Skin Wound Assessment Refsets
- Susan Castillo
- John Kilbourne
- Susan Matney
Owned by Susan Castillo
| Version | Release Date | Number of Refsets | Number of New Concepts | Depends on |
|---|---|---|---|---|
| v .1 release files | November 14, 2017 | 24 | SNOMED CT International Release 07/31/2017 | |
| Refset/Value sets | Version | Date | Purpose | Total Members |
|---|---|---|---|---|
| Anatomic location modifier refset | 20171114 | November 14, 2017 | This refset is an all inclusive list of spatial and laterality modifier terms from the qualifier value branch of SNOMED to be used in conjunction with Anatomic location terms for the purpose of describing the location of conditions such as wounds. | 88 |
| Body Side Refset | TBD | TBD | This reference set is used to document a position to the left, right, or bilateral of an object from a center reference point. Resulting LOINC code 20228-3 "Anatomic part Laterality" | |
| Exudate odor refset | 20171114 | November 14, 2017 | This refset is to record and retrieve data related to exudate odor. | 2 |
| Periwound condition refset | 20171114 | November 14, 2017 | The purpose of this refset is to describe the skin surrounding the wound | 31 |
| Presence absence refset | 20171114 | November 14, 2017 | This refset provides values for recording and retrieving information about the presence or absence of a clinical observation | 2 |
| Pressure ulcer association refset | 20180824 | August 24th 2018 | This reference set contains bony prominences (such as sacrum) and medical devices (such as wheel chair) which may contribute to the cause of a pressure injury. | 2 |
| Skin color enumerated refset | 20171114 | November 14, 2017 | This refset provides an explicit number of entries to document skin color of a wound. | 7 |
| Skin color query refset | 20171114 | November 14, 2017 | Provide a global set of values (drawn from findings, qualifier value, and observable entity hierarchies) that can be drawn from for recording and retrieving skin color in the course of examining a patient. | 32 |
| Skin moisture refset | 20171114 | November 14, 2017 | This refset provides values for recording and retrieving clinical observations related to skin moisture, especially in the context of wound care. | 4 |
| Skin temperature refset | 20171114 | November 14, 2017 | This refset provides values for recording and retrieving clinical observations related to skin temperature, especially in the context of wound care. | 4 |
| Skin turgor refset | 20171114 | November 14, 2017 | This refset provides values for recording and retrieving clinical observations related to skin turgor, especially in the context of wound care. | 3 |
| Volume qualifier refset | 20171114 | November 14, 2017 | This refset provides a set of volume concepts in the Qualifier value hierarchy that can be re-used to record a volume of body fluid (e.g.wound exudate) noted on clinical exam. | 5 |
| Wound anatomic location refset | 20171114 | November 14, 2017 | This refset provides a set of anatomic locations to be used in recording and retrieving data about the location(s) of a patient wound(s) associate with physical exam and other patient care. | 63 |
| Wound bed appearance refset | 20171114 | November 14, 2017 | This refset provides values for recording and retrieving clinical observations obtained in examination of a wound bed or wound base. | 9 |
| Wound edge description refset | 20171114 | November 14, 2017 | This refset provides values for recording and retrieving descriptions of a wound edge. | 7 |
| Wound episode refset | 20171114 | November 14, 2017 | This refset provides the values for documenting the period of the wound, an incident in the course of a wound. | 4 |
| Wound exudate appearance refset | 20171114 | November 14, 2017 | This refset provides values to describe the consistency of exudate that is present in a wound. The values will be used for recording and retrieving the consistency of exudate. | 9 |
| Wound exudate color refset | 20171114 | November 14, 2017 | The purpose of this RefSet is to describe the color of exudate that is present in a wound. The values will be used in conjunction with the values from the Wound exudate amount ordinal refset and the Wound exudate appearance refset to document and retrieve values that describe wound exudate. | 8 |
| 20171114 | November 14, 2017 | Provide values for recording and retrieving clinical observations / findings / phenomena that come about from a clinician examining a patient with a wound. | 5 | |
| Wound exudate appearance refset | 20171114 | November 14, 2017 | This refset provides values to describe the consistency of exudate that is present in a wound. The values will be used for recording and retrieving the consistency of exudate. | 6 |
| Wound Gradation Refset | TBD | TBD | TBD | |
| 20171114 | November 14, 2017 | This reference set contains values for recording exposed body structures or devices visible in a wound. | 13 | |
| Wound bed color refset | 20171114 | November 14, 2017 | The purpose of this refset is to document the colors within the base of the wound. The mobile app "Tissue Analytics" color and texture to determine color. | 8 |
| Wound Shape refset | TBD | TBD | The purpose of this reference set is to characterize the outline of a wound. Referencing LOINC code XXX (requested). | |
| Wound trend refset | 20171114 | November 14, 2017 | This refset provides values to document a measure of improvement or deterioration in wound healing. | 5 |
| Wound type etiology refset | 20171114 | November 14, 2017 | The purpose of this refset is to provide a limited set of causes for a wound. | 10 |
| 20171114 | November 14, 2017 | The purpose of this Refset is to describe types of wounds and skin injuries. Differentiating pressure ulcers and other types of wounds is important for an accurate count of their number and for identifying appropriate wound treatment. | 31 | |
| Yes No refset | 20171114 | November 14, 2017 | A clinician wants to record a 'yes' or 'no' value; e.g. Wound associated with device – yes" | 2 |