{"dataset": [{"version": "1.0", "name": "Wound assessment and treatment", "description": "\n                         <p>The wound assessment and treatment domain is the major development of the standard, the design of this domain supports the use of assessment frameworks such as SINBAD, TIME etc. There are some notable differences between the three wound types, these are identified here by wound type specific data concepts</p> \n                    ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Risks", "implamentationGuidance": "<p>Risk factors for delayed healing: Including diseases and conditions that affect wound healing (e.g. diabetes, auto-immune conditions), systemic and local blood supply to the wound, susceptibility to infection, medication affecting wound healing, skin integrity and other factors that affect healing such as obesity.</p>     <p> Risks to the healing\n                                    process - pressure, ischaemia, infection, concordance, mobility, nutrition</p>     <ul><li><p>Vascular (Ischaemia; venous insufficiency),\u00a0\u200b</p></li><li><p>lymphoedema,\u00a0\u200b</p></li><li><p>Infection (IDSA - none, mild, moderate, severe infection),\u00a0\u200b</p></li><li><p>Neuropathy,\u00a0\u200b</p></li><li><p>Pressure - dynamic or static (PURPOSE-T for static, dynamic = walking/ movement\n                                            causing pressure),\u00a0\u200b</p></li><li><p>Dermatology concerns,\u00a0\u200b</p></li><li><p>Acute infection of leg or foot (e.g. increasing unilateral redness, swelling, pain, pus, heat).\u200b</p></li><li><p>Symptoms of sepsis\u200b</p></li><li><p>Acute or chronic limb threatening ischaemia <em>(e.g., PAD with rest pain, gangrene,)</em>\u200b</p></li><li><p>Suspected acute deep vein\n                                            thrombosis (DVT).\u200b</p></li><li><p>Suspected skin cancer.\u200b</p></li><li><p>Bleeding varicose veins\u200b</p></li><li><p>Charcot\u200b</p></li><li><p>Skin tear\u200b</p></li><li><p>Laceration\u200b</p></li><li><p>Haemorrhage / Catastrophic dehiscence\u200b</p></li><li><p>\u2018burst abdomen\u2019 with visible internal organs.\u200b</p></li><li><p>Systemic signs of\n                                            infection/sepsis.\u200b</p></li><li><p>Follow NICE Guideline for Sepsis: Recognition, Diagnosis and Early Management\u200b</p></li><li><p>Spreading cellulitis, or\u200b</p></li><li><p>Dehiscence if:\u200b</p></li><li><p>Surgery involved implants (e.g. mesh, prosthesis).\u200b</p></li><li><p>Aesthetically or functionally important surgical site (e.g. face or\n                                            joints).\u200b</p></li><li><p>Dehiscence exposing subcutaneous layers and fascia.\u200b</p></li><li><p>Suspected sinus / fistula / tunnelling.\u200b</p></li><li><p>Stoma within wound boundaries.</p></li></ul>", "description": "Details of any risks related to the person.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Risks record entry", "implamentationGuidance": "<p>Risk factors for delayed healing: Including diseases and conditions that affect wound healing (e.g. diabetes, auto-immune conditions), systemic and local blood supply to the wound, susceptibility to infection, medication affecting wound healing, skin integrity and other factors that affect healing such as obesity. Risks to the healing\n                                    process - pressure, ischaemia, infection, concordance, mobility, nutrition</p>", "description": "This is a risks record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Start date of risk", "description": "The start date of the risk.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "End date of risk", "description": "The date the risk ended.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Risk", "description": "The risk to the person or others, this includes any risk the person might cause to themselves or to others. e.g. suicide, self harm.\u00a0", "valueSets": "\n                             <br clear=\"none\"/> \n                        ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "<table><tbody><tr><td><p>A risk that compromises healing</p></td></tr></tbody></table>", "description": "The coded value for risk.\u00a0", "valueSets": "<p class=\"MsoNormal\">SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=281694009&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;281694009 |Finding of at\n                                        risk (finding)|</a></p> <p class=\"MsoNormal\">\u00a0</p> <div><br clear=\"none\"/>\n                                </div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available.", "valueSets": "Free text.", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "name": "Comment", "description": "Additional details about the risk.