Draft| Description |
This template represents acquired or surgical wounds and is not intended to encompass all wound types. The template applies to wounds such as pressure ulcers, surgical incisions, and deep tissue injury wounds. Information in this template may include information about the wound measurements characteristics. |
| Used by 7 transactions and 14 templates, Uses 5 templates | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Transfer Summary (V2)
Health Concern Act (harmonized) (0.1)
ref
ad1bbr-
Version: template 2.16.840.1.113883.10.20.22.4.114 Longitudinal Care Wound Observation (V2) (DYNAMIC)
| Item | DT | Card | Conf | Description | Label | |
|---|---|---|---|---|---|---|
| cda:observation | Long onV2 | |||||
| @classCode | cs | 1 … 1 | F | OBS | CONF1012 | |
| SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-31012). | ||||||
| @moodCode | cs | 1 … 1 | F | EVN | CONF1013 | |
| SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1198-31013). | ||||||
| cda:templateId | II | 1 … 1 | M | C-CDA R1.1 templateId root without an extension | CONF2936 | |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.114 | ||
| cda:templateId | II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-29473) such that it | CONF9473 | |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.114 | CONF9474 | |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.114" (CONF:1198-29474). | ||||||
| @extension | st | 1 … 1 | F | 2015-08-01 | CONF2913 | |
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32913). | ||||||
| cda:code | CD | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:1198-29476). | CONF9476 | |
| @code | CONF | 1 … 1 | F | ASSERTION | ||
| @codeSystem | 1 … 1 | F | 2.16.840.1.113883.5.4 | |||
| cda:value | CD | 1 … 1 | M | SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Wound Type urn:oid:2.16.840.1.113883.1.11.20.2.6 DYNAMIC (CONF:1198-29485). | CONF9485 | |
| CONF |
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| cda:targetSiteCode | 0 … 1 | R | SHOULD contain zero or one [0..1] targetSiteCode, which SHOULD be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1198-29488) such that it | CONF9488 | ||
| CONF |
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| cda:qualifier | 0 … * | MAY contain zero or more [0..*] qualifier (CONF:1198-29490). If targetSite/qualifierCode name/value pairs are used, care must be taken to avoid conflict with the SNOMED-CT body structure code used in observation/value. SNOMED-CT body structure codes are often pre-coordinated with laterality. | CONF9490 | |||
| cda:name | 1 … 1 | M | CONF9491 | |||
| @code | 1 … 1 | F | 272741003 | CONF9492 | ||
| This name SHALL contain exactly one [1..1] @code="272741003" laterality (CONF:1198-29492). | ||||||
| @codeSystem | 1 … 1 | F | 2.16.840.1.113883.6.96 | CONF1524 | ||
| This name SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:1198-31524). | ||||||
| cda:value | 1 … 1 | CONF9493 | ||||
| @code | 1 … 1 | R | This value SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet TargetSite Qualifiers urn:oid:2.16.840.1.113883.11.20.9.37 DYNAMIC (CONF:1198-29494). | CONF9494 | ||
| CONF |
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| cda:author | 0 … * | R | SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-31542). Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) | CONF1542 | ||
| cda:entryRelationship | 0 … * | R | Contains 2.16.840.1.113883.10.20.22.4.133 Wound Measurement Observation (2015‑08‑13) | CONF9495 | ||
| @typeCode | cs | 1 … 1 | F | COMP | CONF9496 | |
| SHALL contain exactly one [1..1] @typeCode="COMP" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-29496). | ||||||
| cda:entryRelationship | 0 … * | R | Contains 2.16.840.1.113883.10.20.22.4.134 Wound Characteristic (2015‑08‑13) | CONF9503 | ||
| @typeCode | cs | 1 … 1 | F | COMP | CONF9504 | |
| SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:1198-29504). | ||||||
| cda:entryRelationship | 0 … * | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Number of Pressure Ulcers. Contains 2.16.840.1.113883.10.20.22.4.76 Number of Pressure Ulcers Observation (V3) (2015‑08‑01) | CONF1890 | |||
| @typeCode | cs | 1 … 1 | F | COMP | CONF1891 | |
| SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31891). | ||||||
| cda:entryRelationship | 0 … 1 | When the wound observed is a type of pressure ulcer, then this template SHOULD contain an entry for the Highest Pressure Ulcer Stage. Contains 2.16.840.1.113883.10.20.22.4.77 Highest Pressure Ulcer Stage (2015‑08‑13) | CONF1893 | |||
| @typeCode | cs | 1 … 1 | F | COMP | CONF1894 | |
| SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31894). | ||||||