Clinical input form for the initial observation of a wound or wounds on a patient. Includes only basic who/what/where aspects, not the complete assessment. Addresses the use case of a new patient being evaluated for the presence or absence of wounds.

Information about a wound at a single time, structured into logical groupings for input or display.

A collection of all information about a single wound, possibly including many observations taken by different people at different times. Everything in the aggregation relates to the same wound.

A photographic documentation of a condition, location, person, etc…

Documents the absence of a wound.

Area of the wound.

Overall assessement of whether the wound is within normal parameters.

Area of wound bed portion appearance/Entire ​Area of wound bed – Linked to a wound bed appearance

Appearance of wound base (bed)

Depth of the wound.

Color of Wound edge.

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

Whether the wound is initial or recurrent.

Drainage amount of wound

Appearance of exudate from wound

Color of exudate from wound

Odor of exudate from wound

Appearance of exudate from wound

Length of the wound (longest dimension).

Body location of a wound.

A description of the skin around the wound (periwound).

The presence or absence of a wound. Observations and measurements associated with the same wound must link back to the same wound assertion. Therefore, the same wound should not be asserted more than once. The ‘same-as’ relationship can be used to link multiple assertions of the same wound, if necessary.

Is the wound associated with a device or pressure point?

The presence of a wound.

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

The length of a wound tunnel, in cm.

The presence or absence of a discharging blind-ended track that extends from the surface of an organ to an underlying area or abscess cavity. Each wound tunnel can be persistently identified to enable tracking of the condition of the tunnel over time.

The presence of a wound tunnel.

The source or key factor in the formation or acquisition of the wound.

The type of wound, for example, abrasion or laceration.

Clock position of wound undermining

Length of wound undermining.

The presence or absence 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 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).

A collection of statements and groups.

A set of one or more statements or aggregations that should be interpreted together, exchanged as a collection, or may be aggregregated for the purpose of clinical input or output.

Whether the condition was present when the patient was admitted.

A disorder of structure or function in a human, animal, or plant, especially one that produces specific signs or symptoms, and is not simply a direct result of physical injury

An assertion of a physical or conceptual entity, relationship, situation, condition, or phenomenon present or absent.

A determination, such as an observation, assertion, opinion, fact, or judgment.

An assertion of a physical or conceptual entity, relationship, role, situation, condition, or phenomenon present or absent.

A statement that asserts the value of a property (observable) of the subject. The subject is often the patient, but may be a condition, a physical structure, or another clinical statement. For example, an interpretation is a finding about an observation.

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

The end, remission or resolution of a disease.

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

Assessment of the wound bed (base) and edge, including the appearance and color of each.

The appearance of a percentage area of the wound bed (base

The color of a percentage area of the wound bed (base)

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

Color of a portion or entire wound base (bed).

Description of the color and condition of the edige of the wound.

Descriptions of the exudate of the wound. Applicable only if wound exudate is present.

A group of observations that together describe initial observations about a wound.

The dimensions of the wound.

Clock position of wound tunnel

Assessment and measurement of tunnels and undermining of the wound.

Description of a specific single tunnel on a specific wound. Applicable only if tunnel(s) are present

Description of the undermining of the wound. Applicable only if undermining is present