\u00a0", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound assessment and treatment", "implamentationGuidance": "\n                                   <p>This section contains the assessments, observations and treatments that the health care professional makes about wounds</p>   \n                            ", "description": "\n                     <p>Top level concept that contains the wound specific concepts covering </p> \n                     <ul>\n                        <li>\n                            <p> baseline information, </p>\n                        </li>\n                        <li>\n                            <p>treatment, </p>\n                        </li>\n                        <li>\n                            <p>assessment</p>\n                        </li>\n                        <li>\n                            <p>observation </p>\n                        </li>\n                    </ul> \n                ", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "*", "mro": "M", "name": "Baseline information", "implamentationGuidance": "<p>The baseline section contains details of the initial state of the wound, there could be more than one wound being treated and therefore there will be a baseline for each wound, the baseline information would be accompanied by a formal structured assessment (see below) which will be flagged as the initial (primary) assessment </p>", "description": "\n                         <p>Initial description, mapping and number of wounds that exist at the start of the wound care episode</p> \n                    ", "informationType": "\n                         &lt;p&gt;Event.Record&lt;/p&gt; \n                    ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound Classification", "implamentationGuidance": "<p><em>Wound type/classification</em>: Surgical wounds should be classified by the amount of contamination which could lead to delayed wound healing and infection: Clean, Clean-Contaminated, Contaminated, Dirty</p>     <p>&lt;225552003 |Wound finding (finding)|</p>", "description": "<p>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, </p> <p>Surgical wounds should be classified by the amount of contamination which could lead to delayed wound healing and infection: </p> <p>Clean, Clean-Contaminated,\n                                Contaminated, Dirty &lt;225552003 |Wound finding (finding)|</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value for the wound classification</p>", "valueSets": "<p>SNOMED CT : - &lt;225552003 |Wound finding (finding)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list", "implamentationGuidance": "<p>This section allows for all relevant diagnoses, symptoms, conditions, problems, and issues relating to the cause or diagnosis of the wound.</p>     <p><br/>When a diagnosis has not yet been made, the most granular clinical concept with the highest level of certainty should be displayed. This may be a problem, symptom, sign, or test result, and\n                                    may evolve over time, as a conventional diagnosis is reached.\u00a0</p>     <p>In some situations, a confirmed diagnosis may need to be qualified by a number of attributes to give further detail (e.g. severity, distribution (body site), laterality, or stage of disease etc. \u00a0 \u2018Onset date\u2019 should be included where available even if this is estimated in source\n                                    systems.\u00a0</p>     <p><br/>It is essential that where a diagnosis is unconfirmed (e.g. suspected, disputed, or excluded) that this is not misinterpreted or coded as a confirmed diagnosis.<br/><br/>In a problem list there should be only one entry for each occurrence of a problem. Thus for chronic problems such as diabetes, there should only ever be one entry. Acute\n                                    problems such as heart attacks may occur multiple times in the problem list, but each entry should represent a separate clinical event and not merely a new consultation relating to that event. All a person's problems should be visible in the diabetes record.<br/><br/>Problem list relates solely to the wound diagnosis (aetiology), the list of potential codes will\n                                    need to be extensive for each category of wound.</p>     <ul><li><p>EPUAP (European pressure ulcer advisory panel) grade 1 ulcer &lt;&lt;376951000000105 |European pressure ulcer advisory panel grade 1 ulcer (disorder)|</p></li><li><p>EPUAP (European pressure ulcer advisory panel) grade 2 ulcer &lt;&lt;376961000000108 |European pressure ulcer advisory panel grade 2\n                                            ulcer (disorder)|</p></li><li><p>EPUAP (European pressure ulcer advisory panel) grade 3 ulcer. &lt;&lt;376971000000101 |European pressure ulcer advisory panel grade 3 ulcer (disorder)|</p></li><li><p>EPUAP (European pressure ulcer advisory panel) grade 4 ulcer &lt;&lt;376981000000104 |European pressure ulcer advisory panel grade 4 ulcer\n                                        (disorder)|</p></li><li><p>EPUAP (European pressure ulcer advisory panel unstageable / unclassified</p></li><li><p>Fungating lesion 945811000000102 |Fungating wound (finding)|</p></li><li><p>Moisture lesion</p></li><li><p>Leg ulcer &lt;&lt;95344007 |Ulcer of lower extremity (disorder)|</p></li><li><p>Abscess of skin &lt;&lt;31928004 |Abscess of skin and/or\n                                            subcutaneous tissue (disorder)|</p></li><li><p>Wound dehiscence &lt;&lt;225553008 |Wound dehiscence (disorder)|</p></li><li><p>Pilonidal sinus &lt;&lt;238496008 |Hair sinus (disorder)|</p></li><li><p>Laceration &lt;&lt;312608009 |Laceration - injury (disorder)|</p></li><li><p>Burn &lt;&lt;125666000 |Burn (disorder)|</p></li><li><p>Surgical wound\n                                            945791000000103 |Surgical wound (disorder)|</p></li><li><p>Wound Not specified &lt;417163006 |Traumatic or non-traumatic injury (disorder)|</p></li><li><p>Venous ulcer of leg &lt;&lt;402863005 |Venous stasis ulcer of leg (disorder)| or |Ulcer of limb due to chronic