General information
Name: nl.zorg.Wound 
Version: 3.0
HCIM Status:Final
Publication: 2016
Release status: Published
Publication 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.
|
| 405009004 Infection status
|
|
|
|
|
NL-CM:19.2.6
|
|
WoundMoisture
|
0..1
|
Description of the moisture in the wound.
|
| 298007001 Moistness of wound
|
|
|
|
|
NL-CM:19.2.11
|
|
WoundEdge
|
0..1
|
Description of the condition of the outer edges of the wound.
|
| 449747006 Wound edge finding
|
|
|
|
NL-CM:19.2.12
|
|
WoundLength
|
0..1
|
The length of the wound.
|
| 401238003 Length of 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.
|
| 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 
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
|
More on this information model
More technical information and HL7/XML documentation you can find on the Nictiz Art-Decor page about this information model[1]
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 28/09/2017 01:10:49
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Wound
WoundType
