Specification - Extended

HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm

Document Description

extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38

Existing Wording

Number of Pressure Ulcers Observation (V3) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.76:2015-08-01 (open)] This template represents the number of pressure ulcers observed at a particular stage. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Pressure Ulcer Stage urn:oid:2.16.840.1.113883.11.20.9.35 STATIC (CONF:1198-14725).

Proposed Wording

Change to DYNAMIC binding and add this concept the the extensionally defined value set: SCT concept 723071003 | Pressure injury of deep tissue (disorder) Number of Pressure Ulcers Observation (V3) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.76:2015-08-01 (open)] This template represents the number of pressure ulcers observed at a particular stage. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Pressure Ulcer Stage urn:oid:2.16.840.1.113883.11.20.9.35 DYNAMIC (CONF:1198-14725). New info on needed concepts in this value set: From: Susan Matney [mailto:Susan.Matney@imail.org] Hi all, We partnered with NPUAP to review and validate our content. The wound types that are used for pressure injuries (no longer called “ulcers”) are the exact set youfound here: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ We have requested the change to SNOMED CT for the description names. This includes: Stage 1 Pressure Injury 421076008 |Pressure ulcer stage 1 (disorder)| Stage 2 Pressure Injury 420324007 |Pressure ulcer stage 2 (disorder)| Stage 3 Pressure Injury 421927004 |Pressure ulcer stage 3 (disorder)| Stage 4 Pressure Injury 420597008 |Pressure ulcer stage 4 (disorder)| Unstageable Pressure Injury (requested) 723071003 |Pressure injury of deep tissue (disorder)| Note that “Unstageable Pressure Injury” is no longer used. Hope this helps….Susan Susan A. Matney, PhD, RNC-OB, FAAN, FACMI Nurse Informaticist Intermountain Healthcare Office: +1 (801) 447-9294 | Cell: +1 (801) 680-2161 email: susan.matney@imail.org NOTE: This brings up an inconsistent approach to identifying Highest Pressure Ulcer Stage. It requires we also consider the Longitudinal Care Wound Observation (V2) [observation: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.4.114:2015-08-01 (open)] tempalte and the Value Set called urn:oid:2.16.840.1.113883.1.11.20.2.6 (Wound Type). This is turning into a tangly problem!