Transaction Wound assessment and treatment 2.16.840.1.113883.3.1937.777.28.4.437

e.g. VLU, DFU, PU, ischaemic, pressure, etc

Top level concept that contains the wound specific concepts covering

• baseline information,

• treatment,

• assessment

• observation

e.g. VLU, DFU, PU, ischaemic, pressure, etc

The cause of the wound, coded to SNOMED CT

Wound type/classification: Surgical wounds should be classified by the amount of contamination which could lead to delayed wound healing and infection: Clean, Clean-Contaminated, Contaminated, Dirty

1. Wounds should be classified by the dominant cause of wounding and/ or non-healing e.g. diabetic foot ulcer, venous leg ulcer, pressure ulcer etc

2. Surgical wounds should be classified by the amount of contamination which could lead to delayed wound healing and infection: Clean, Clean-Contaminated, Contaminated, Dirty

Healed or active more appropriate terminology

Initial description, mapping and number of wounds that exist at the start of the wound care episode

For each wound

The initial wound assessment, for surgical wounds this is the preoperative assessment

Periodic assessments, both structured and unstructured, as recommended by best clinical practice (NWCSP)

DFU examples: SINBAD, University of Texas (not Wagner); Non-DFU examples: WIFI; PU: EPUPAP; no specific ones for surgical wounds

e.g. SINBAD score, wifi score, epuap grade/ stage(?)

Used to calculate area and volume

The shape and size of the wound

Width, length and depth of wound

Clock face or see NWCSP recommendations

Point of reference for measurements

Need a value set for this - TIME(S)

Group containing health care professional observations on the wound

Periwound margin? This can be a list - need a value set for it

Description of the edge and margins of the wound

Will inform offloading

A description of the shape of the limb

Main issue would be presence of Charcot and/ or bony prominences and interaction with footwear. Will inform off-loading outcome

A description of the shape of the foot

Usually expressed in percentages on a list of descriptors (necrosis, slough, granulation, epithelisation, bone, tendon, hypergranulation,

Description of the bed of the wound

need a value set

Description of the surround skin condition

Need a value set

The natural skin colour of the person

FHIR value set : - Confidentiality

Vascular (Ischaemia; venous insufficiency), lymphoedema, infection (IDSA - none, mild, moderate, severe infection), neuropathy, Pressure - dynamic or static (PURPOSE-T for static, dynamic = walking/ movement causing pressure), Dermatology concerns, other

Clinical complications which affect the healing of the wound

This could be a list but will need to be extensive for each category

Assessment to determine the presence and degree of peripheral vascular disease

Assessment of arterial supply to an anatomical location