venous insufficiency (disorder)|</p></li><li><p>Complex venous leg ulcer 1066131000000106\n                                            |Complex venous leg ulcer (disorder)|Mixed arteriovenous leg ulcer</p></li><li><p>Simple venous leg ulcer 1066121000000109 |Simple venous leg ulcer (disorder)|</p></li><li><p>Arterial lower limb ulcer 872381000000101 |Arterial lower limb ulcer (disorder)|</p></li><li><p>Diabetic foot ulcer\u200b &lt;&lt;371087003 |Ulcer of foot due to diabetes mellitus\n                                            (disorder)|</p></li><li><p>Foot ulcer non diabetic &lt;&lt;95345008 |Ulcer of foot (disorder)| MINUS &lt;&lt;371087003 |Ulcer of foot due to diabetes mellitus (disorder)|</p><p>Further guidance on the use of problem lists in systems can be found in PRSB's diagnosis recording guidance\u00a0(see\u00a0<a href=\"https://theprsb.org/standards/diagnosesrecording/).\" rel=\"noopener noreferrer nofollow\">https://theprsb.org/standards/diagnosesrecording/).</a></p></li></ul>", "description": "A summary of the problems that require investigation or treatment.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "name": "Problem list record entry", "description": "This is a problem list record entry.  <br clear=\"none\"/> \n                         <br clear=\"none\"/> There may be 0 to many record entries under problem list.  <br clear=\"none\"/> \n                         <br clear=\"none\"/> Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem", "implamentationGuidance": "\n                                   <p>This section allows for relevant diagnosis of the wound cause (or for free text if it cannot be coded)</p>   \n                                   <p>When a diagnosis has not yet been made, the most granular clinical concept with the highest level of certainty should be displayed. This may be a problem, symptom, sign, or test result, and may evolve over time, as a conventional diagnosis is reached.</p>   \n                                   <p>In some situations, a confirmed diagnosis may need to be qualified by a number of attributes to give further detail (e.g. severity, distribution (body site), laterality, or stage of disease etc.</p>   \n                                   <p>It is essential that where a diagnosis is unconfirmed (e.g. suspected, disputed, or excluded) that this is not misinterpreted or coded as a confirmed diagnosis.</p>   \n                                   <p>Further guidance on the use of problem lists in systems can be found in PRSB's diagnosis recording guidance\u00a0(see\u00a0<a href=\"https://theprsb.org/standards/diagnosesrecording/).\" rel=\"noopener noreferrer nofollow\">https://theprsb.org/standards/diagnosesrecording/).</a></p>   \n                            ", "description": "A condition which needs addressing and so is important for every professional to know about when seeing the person.  <br clear=\"none\"/> \n                             <br clear=\"none\"/> Problems may include diagnoses, symptoms, and social or behavioural issues", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "<p>Coded vale should be constrained to those that are applicable to wounds</p>", "description": "The coded value for the problem list.", "valueSets": "<div>SNOMED CT : - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=1127581000000103&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999000681000001101,999001251000000103\" target=\"_blank\" rel=\"noopener\">^1127581000000103 |Health issues simple\n                                        reference set|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Onset date", "description": "A date or estimated date that the problem began", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End Date", "description": "The date or estimated date the problem was resolved.", "valueSets": "Date and time.", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Body site", "description": "The body site relevant to the problem.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for body site.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Laterality", "description": "\n                             <div>The laterality of the problem (left or right or bilateral).</div> \n                        ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for laterality.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem status", "implamentationGuidance": "<p>Problems and issues may be active (currently relevant to care or under active healthcare management; prominent in the record) or inactive - healed (past conditions or those which do not currently require active healthcare management; less prominent in the record).<br/><br/></p>", "description": "The status of the problem. This can be either active or inactive.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "<p>The problem status of the problem should be coded using only one SNOMED CT concept that is a subtype of the following code:</p>     <p>\u00a0</p>     <p><strong><u>SNOMED CT ID</u></strong>\u00a0<strong>\u00a0\u2502\u00a0</strong>\u00a0<strong><u>Fully specified name (FSN)</u></strong>\u00a0<strong>\u00a0\u2502\u00a0</strong>\u00a0<strong><u>Implementation guidance</u></strong></p>     <p>\u00a0</p>     <p>394731006\n                                    \u2502\u00a0Problem statuses (qualifier value) \u2502 Descendant of concept.