HL7 FHIR Profile: Skin and Wound Assessment, Release 1 (For Comment) (SW) Reference Model Specification

The end, remission or resolution.

Identifier assigned by the lab

If the ActiveFlag is false, it indicates the record or item is no longer to be used and should generally be hidden for the user in the UI.

If the ActiveFlag is false, it indicates the record or item is no longer to be used and should generally be hidden for the user in the UI.

True if the group is an actual group (as opposed to definitional).

A text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.

Additive associated with container.

An address expressed using postal conventions (as opposed to GPS or other location definition formats). This data type may be used to convey addresses for use in delivering mail as well as for visiting locations and which might not be valid for mail delivery. There are a variety of postal address formats defined around the world. (Source: HL7 FHIR).

Part of an address that contains the house number, apartment number, street name, street direction, P.O. Box number, delivery hints, and similar address information. (Source: HL7 FHIR).

A gender classification used for administrative purposes. Administrative gender is not necessarily the same as a biological description or a gender identity. This attribute does not include terms related to clinical gender.

How long someone has been alive, or something has existed.

Anatomical location or specimen further detailing directionality.

A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.

The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so.

Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race.

Statement that a finding is absent.

Statement that a finding is present.

A clinical statement that asserts presence or absence.

Information ascribing the record to a particular contributor or responsible person.

The data itself.

If the product is branded, and if so, the brand name of a product.

The marketing name for a brand name product

Container volume or size.

The type, kind, or class of this item.

The degree of confidence in a conclusion or assertion.

The name of a municipality, city, town, village or other community or delivery center. (Source: HL7 FHIR).

An entry concerning a patient where the result is a narrative text.

A special type of information entry consisting of a topic and a context. The ClinicalStatement class provides the core pattern for more specific clinical statement classes, such as a statement that a finding has been found in a patient or that a procedure has been proposed by a clinical decision support system. The ClinicalStatement pattern defines the core attributes common to most clinical statements and specifies a composition pattern that encourage model component reuse and better alignment with the SNOMED CT Concept Model.

A flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).

A set of codes drawn from different coding systems, representing the same concept.

An evaluation component whose value is a code (concept).

A formal terminology system.

The version of the vocabulary being used, if applicable.

Coding of a concept, drawn from a controlled vocabulary. Includes the vocabulary and version, if applicable. May include a display text, and a descriptor expressing the intended interpretation of the code.

How the specimen was obtained.

The body site where specimen was collected

The person or thing the sample was obtained from.

When the sample was obtained, as a specific time or time period.

An observation with components, but without a result value or panel members.

A finding that a condition is or was not present in the subject at a certain time, not necessarily the time the information is gathered.

The cause of the condition. This includes such causes as disease vectors and endogenous states (e.g., macular degeneration due to diabetes), substances, medications, micro-organisms, and forces associated with the occurrence of a Condition from temporal or causative perspectives

A human-readable identifier for the condition at the finding site, for example, a wound number or tumor identifier.

A condition that is or may be present in a subject. 'Condition' is interpreted broadly and could be a disorder, abnormality, problem, injury, complaint, functionality, illness, disease, ailment, sickness, affliction, upset, difficulty, disorder, symptom, worry, or trouble.

An electronic means of contacting an organization or individual.

Abstract ancestor of all concrete content types. A unit of content that makes up a composition - e.g., a clinical statement in a patient record, a simple or composite action is a knowledge document, a catalog entry in a catalog.

Mime type of the content, with charset etc.

Code representing the sense in which the statement is interpreted, for example, the degree of presence in a PresenceStatement.

The number of items (0 or more), as an integer.

Country - a nation as commonly understood or generally accepted, expressed in ISO 3166 Alpha-2 (2-letter) codes.

The point in time when the information was recorded in the system of record.

The potential clinical harm associated with a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.

A date of birth or approximate year or period (year or date range), if estimated.

Indicator of significant change (delta) from the last or previous measurement.

The divisor of a fraction.

A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.

Unique Device Identifier (UDI) Barcode string number for a device, assigned by the organization using the device.

