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.

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

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

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

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

Description of the fluid produced by a wound.

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.

The estimated or measured dimensions of a wound.

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.

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.

Identifier assigned by the lab

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

Statement that a finding is absent.

Statement that a finding is present.

A clinical statement that asserts presence or absence.

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.

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.

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.

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.

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.

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

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.

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.

A unique string that identifies a specific person or thing.

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.

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

An observation not based on a specimen.

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.

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

A social or legal structure formed by human beings.

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

A person who practices a healing art.

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

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

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.

Treatment performed on the specimen.

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