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General information
Name: nl.zorg.PressureUlcer
Version: 3.2
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018
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 |
2.16.840.1.113883.2.4.3.11.60.40.3.19.1
|
DCM::KeywordList |
Decubitus, doorligwond, wond
|
DCM::LifecycleStatus |
Final
|
DCM::ModelerList |
Werkgroep RadB Verpleegkundige Gegevens
|
DCM::Name |
nl.zorg.DecubitusWond
|
DCM::PublicationDate |
01-10-2018
|
DCM::PublicationStatus |
Prepublished
|
DCM::ReviewerList |
Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron
|
DCM::RevisionDate |
31-12-2017
|
DCM::Superseeds |
nl.zorg.DecubitusWond-v3.1
|
DCM::Version |
3.2
|
HCIM::PublicationLanguage |
EN
|
Revision History
Only available in Dutch
Publicatieversie 1.0 (01-07-2015)
Publicatieversie 3.0 (01-05-2016)
Publicatieversie 3.1 (04-09-2017)
ZIB-530
|
Verwijzingen naar de bouwsteen Verpleegkundige Interventie verwijderd
|
ZIB-533
|
Toestaan dat de bouwsteen meer dan één foto kan bevatten
|
ZIB-549
|
De Engelse naam van de bouwsteen en het rootconcept zijn niet correct
|
ZIB-585
|
Toevoegen concept Lateraliteit aan het concept Anatomische Locatie
|
Publicatieversie 3.2 (31-12-2017)
.
Concept
A pressure ulcer is localized damage to the skin and/or underlying tissue, often over a bony prominence, as a result of pressure or pressure combined with friction.
A pressure ulcer involves a major disease burden and reduces the quality of life for a patient. Adequate risk evaluation, prevention and treatment of pressure ulcers can lead to a fewer incidences and prevalence of pressure ulcers.
Purpose
Information on the pressure ulcer is of importance in starting or continuing the best possible wound treatment, curatively and preventatively, and to be able to properly monitor the wound healing process.
Evidence Base
To describe the wound, there are 4 categories, based on the international NPUAP/EPUAP decubitus classification system:
- Category 1: non-removable redness of intact skin;
- Category 2: loss of a partial layer of skin or blister;
- Category 3: loss of an entire layer of skin (visible fat);
- Category 4: loss of an entire layer of tissue (visible muscle/bone).
Information Model
Type |
Id |
Concept |
Card. |
Definition |
DefinitionCode |
Reference
|
|
NL-CM:19.1.1
|
PressureUlcer
|
|
Root concept of the DecubitusWound information model. This root concept contains all data elements of the DecubitusWound information model.
|
|
|
|
NL-CM:19.1.2
|
|
DecubitusCategory
|
1
|
Description of the condition of the pressure ulcer, ranging from category 1 - 4.
|
45780-4 Pressure injury stage [Minimum Data Set]
|
|
|
|
NL-CM:19.1.3
|
|
DateOfOnset
|
0..1
|
The date on which the pressure ulcer appeared.
|
|
|
|
NL-CM:19.1.4
|
|
AnatomicalLocation
|
0..1
|
The location of the decubitus wound on the body.
|
|
|
|
NL-CM:19.1.13
|
|
Laterality
|
0..1
|
Laterality adds information about body side to the anatomic location, e.g. left
|
|
|
|
NL-CM:19.1.8
|
|
DateOfLastDressingChange
|
0..1
|
The date on which the dressing was last changed.
|
|
|
|
NL-CM:19.1.9
|
|
WoundLength
|
0..1
|
The length of the decubitus wound.
|
|
|
|
NL-CM:19.1.10
|
|
WoundWidth
|
0..1
|
The width of the decubitus wound.
|
|
|
|
NL-CM:19.1.11
|
|
WoundDepth
|
0..1
|
The depth of the decubitus wound.
|
|
|
|
NL-CM:19.1.12
|
|
WoundImage
|
0..*
|
A photo of the decubitus wound as visual information.
|
|
|
|
NL-CM:19.1.5
|
|
Comment
|
0..1
|
A comment of the decubitus wound.
|
48767-8 Annotation comment [Interpretation] Narrative
|
|
|
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
DecubitusWond
|
AnatomischeLocatie
|
Hiel
|
Lateraliteit
|
Links
|
DecubitusCategorie
|
Decubitus categorie 2
|
Wondlengte
|
3 cm
|
Wondbreedte
|
2 cm
|
Wonddiepte
|
-
|
OntstaansDatum
|
01-09-2014
|
Toelichting
|
Blaar met vocht op hiel.
|
References
1. V&VN (2011) Landelijke multidisciplinaire richtlijn. Decubitus preventie en behandeling. [Online] Beschikbaar op:www.diliguide.nl/document/1613/file/pdf/ [Geraadpleegd: 13 februari 2015]
Valuesets
DecubitusAnatomicalLocationCodelist
Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.19.1.2
|
Binding: Extensible
|
Conceptname
|
Codesystem name |
Codesystem OID
|
SNOMED CT: < 442083009|Anatomical or acquired body structure|
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
DecubitusCategoryCodelist
Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.19.1.1
|
Binding: Required
|
Conceptname
|
Conceptcode
|
Conceptvalue
|
Codesystem name |
Codesystem OID
|
Description
|
Pressure ulcer stage 1
|
421076008
|
1
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Decubitus categorie 1
|
Pressure ulcer stage 2
|
420324007
|
2
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Decubitus categorie 2
|
Pressure ulcer stage 3
|
421927004
|
3
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Decubitus categorie 3
|
Pressure ulcer stage 4
|
420597008
|
4
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Decubitus categorie 4
|
DecubitusWoundLateralityCodelist
Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.19.1.3
|
Binding: Required
|
Conceptname
|
Conceptcode
|
Codesystem name |
Codesystem OID
|
Description
|
Left
|
7771000
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Links
|
Right
|
24028007
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Rechts
|
Right and left
|
51440002
|
SNOMED CT
|
2.16.840.1.113883.6.96
|
Rechts en links
|
This information model in other releases
Information model references
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This inforation model is used in
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Technical specifications in HL7v3 CDA and HL7 FHIR
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
Downloads
This information model is also available as pdf file or as spreadsheet
About this information
The information in this wikipage is based on Prerelease 2018 #1
SNOMED CT and LOINC codes are based on:
- SNOMED Clinical Terms version: 20180731 [R] (July 2018 Release)
- LOINC version 2.64
Conditions for use are located on the mainpage
This page is generated on 01/11/2018 22:21:37 with ZibExtraction v. 2.0.6879.31307