A diagnosis, which is a disease or injury determined to be present through evaluation of patient history, examination, and/or review of laboratory data.

A string meant for reading by a person, for example, accompanying a code.

The name of the administrative area at a level below that of a state but above that of a city or town. In the US, a county. Outside the US, a district or the equivalent. (Source: HL7 FHIR).

The form in which active and/or inert ingredient(s) are physically presented.

The date and time span for which something is active, valid, or in force.

Abstract class defining the common metadata of all types of encapsulated data, such as images.

A 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.

Concepts representing classification of patient encounter such as ambulatory (outpatient), inpatient, emergency, home health or others due to local variations.

Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation).

Root class for entities such as people, organizations, and devices that have a separately identifiable existence.

CIMI parent class for both Entity and Role.

A simplified, non-separable evaluation consisting of a finding code (represented by the Concept), value (or exception value), reference range, and interpretation. The subject of the evaluation component is the same as in the parent evaluation.

Reason that a value associated with a test or other finding is missing.

If true, exclude the subjects that match the criterion.

When the item (medication, device, etc.) will expire.

The portion of a person's name that reflects the genealogy of the person. In western cultures, this is the 'last' name. In eastern cultures, the family name appears before the person's given name(s). In some cultures (e.g. Eritrea) the family name of a son is the first name of his father. (Source: HL7 V3).

The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.

Absence of a distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. Body structures are continuants that allow observations of the same body structure to be related to be tracked over time.

Presence of a distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. Body structures are continuants that allow observations of the same body structure to be related to be tracked over time.

Any clinical statement representing a finding.

The countries of the world and major geopolitical subregions, such as US states.

The person's given name - e.g., John

A set of entities (personnel, material, or places) to be considered together. May be a pool of like-type resources, a team, or combination of personnel, material and places.

An inclusion or exclusion criterion as part of defining a cohort. If the criterion is an unary, then TopicCode must be SCT#385432009 (not applicable)

A code describing the characteristic present, absent, or having a value in this group.

Cautions on the handling of this specimen.

A hash code of the data (sha-1, base64ed)

A photograph showing a person's face.

The CIMI person name, constrained to map correctly to FHIR.

A unique string that identifies a specific person or thing.

Base class for classes in CIMI that stand alone. Analogous to FHIR's DomainResource.

An entry in a patient record or in a report, generally used for the documentation of clinical information about a subject of information such as a patient or a relative of the patient, asserted by a particular source, recorded, and potentially verified.

Specifies an material component in a non-medication substance.

The amount of an ingredient in a mixture, as a ratio. For example, 250 mg per tablet is expressed as a ratio where the numerator is 250mg and the denominator is 1 tablet.

A Quantity that is an integer.

A clinical interpretation of a finding (applies to both assertions and observation).

True if the ingredient is an active ingredient in the medication.

An organization who issues a qualification, identifier, or license.

A human language, spoken or written.

Additional information about a person's use of language.

Language used for communication by a human, either the subject of record, parent, or other involved person.

Anatomical location or specimen further detailing the side(s) of interest.

Abstract top level class in the CIMI hierarchy. The Locatable class reflects CIMI's implementation using Archetype Description Language (ADL). Its attributes (archetypenodeid, name, and archetype_details) are necessary to serialize CIMI definitions in ADL, but have no clinical relevance. To avoid complicating the profiles with irrelevant extensions, the attributes of Locatable have been omitted.

A distinctive alpha-numeric identification code assigned by the manufacturer or distributor to a specific quantity of manufactured material or product within a batch.

The lower limit on a range

When the item (medication, device, etc.) was produced.

The organization producing the product or test.

The name of the company who produce the device.

The most recent marital status of a person.

A file that contains audio, video, image, or similar content.

A type of prescription drug or over-the-counter drug that is used to prevent, treat, or relieve symptoms of a disease or abnormal condition, but excluding vaccines.

Specifies an material component in a medication.

A person or entity in a group.

The person's middle name.

Abstract supertype for the name of an entity.

The name as plain unstructured or semi-structured text.

