.2.16 Arrowright.pngPlannedProcedure::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.
Block.png PlannedCareActivityForTransfer
ED.png NL-CM:19.2.15 Arrowright.pngWoundImage 0..1 A photo of the wound.
ST.png NL-CM:19.2.9 Arrowright.pngExplanation 0..1 Explanation of the wound.
48767-8 Annotation comment

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page List2.png

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 Binding:
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 Binding:
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 Binding:
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 Binding:
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 Binding:
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 Binding:
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

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About this information

The information in this wikipage is based on Registratie aan de bron publication 2015 including errata dd. 16-07-2015
Conditions for use are located on the mainpage List2.png
This page is generated on 20/12/2018 16:37:08 with ZibExtraction v. 3.0.6928.28729

Back 16.png Back to HCIM list
Overgenomen van "https://zibs.test-nictiz.nl/index.php?title=Wound-v1.0(2015EN)&oldid=15050"