Wound-v3.0(2016EN): verschil tussen versies
(Een tussenliggende versie door dezelfde gebruiker niet weergegeven) | |||
Regel 1: | Regel 1: | ||
− | ==General information== | + | <!-- Hieronder wordt een transclude page aangeroepen --> |
− | Name: '''nl.zorg.Wound''' [[Bestand:NL.png|link=Wond-v3.0(2016NL)]]<BR> | + | {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.19.2(EN)|1|Wound-v3.0(2016EN)}} |
− | Version: '''3.0''' <br> | + | <!-- Tot hier de transclude page --> |
− | HCIM Status:Final<br> | + | ==General information<!--hdGeneralInformation-->== |
− | Release: '''2016''' <br> | + | Name<!--hdName-->: '''nl.zorg.Wound''' [[Bestand:NL.png|link=Wond-v3.0(2016NL)]]<BR> |
− | Release status: Published<br> | + | Version<!--hdVersion-->: '''3.0''' <br> |
− | Release date: 1-5-2016 | + | HCIM Status<!--hdStatus-->:Final<br> |
+ | Release<!--hdPublication-->: '''2016''' <br> | ||
+ | Release status<!--hdPublicationStatus-->: Published<br> | ||
+ | Release date<!--hdPublicationDate-->: 1-5-2016 | ||
----- | ----- | ||
− | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= | + | <div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2016(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2016(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div> |
==Metadata== | ==Metadata== | ||
Regel 61: | Regel 64: | ||
==Revision History== | ==Revision History== | ||
<div class="mw-collapsible mw-collapsed"> | <div class="mw-collapsible mw-collapsed"> | ||
− | ''Only available in Dutch'' | + | ''Only available in Dutch<!--noTranslation-->'' |
<u>Publicatieversie 1.0</u> (01-07-2015) | <u>Publicatieversie 1.0</u> (01-07-2015) | ||
Regel 106: | Regel 109: | ||
==Information Model== | ==Information Model== | ||
<BR> | <BR> | ||
− | <imagemap> Bestand:Wound-v3.0Model( | + | <imagemap> Bestand:Wound-v3.0Model(2016EN).png | center |
− | rect | + | rect 810 636 930 686 [[#WoundEdgeCodelist]] |
− | rect | + | rect 91 332 283 382 [[#WoundAnatomicalLocationCodelist]] |
− | rect | + | rect 92 235 284 285 [[#WoundTypeCodelist]] |
− | rect | + | rect 471 43 599 113 [[NursingIntervention-v3.0(2016EN)]] |
− | rect | + | rect 303 408 431 478 [[#10125]] |
− | rect | + | rect 305 516 433 586 [[#10129]] |
− | rect | + | rect 634 516 762 586 [[#10130]] |
− | rect | + | rect 303 134 431 204 [[#10131]] |
− | rect | + | rect 795 407 944 477 [[#10132]] |
− | rect | + | rect 476 516 604 586 [[#10133]] |
− | rect | + | rect 205 637 361 687 [[#WoundTissueWCSCodelist]] |
− | rect | + | rect 622 637 772 687 [[#WoundMoistureCodelist]] |
− | rect | + | rect 303 225 431 295 [[#10120]] |
− | rect | + | rect 302 322 430 392 [[#10117]] |
− | rect | + | rect 559 192 659 272 [[#10119]] |
− | rect | + | rect 636 43 764 113 [[PlannedCareActivityForTransfer-v3.0(2016EN)]] |
− | rect | + | rect 300 43 436 113 [[MedicalDevice-v3.0(2016EN)]] |
− | rect | + | rect 795 516 943 586 [[#10321]] |
− | rect | + | rect 236 704 391 754 [[#WoundTissueOncoUlcerCodelist]] |
− | rect | + | rect 795 43 944 113 [[#10720]] |
− | rect | + | rect 795 134 944 204 [[#10721]] |
− | rect | + | rect 795 225 944 295 [[#10722]] |
− | rect | + | rect 795 316 944 386 [[#10723]] |
desc none | desc none | ||
</imagemap> | </imagemap> | ||
Regel 135: | Regel 138: | ||
{| 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" | ||
|-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; " | |-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; " | ||
− | |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<!--imType-->||style="width:100px;"|Id<!--imId-->||colspan="6 " style="width:140px;"|Concept<!--imConcept-->||Card.<!--imCard-->||style="width: 600px;"|Definition<!--imDefinition-->||style="width:200px;"|DefinitionCode<!--imDefinitionCode-->||style="width:200px;"|Reference<!--imReference--> |
|-style="vertical-align:top; background-color: #E3E3E3; " | |-style="vertical-align:top; background-color: #E3E3E3; " | ||
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]] | |style = "text-align:center" |[[Bestand: block.png| 20px | link=]] | ||
Regel 182: | Regel 185: | ||
{| | {| | ||
|- | |- | ||
− | |<span | + | |<span title = "Codesystem: SNOMED CT>[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=405009004 405009004] Infection status</span> |
|} | |} | ||
| | | | ||
Regel 195: | Regel 198: | ||
{| | {| | ||
|- | |- | ||
− | |<span | + | |<span title = "Codesystem: SNOMED CT>[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=298007001 298007001] Moistness of wound</span> |
|} | |} | ||
| | | | ||
Regel 212: | Regel 215: | ||
{| | {| | ||
|- | |- | ||