<br/><br/>Where required codes are unavailable the free text field should be used and consideration given to the submission of a new code request to UK SNOMED CT request submission portal (see <a href=\"https://isd.digital.nhs.uk/rsp/user/guest/home.jsf).\" rel=\"noopener noreferrer nofollow\">https://isd.digital.nhs.uk/rsp/user/guest/home.jsf).</a> Contact info@thePRSB.org for further information.</p>     <p><br/>Further guidance on the use of problem lists in systems can be found in PRSB's diagnosis recording guidance\u00a0(see\u00a0<a href=\"https://theprsb.org/standards/diagnosesrecording/).\" rel=\"noopener noreferrer nofollow\">https://theprsb.org/standards/diagnosesrecording/).</a></p>     <p>Value domain typeCode</p>", "description": "The coded value for problem status.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem priority", "implamentationGuidance": "<p>Some systems provide the ability to categorise problems as \u2018major\u2019 ('significant' in this standard) or \u2018minor\u2019, or assign a priority number. \u2018Minor\u2019 problems may automatically become inactive after a period of time. The use of these classifications is not currently standardised, so it should not be relied upon to identify all serious\n                                    conditions.<br/><br/>Further guidance on the use of problem lists in systems can be found in PRSB's diagnosis recording guidance\u00a0(see\u00a0<a href=\"https://theprsb.org/standards/diagnosesrecording/).\" rel=\"noopener noreferrer nofollow\">https://theprsb.org/standards/diagnosesrecording/).</a></p>", "description": "The problem priority level. This can be either significant or minor.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "<p>The problem status of the problem should be coded using only one SNOMED CT concept from the following value set:</p>     <p>\u00a0</p>     <p><strong><u>SNOMED CT ID</u></strong>\u00a0<strong>\u00a0\u2502\u00a0</strong>\u00a0<strong><u>Fully specified name (FSN)</u></strong>\u00a0<strong>\u00a0\u2502\u00a0</strong>\u00a0<strong><u>Implementation guidance</u></strong></p>     <p>\u00a0</p>     <p>386134007 \u2502\u00a0Significant\n                                    (qualifier value) \u2502 Equal of concept.<br/>255606000 \u2502\u00a0Minor (qualifier value) \u2502 Equal of concept.\u00a0</p>     <p>\u00a0</p>     <p>Where required codes are unavailable the free text field should be used and consideration given to the submission of a new code request to UK SNOMED CT request submission portal (see <a href=\"https://isd.digital.nhs.uk/rsp/user/guest/home.jsf).\" rel=\"noopener noreferrer nofollow\">https://isd.digital.nhs.uk/rsp/user/guest/home.jsf).</a> Contact info@thePRSB.org for further information.</p>     <p><br/>Further guidance on the use of problem lists in systems can be found in PRSB's diagnosis recording guidance\u00a0(see\u00a0<a href=\"https://theprsb.org/standards/diagnosesrecording/).\" rel=\"noopener noreferrer nofollow\">https://theprsb.org/standards/diagnosesrecording/).</a></p>     <p>Value domain typeCode</p>", "description": "The coded value for problem priority.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Anatomical site", "implamentationGuidance": "<p>Anatomical site of the wound</p>     <p/>     <p>&lt;123037004 |Body structure (body structure)|</p>", "description": "The body site of the procedure", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of the anatomical site.", "valueSets": "<div>SNOMED CT :- <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=123037004&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;123037004 |Body structure (body\n                                        structure)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Body map", "implamentationGuidance": "<p>A graphical representation showing the location of the wound(s). Only one body map expected, regardless of how many wounds are being treated</p>", "description": "\n                             <p>Diagram or image showing the location of one or more wounds</p> \n                        ", "valueSets": "<p>Body schematic</p>", "valueDomain": [{"type": "complex"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound description", "description": "\n                             <p>Description of the wound</p> \n                        ", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date wound occurred", "description": "\n                             <p>To be used to calculate wound duration</p> \n                        ", "valueSets": "<p>Date</p>", "valueDomain": [{"type": "date"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Surgical wound specific", "description": "\n                             <p>This group includes data concepts that are specific to surgical wounds management</p> \n                        ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Type of surgery", "implamentationGuidance": "<p>&lt;387713003 |Surgical procedure (procedure)| OR &lt;161615003 |History of surgery (situation)|</p>", "description": "<p>Certain surgeries by definition are contaminated/ dirty and therefore more at risk of surgical wound complications</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value of the type of surgery </p>", "valueSets": "<p>SNOMED CT &lt;387713003 |Surgical procedure (procedure)</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Emergency / Elective Surgery", "description": "<p>What type of Surgery was it, Emergency surgery means that the patient has not had a preoperative risk assessment and is not optimised.