HL7 FHIR Profile: Skin and Wound Assessment, Release 1 (For Comment)

WoundPresenceAssertionModel

 

The official URL for this logical model is: 

http://hl7.org/fhir/us/sw/StructureDefinition/sw-WoundPresenceAssertion-model

A determination that a wound that exists at a particular body site. The WoundIdentifier serves as a link between this assertion and assessments of the wound that might occur at later times. Multiple wound assessments can be associated with a single wound.

This logical model was published on Fri Aug 17 00:00:00 EDT 2018 as a draft by HL7 Patient Care and Clinical Information Modeling Initiative Work Groups.

View the corresponding WoundPresenceAssertionProfile profile.

NameFlagsCard.TypeDescription & Constraintsdoco
.. sw-WoundPresenceAssertion-model 0..*
... personOfRecord 1..1Reference(SW Person Logical Model)The person this entry belongs to.
... recorded 0..1AttributionModelThe person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
... signed 0..1AttributionModelProvenance information specific to the signing of the clinical statement.
... additionalText 0..1stringA text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
... contextCode 0..1CodingCode representing the sense in which the statement is interpreted, for example, the degree of presence in a PresenceStatement.
Binding: SW PresenceContextVS ValueSet (required)
... encounter 0..1EncounterModelA description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.
... interpretation 0..1CodingA clinical interpretation of a finding (applies to both assertions and observation).
Binding: Observation Interpretation Codes (extensible)
... relevantTime 0..1dateTime, TimePeriodModelThe time or time period that the finding addresses.
... findingMethod 0..1CodingThe technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Binding: SW FindingMethodVS ValueSet (preferred)
... media 0..*MediaModelA file that contains audio, video, image, or similar content.
... verificationStatus 1..1CodingWhether an assessment has been confirmed by testing or observation.
... onset 0..1dateTimeThe beginning or first appearance of a mental or physical disorder.
... abatement 0..1dateTimeThe end, remission or resolution.
... topicCode 1..1CodingThe concept representing the finding or action that is the topic of the statement.
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
.... version Σ0..1stringVersion of the system - if relevant
.... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 416462003
.... display Σ0..1stringRepresentation defined by the system
.... userSelected Σ0..1booleanIf this coding was chosen directly by the user
... category 1..1CodingThe type, kind, or class of this item.
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/observation-category
.... version Σ0..1stringVersion of the system - if relevant
.... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: exam
.... display Σ0..1stringRepresentation defined by the system
.... userSelected Σ0..1booleanIf this coding was chosen directly by the user
... woundAnatomicalLocation 1..1WoundAnatomicalLocationModelWoundAnatomicalLocation
... woundTypeEtiology 0..1CodingA specialization of condition cause, specific to the causes of injuries (or not having injury in the wound absent context).
Binding: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.3/expansion (required)
... woundIdentifier 0..1stringA human-readable identifier for the lesion; e.g., a letter or integer.
... clinicalStatus 1..1codeA flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).
Binding: Condition Clinical Status Codes (required)
... whenClinicallyRecognized 0..1dateThe time at which a condition or condition was first identified in a healthcare context.
... presentOnAdmission 0..1CodingIf the problem or condition existed before the current episode of care.
Binding: SW YesNoUnknownVS ValueSet (required)
... stage 0..1StageModelThe relative advancement in the course of a disease. The value is the summary stage or stage group. StageDetail optionally contains the full staging information.
... woundType 1..1CodingA type code describing the wound or skin injury.
Binding: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.1.11.20.2.6/expansion (extensible)

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, TTL)

 

Terminology Bindings

PathNameConformanceValueSet
sw-WoundPresenceAssertion-model.contextCodeSW PresenceContextVS ValueSetrequiredPresenceContextVS
sw-WoundPresenceAssertion-model.interpretationObservation Interpretation CodesextensibleObservation Interpretation Codes
sw-WoundPresenceAssertion-model.findingMethodSW FindingMethodVS ValueSetpreferredFindingMethodVS
sw-WoundPresenceAssertion-model.woundTypeEtiology?extrequiredhttps://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1181.3/expansion
sw-WoundPresenceAssertion-model.clinicalStatusCondition Clinical Status CodesrequiredCondition Clinical Status Codes
sw-WoundPresenceAssertion-model.presentOnAdmissionSW YesNoUnknownVS ValueSetrequiredYesNoUnknownVS
sw-WoundPresenceAssertion-model.woundType?extextensiblehttps://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.1.11.20.2.6/expansion