− | |<span | + | |<span title = "Codesystem: SNOMED CT>[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=449747006 449747006] Wound edge finding</span> |
|} | |} | ||
| | | | ||
Regel 229: | Regel 232: | ||
{| | {| | ||
|- | |- | ||
− | |<span | + | |<span title = "Codesystem: SNOMED CT>[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=401238003 401238003] Length of wound</span> |
|} | |} | ||
| | | | ||
Regel 242: | Regel 245: | ||
{| | {| | ||
|- | |- | ||
− | |<span | + | |<span title = "Codesystem: SNOMED CT>[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=401239006 401239006] Width of wound</span> |
|} | |} | ||
| | | | ||
Regel 255: | Regel 258: | ||
{| | {| | ||
|- | |- | ||
− | |<span | + | |<span title = "Codesystem: SNOMED CT>[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=425094009 425094009] Depth of wound</span> |
|} | |} | ||
| | | | ||
Regel 299: | Regel 302: | ||
{| | {| | ||
|- | |- | ||
− | |<span | + | |<span title = "Codesystem: SNOMED CT>[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=258646005 258646005] Wound drain</span> |
|} | |} | ||
| | | | ||
Regel 351: | Regel 354: | ||
{| | {| | ||
|- | |- | ||
− | |<span | + | |<span title = "Codesystem: LOINC>[https://terminologie.nictiz.nl/art-decor/loinc?conceptId=48767-8 48767-8] Annotation comment</span> |
|} | |} | ||
| | | | ||
|} | |} | ||
− | Columns Concept and DefinitionCode: hover over the values for more information<BR> | + | Columns Concept and DefinitionCode: hover over the values for more information<!--imHover--><BR> |
− | For explanation of the symbols, please see the legend page [[Bestand:list2.png|link=Legend]] | + | For explanation of the symbols, please see the legend page<!--imLegend--> [[Bestand:list2.png|link=Legend<!--wikiLegend-->]] |
==Example Instances== | ==Example Instances== | ||
− | ''Only available in Dutch'' | + | ''Only available in Dutch<!--noTranslation-->'' |
{|class="wikitable" width="621px" style= "font-size: 9.5pt;" | {|class="wikitable" width="621px" style= "font-size: 9.5pt;" | ||
Regel 422: | Regel 425: | ||
{| class="wikitable" width="60%" | {| class="wikitable" width="60%" | ||
|-style='vertical-align:top; background-color: #E8D7BE;' | |-style='vertical-align:top; background-color: #E8D7BE;' | ||
− | |Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.6 | + | |Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.6 |
+ | |Binding<!--vsBindingTag-->: | ||
|} | |} | ||
{| class="wikitable" width="60% " | {| class="wikitable" width="60% " | ||
|-style="background-color: #1F497D; color: white; font-weight: bold; " | |-style="background-color: #1F497D; color: white; font-weight: bold; " | ||
− | |Conceptname | + | |Conceptname<!--vsConceptName--> |
− | |Codesystem name||Codesystem OID | + | |Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--> |
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
− | |SNOMED CT: <<91723000 <noWiki>|</noWiki> anatomical structure <noWiki>|</noWiki> | + | |SNOMED CT: <<[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=91723000 91723000]<noWiki>|</noWiki>anatomical structure<noWiki>|</noWiki> |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
|} | |} | ||
− | |||
=== WoundEdgeCodelist=== | === WoundEdgeCodelist=== | ||
{| class="wikitable" width="60%" | {| class="wikitable" width="60%" | ||
|-style='vertical-align:top; background-color: #E8D7BE;' | |-style='vertical-align:top; background-color: #E8D7BE;' | ||
− | |Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.5 | + | |Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.5 |
+ | |Binding<!--vsBindingTag-->: | ||
|} | |} | ||
{| class="wikitable" width="60% " | {| class="wikitable" width="60% " | ||
|-style="background-color: #1F497D; color: white; font-weight: bold; " | |-style="background-color: #1F497D; color: white; font-weight: bold; " | ||
− | |Conceptname | + | |Conceptname<!--vsConceptName--> |
− | |Conceptcode | + | |Conceptcode<!--vsConceptCode--> |
− | |Codesystem name||Codesystem OID | + | |Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--> |
− | |Description | + | |Description<!--vsDescription--> |
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Wound epithelialisation | |Wound epithelialisation | ||
− | |449743005 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=449743005 449743005] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 453: | Regel 457: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Skin irritation | |Skin irritation | ||
− | |367466007 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=367466007 367466007] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 459: | Regel 463: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Wound tissue undermining | |Wound tissue undermining | ||