A unique 10 digit number to allow US healthcare providers to identify themselves in a standard way throughout the healthcare industry.

Parent for classes in CIMI that cannot stand alone. These reusable building blocks/data elements can be used to create classes by composition.

An observation not based on a specimen.

The dividend of a fraction.

Represents the result of evaluations (measurements, tests, or questions) that have been performed. Observation has a value representing the result (answer), or an ExceptionValue indicating why the value is not present. The subject of a finding can be the entire patient, or an entity such as a location body structure, intervention, or condition. Things observed about the subject can include social and behavioral factors, subjective and objective observations, and assessments.

The party represented by the actual participant.

The beginning or first appearance of a mental or physical disorder.

A social or legal structure formed by human beings.

A list of alternate names that the organization is known as, or was known as in the past.

An identifier of the organization. An NPI preferred, tax id is allowed, and a local id is allowed in addition to ‘authoritative’ identifier

The name of the organization.

True if the medication is available to consumers without a prescription.

The kind of container the medication comes in.

PanelMembers represent the elements of a group of a related but independent evaluations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent evaluation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.

The point in time or span of time the participant is involved.

The larger entity that this is a portion of. For example, an organization might be part of a larger organization, or an encounter with a hospitalist might be part of a larger hospitalization encounter.

A person in the role of a patient.

A person relevant to the health or social situation of the subject (including the person of record him or herself).

A name used by a human being, written as it would be typically expressed. May include a breakdown of the various elements of the name (family name, given name, etc.).

The person this entry belongs to.

A sequence of letters and digits used as part of a postal address, often designating a geographic region

A person who practices a healing art.

A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.

Contains a set of honorific terms that typically appear before a person's name, for example Mr., Mrs., Dr., etc.

If the problem or condition existed before the current episode of care.

An indication of the importance of an action.

Why the item is used.

A right to practice medicine obtained by training and certification.

A quantity with units, whose value may be bounded from above or below, as defined in FHIR

An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.

A unit of measurement for the quotient of the amount of one entity to another.

Time the item was delivered to, or accepted by, the receiving facility or unit.

The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.

The time of the attribution action.

The usual or acceptable range for a test result.

The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).

URI where data can be found.

Number of bytes of content in the resource (if url provided)

The finding itself, such as the blood pressure value recorded.

Capacity in which an actor is involved in an activity. For instance, 'attending physician'. Note that attributes of the actor (an entity) that remain constant regardless of the role the actor plays should be part of the entity and not the role. For instance, a person may be a practitioner and a patient. In both cases their date of birth will be the same and thus such information should not be part of the role.

The sequence number for this specimen in a collection of specimens.

Degree of harshness or extent of a symptom, disorder, or condition.

The party signing.

A digital Signature - XML DigSig, JWT, Graphical image of signature, etc.

Type of signature

Provenance information specific to the signing of the clinical statement.

A quantity where the comparator is not used, as defined in FHIR

Identifier for the source specimen from which this specimen was derived.

Information about the proper handling of the specimen.

A specimen is a substance, physical object, or collection of objects, that the laboratory considers a single discrete, uniquely identified unit that is the subject of one or more steps in the laboratory workflow. A specimen may include multiple physical pieces as long as they are considered a single unit within the laboratory workflow. A specimen results from one to many specimen collection procedures, and may be contained in multiple specimen containers. Specimen may have one or more processing activities.

Direct container of specimen (tube/slide, etc.)

Quantity of specimen within container.

State of the specimen, such as obtained, processed, used.

Treatment performed on the specimen.

Accuracy and fluency in spoken communication in a language.

The relative advancement in the course of a disease. The value is the summary stage or stage group. StageDetail optionally contains the full staging information.

The full staging information

Sub-unit of a country with limited sovereignty in a federally organized country. A code may be used if codes are in common use (i.e. US 2 letter state codes). (Source: HL7 FHIR).

Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement.

StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc…), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).

The current standing or state.

Any matter of defined composition that has discrete existence, whose origin may be biological, mineral or chemical.

