PressureUlcer-v3.2(2018EN)

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General information

Name: nl.zorg.PressureUlcer NL.png
Version: 3.2
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018


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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 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)

ZIB-646 Aanpassing SNOMED codes

.

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


#DecubitusAnatomicalLocationCodelist#12318#10087#10088#10089#10090#DecubitusCategoryCodelist#10177#DecubitusWoundLateralityCodelist#10724#10681#10725#10726#10727PressureUlcer-v3.2Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:19.1.1 Arrowdown.pngPressureUlcer Root concept of the DecubitusWound information model. This root concept contains all data elements of the DecubitusWound information model.
399912005 Pressure ulcer
CO.png NL-CM:19.1.2 Arrowright.pngDecubitusCategory 1 Description of the condition of the pressure ulcer, ranging from category 1 - 4.
45780-4 Pressure injury stage [Minimum Data Set]
List2.png DecubitusCategoryCodelist
TS.png NL-CM:19.1.3 Arrowright.pngDateOfOnset 0..1 The date on which the pressure ulcer appeared.
CD.png NL-CM:19.1.4 Arrowright.pngAnatomicalLocation 0..1 The location of the decubitus wound on the body.
363698007 Finding site
List2.png DecubitusAnatomicalLocationCodelist
CD.png NL-CM:19.1.13 Arrowright.pngLaterality 0..1 Laterality adds information about body side to the anatomic location, e.g. left
272741003 Laterality
List2.png DecubitusWoundLateralityCodelist
TS.png NL-CM:19.1.8 Arrowright.pngDateOfLastDressingChange 0..1 The date on which the dressing was last changed.
PQ.png NL-CM:19.1.9 Arrowright.pngWoundLength 0..1 The length of the decubitus wound.
39126-8 Length of Wound
PQ.png NL-CM:19.1.10 Arrowright.pngWoundWidth 0..1 The width of the decubitus wound.
39125-0 Width of Wound
PQ.png NL-CM:19.1.11 Arrowright.pngWoundDepth 0..1 The depth of the decubitus wound.
39127-6 Depth of Wound
ED.png NL-CM:19.1.12 Arrowright.pngWoundImage 0..* A photo of the decubitus wound as visual information.
72170-4 Photographic image
ST.png NL-CM:19.1.5 Arrowright.pngComment 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 List2.png

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

This information model refers to

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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 Artdecor.jpg
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png

Downloads

This information model is also available as pdf file PDF.png or as spreadsheet Xlsx.png

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 List2.png
This page is generated on 01/11/2018 22:21:37 with ZibExtraction v. 2.0.6879.31307


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