− | |449752001 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=449752001 449752001] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 465: | Regel 469: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Macerated skin | |Macerated skin | ||
− | |3644009 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=3644009 3644009] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 476: | Regel 480: | ||
|Anders | |Anders | ||
|} | |} | ||
− | |||
=== WoundMoistureCodelist=== | === WoundMoistureCodelist=== | ||
{| class="wikitable" width="60%" | {| class="wikitable" width="60%" | ||
|-style='vertical-align:top; background-color: #E8D7BE;' | |-style='vertical-align:top; background-color: #E8D7BE;' | ||
− | |Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.3 | + | |Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.3 |
+ | |Binding<!--vsBindingTag-->: | ||
|} | |} | ||
{| class="wikitable" width="60% " | {| class="wikitable" width="60% " | ||
|-style="background-color: #1F497D; color: white; font-weight: bold; " | |-style="background-color: #1F497D; color: white; font-weight: bold; " | ||
− | |Conceptname | + | |Conceptname<!--vsConceptName--> |
− | |Conceptcode | + | |Conceptcode<!--vsConceptCode--> |
− | |Codesystem name||Codesystem OID | + | |Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--> |
− | |Description | + | |Description<!--vsDescription--> |
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Droge wond | |Droge wond | ||
Regel 507: | Regel 511: | ||
|Natte wond | |Natte wond | ||
|} | |} | ||
− | |||
=== WoundTissueOncoUlcerCodelist=== | === WoundTissueOncoUlcerCodelist=== | ||
{| class="wikitable" width="60%" | {| class="wikitable" width="60%" | ||
|-style='vertical-align:top; background-color: #E8D7BE;' | |-style='vertical-align:top; background-color: #E8D7BE;' | ||
− | |Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.2 | + | |Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.2 |
+ | |Binding<!--vsBindingTag-->: | ||
|} | |} | ||
{| class="wikitable" width="60% " | {| class="wikitable" width="60% " | ||
|-style="background-color: #1F497D; color: white; font-weight: bold; " | |-style="background-color: #1F497D; color: white; font-weight: bold; " | ||
− | |Conceptname | + | |Conceptname<!--vsConceptName--> |
− | |Conceptcode | + | |Conceptcode<!--vsConceptCode--> |
− | |Codesystem name||Codesystem OID | + | |Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--> |
− | |Description | + | |Description<!--vsDescription--> |
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Graad I | |Graad I | ||
Regel 550: | Regel 554: | ||
|Graad V | |Graad V | ||
|} | |} | ||
− | |||
=== WoundTissueWCSCodelist=== | === WoundTissueWCSCodelist=== | ||
{| class="wikitable" width="60%" | {| class="wikitable" width="60%" | ||
|-style='vertical-align:top; background-color: #E8D7BE;' | |-style='vertical-align:top; background-color: #E8D7BE;' | ||
− | |Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.1 | + | |Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.1 |
+ | |Binding<!--vsBindingTag-->: | ||
|} | |} | ||
{| class="wikitable" width="60% " | {| class="wikitable" width="60% " | ||
|-style="background-color: #1F497D; color: white; font-weight: bold; " | |-style="background-color: #1F497D; color: white; font-weight: bold; " | ||
− | |Conceptname | + | |Conceptname<!--vsConceptName--> |
− | |Conceptcode | + | |Conceptcode<!--vsConceptCode--> |
− | |Codesystem name||Codesystem OID | + | |Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--> |
− | |Description | + | |Description<!--vsDescription--> |
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Rode wond | |Rode wond | ||
Regel 581: | Regel 585: | ||
|met necrose | |met necrose | ||
|} | |} | ||
− | |||
=== WoundTypeCodelist=== | === WoundTypeCodelist=== | ||
{| class="wikitable" width="60%" | {| class="wikitable" width="60%" | ||
|-style='vertical-align:top; background-color: #E8D7BE;' | |-style='vertical-align:top; background-color: #E8D7BE;' | ||
− | |Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.4 | + | |Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.19.2.4 |
+ | |Binding<!--vsBindingTag-->: | ||
|} | |} | ||
{| class="wikitable" width="60% " | {| class="wikitable" width="60% " | ||
|-style="background-color: #1F497D; color: white; font-weight: bold; " | |-style="background-color: #1F497D; color: white; font-weight: bold; " | ||
− | |Conceptname | + | |Conceptname<!--vsConceptName--> |
− | |Conceptcode | + | |Conceptcode<!--vsConceptCode--> |
− | |Codesystem name||Codesystem OID | + | |Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--> |