Part of the name that is acquired as a title due to academic, legal, employment or nobility status, etc. and that appears at the end of the name.

A user name or other identifier on a telecommunication network, such as a telephone number (including country code and extension, if necessary), email address, or SkypeID.

A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.

The time at which something is to end or did end. Boundary is considered inclusive.

The time at which something is to take effect, start, or did start. Boundary is considered inclusive.

A distinguishing word or group of words naming an item.

The concept representing the finding or action that is the topic of the statement.

For action topics, the TopicCode represents the action being described. For findings, the TopicCode represents the 'question' or property being investigated. For evaluation result findings, the TopicCode contains a concept for an observable entity, such as systolic blood pressure. For assertion findings, the TopicCode contains a code representing the condition, allergy, or other item being asserted. In all cases, the TopicCode describes the topic of the action or the finding.

The most specific code (lowest level term) describing the kind or sort of thing being represented.

Code for the unit of measure of the quantity.

The upper limit on a quantitative value.

A unique URL on which the device may be contacted directly.

The model number of the device, assigned by the manufacturer or vendor.

Whether an assessment has been confirmed by testing or observation. CIMI Alignment: This attribute has been defined to align with FHIR. In AllergyIntolerance, the type is code.

A number or code associated with the product that identifies a particular release iteration.

The time at which a condition or condition was first identified in a healthcare context.

Documents the absence of a wound at a given body site. No wounds anywhere on the body can be indicated by omitting the anatomical location, or using the Snomed code #181469002 (Entire skin (body structure)) in WoundAnatomicalLocation.

Area of the wound.

Overall assessement of whether the wound is within normal parameters.

Group of observations regarding the properties and severity of a wound.

Appearance of wound base (bed).

The appearance of the base (bed) of the wound, together with the percentage of the bed with each type of appearance.

Area of wound bed appearance/Entire ​Area of wound bed.

Color of Wound base (bed).

Wound bed area identified by color/​Area of wound bed.

Color of part or all of the wound base (bed), and the percentage of the area with that color.

Depth of the wound.

Color of Wound edge.

Edge of wound description.

The state of the tissue at the edge of the wound.

Wound episode refers to a period of the wound, an incident in the course of a wound

Drainage amount of wound

Appearance of exudate from wound

Color of exudate from wound

Description of the fluid produced by a wound.

Odor of exudate from wound

The presence or absence of wound exudate.

Appearance of exudate from wound

A human-readable identifier for the lesion; e.g., a letter or integer.

Length of the wound (longest dimension).

A description of the skin around the wound (periwound). Color, induration, warmth and edema should be assessed. Redness of the surrounding skin can be indicative of unrelieved pressure. Irritation of the surrounding skin can result from exposure to feces or urine, a reaction to the dressing or tape, or inappropriate removal of dressing or tape. Redness, tenderness, warmth and swelling are classical clinical signs of infection. [Reference: Brown, P., 2009]

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.

Is the wound associated with a device or pressure point?

The estimated or measured dimensions of a wound.

Whether a condition is improving, worsening, stable, or resolved.

Clock position of wound tunnel

A discharging blind-ended track that extends from the surface of an organ to an underlying area or abscess cavity. The track is invariably lined with granulation tissue. In chronic cases this may be augmented with epithelial tissue.

The presence or absence of wound tunneling.

Length of wound tunneling.

A type code describing the wound or skin injury. Differentiating pressure ulcers and other types of wounds is important for an accurate count of their number and for identifying appropriate wound treatment. The values will be used for documenting and retrieving data regarding the number and types of wounds present.

A specialization of condition cause, specific to the causes of injuries (or not having injury in the wound absent context).

Clock position of wound undermining

Length of wound undermining.

Assessment of deep tissue (subcutaneous fat and muscle) damage around the wound margin. Undermining are narrow sinus tracts away from the wound margins and go downward into the wound.

The presence or absence of wound undermining.

Exposed body structures, devices, and/or foreign bodies visible by the naked eye in a wound.

Width of the wound (perpendicular to longest dimension).

Accuracy and fluency of reading and writing in a language.