Wound-v3.1(2017EN)

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General information

Name: nl.zorg.Wound
Version: 3.1
HCIM Status:Final
Publication: 2017
Release status: Prepublished
Publication date: 04-09-2017

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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 04-09-2017
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep RadB Verpleegkundige Gegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 04-09-2017
DCM::Superseeds nl.zorg.Wond-v3.0
DCM::Version 3.1
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-572 Toevoegen code voor Skin Tear
ZIB-585 Toevoegen concept Lateraliteit aan het concept Anatomische Locatie

.

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 health professionals. 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.
WoundTypeCodelist
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.
WoundTissueOncoUlcerCodelist
WoundTissueWCSCodelist
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
WoundMoistureCodelist
NL-CM:19.2.11 WoundEdge 0..1 Description of the condition of the outer edges of the wound.
449747006 Wound edge finding
WoundEdgeCodelist
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.
401239006 Width of wound
NL-CM:19.2.14 WoundDepth 0..1 The depth of the wound.
425094009 Depth of wound
NL-CM:19.2.8 AnatomicalLocation 0..1 The location of the wound on the body.
363698007 Finding site
WoundAnatomicalLocationCodelist
NL-CM:19.2.18 Laterality 0..1 Laterality adds information about body side to the anatomic location, e.g. left
272741003 Laterality
WoundLateralityCodelist
NL-CM:19.2.2 WoundDateOfOnset 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::MedicalDevice 0..1 A drain is a medical aid placed to drain blood and exudate from the wound area.
258646005 Wound drain
MedicalDevice
NL-CM:10.1.3 ProductType Type of drain applied to the wound.
WoundDrainTypeCodelist
NL-CM:19.2.15 WoundImage 0..* A photo of the wound.
NL-CM:19.2.9 Comment 0..1 Comment on 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
Lateraliteit 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
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: < 442083009 |Anatomical or acquired body structure| SNOMED CT 2.16.840.1.113883.6.96

WoundDrainTypeCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.7
Conceptname Codesystem name Codesystem OID
SNOMED CT: << 32712000| drain | 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

WoundLateralityCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.8
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

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
Skin tear 428220001 SNOMED CT 2.16.840.1.113883.6.96 Skin tear
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 Prerelease 2017 #1
Conditions for use are located on the mainpage
This page is generated on 21/09/2017 15:49:09

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