− | |Description | + | |Description<!--vsDescription--> |
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Surgical wound | |Surgical wound | ||
− | |112633009 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=112633009 112633009] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 601: | Regel 605: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Wound | |Wound | ||
− | |416462003 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=416462003 416462003] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 607: | Regel 611: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Ulcer of lower extremity | |Ulcer of lower extremity | ||
− | |95344007 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=95344007 95344007] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 613: | Regel 617: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Secondary malignant neoplasm of skin | |Secondary malignant neoplasm of skin | ||
− | |94579000 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=94579000 94579000] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 619: | Regel 623: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Radiation ulcer | |Radiation ulcer | ||
− | |403722002 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=403722002 403722002] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 625: | Regel 629: | ||
|-style="vertical-align:top; " | |-style="vertical-align:top; " | ||
|Diabetic foot ulcer | |Diabetic foot ulcer | ||
− | |371087003 | + | |[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=371087003 371087003] |
|SNOMED CT | |SNOMED CT | ||
|2.16.840.1.113883.6.96 | |2.16.840.1.113883.6.96 | ||
Regel 637: | Regel 641: | ||
|} | |} | ||
− | + | ==This information model in other releases<!--ftOtherReleases-->== | |
− | ==This information model in other releases== | + | <!-- Hieronder wordt een transclude page aangeroepen --> |
− | < | + | {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.19.2(EN)|2|2016}} |
− | < | + | <!-- Tot hier de transclude page --> |
− | + | ==Information model references<!--ftReferences-->== | |
− | + | ====This information model refers to<!--ftRefersTo-->==== | |
− | == | + | *[[MedicalDevice-v3.0(2016EN)|MedicalDevice-v3.0]] |
+ | *[[NursingIntervention-v3.0(2016EN)|NursingIntervention-v3.0]] | ||
+ | *[[PlannedCareActivityForTransfer-v3.0(2016EN)|PlannedCareActivityForTransfer-v3.0]] | ||
+ | ====This information model is used in<!--ftReferredBy-->==== | ||
+ | :-- | ||
+ | ==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->== | ||
To exchange information based on health and care information models, additional, more technical specifications are required.<BR> | 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: | + | Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro--> |
<ul> | <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® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [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 | + | <li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2016}}</li> |
</ul> | </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=]] | + | ==Downloads<!--ftDownloadTitle-->== |
− | ==About this information== | + | 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=]]<!--ftDownloads--> |
− | The information in this wikipage is based on Release summer 2016 <BR> | + | ==About this information<!--ftHeader2-->== |
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Huidige versie van 24 dec 2018 om 12:11
Inhoud
- 1 General information
- 2 Metadata
- 3 Revision History
- 4 Concept
- 5 Purpose
- 6 Evidence Base
- 7 Information Model
- 8 Example Instances
- 9 References
- 10 Valuesets
- 11 This information model in other releases
- 12 Information model references
- 13 Technical specifications in HL7v3 CDA and HL7 FHIR
- 14 Downloads
- 15 About this information
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 | 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 |
This information model in other releases
- Release 2015, (Version 1.0)
- Release 2017, (Version 3.1)
- Prerelease 2018-2, (Version 3.1)
- Prerelease 2019-2, (Version 3.2)
- Release 2020, (Version 3.3)
- Prerelease 2021-2, (Version 3.4)
- Prerelease 2022-1, (Version 3.4)
- Prerelease 2023-1, (Version 3.5)
- Prerelease 2024-1, (Version 3.6)
Information model references
This information model refers to
This information model is used in
- --
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 Release summer 2016
Conditions for use are located on the mainpage
This page is generated on 21/12/2018 16:29:38 with ZibExtraction v. 3.0.6929.24609