\u00a0 Often emergency surgery is contaminated/dirty</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>Coded value for emergency / elective surgery</p>", "valueSets": "<p>SNOMED CT &lt;&lt; 387713003 |Surgical procedure (procedure)| : &lt;&lt; 260870009 |Priority (attribute)| = 25876001 |Emergency (qualifier value)| OR &lt;&lt; 260870009 |Priority (attribute)| = &lt;&lt; 103390000 |Elective (qualifier value)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Number of Surgical Wounds", "description": "<p>How many wounds were created during the surgery, for example there could be a wound for graft site as well as where the donor graft was taken from</p>", "valueSets": "<p>Numeric</p>", "valueDomain": [{"type": "count"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of Surgery", "description": "<p>The date that the surgery took place</p>", "valueSets": "<p>Date</p>", "valueDomain": [{"type": "date"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Duration of surgery", "description": "\n                                 <p>\n                                    <em>Surgery of &gt;2 hours increase the risk of surgical wound complications</em>\n                                </p> \n                            ", "valueSets": "<p>Duration in hours and mins hh:mm</p>", "valueDomain": [{"type": "duration"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound Closure Method", "implamentationGuidance": "<p>&lt;746011009 |Closure of skin wound (procedure)| OR &lt;&lt;427546003 |Glue closure of skin wound (procedure)| OR &lt;&lt;50015006 |Closure by staple (procedure)|</p>", "description": "<p>The method that was used to close the wound(s)</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value for wound closure method</p>", "valueSets": "<p>SNOMED CT &lt;746011009 |Closure of skin wound (procedure)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of closure removal", "description": "<p>The date that closures are scheduled to be removed</p>", "valueSets": "<p>Date dd/mm/yyyy</p>", "valueDomain": [{"type": "date"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Drain in situ", "implamentationGuidance": "<p>835421000000100 |Drainage tube in situ (finding)|</p>", "description": "<p>If there is a drain in place - what type of drain</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>Coded value for the drain</p>", "valueSets": "<p>SNOMED CT 835421000000100 |Drainage tube in situ (finding)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Prosthesis / implant present", "implamentationGuidance": "<p>722810000 |Prosthesis in situ (finding)|</p>", "description": "<p>Has a prosthesis or implant been fitted, if so what</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>Coded value for prosthesis or implant </p>", "valueSets": "<p>SNOMED CT &lt;835421000000100 |Drainage tube in situ (finding)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Antibiotic prophylaxis given", "implamentationGuidance": "<p>Where antibiotic prophylaxis given</p>     <p>422181004 |Administration of prophylactic antibiotic (procedure)|</p>", "description": "\n                                 <p>Boolean to indicate whether antibiotic has been given post surgery </p> \n                            ", "valueSets": "<p>Given </p> <p>Not Given</p>", "valueDomain": [{"type": "boolean", "example": [{"type": "valid", "caption": "Antibiotic prophylaxis given", "#text": "Yes"}, {"type": "valid", "caption": "Antibiotic prophylaxis  not given", "#text": "No"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "*", "mro": "M", "name": "Contacts with professionals", "implamentationGuidance": "\n                                   <p>This section includes the details of the person\u2019s contacts with services, their encounters. This information may need to be filtered to only display what is relevant for a particular use case and professional\u2019s discipline. This includes outpatient appointments, home visits, hospital and outpatient attendances, out of hours GP visits, clinic appointments, social\n                                    worker visits etc.</p>   \n                            ", "description": "The details of the person\u2019s contact with a professional.", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Contacts with professionals record entry", "description": "This is a contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Seen by", "description": "The professional that saw the person.", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional that saw the person", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Role", "description": "The role of the person providing the service.", "valueSets": "FHIR values set : -\u00a0 <a class=\"\" href=\"https://simplifier.net/HL7FHIRUKCoreR4/UKCore-PractitionerRoleCode\" target=\"_blank\" title=\"\">ukcorepractitionerrolecode</a> \n                        "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Location type", "description": "The type of location where the contact took place e.g. person's home", "valueSets": "NHS data dictionary -  <a href=\"https://datadictionary.nhs.uk/data_elements/activity_location_type_code.html?hl=activity%2Clocation%2Ctype%2Ccode\" target=\"\" title=\"\">Activity location type code</a> \n                        ", "valueDomain": [{"type": "string", "property": [{"maxLength": "3"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Reason for service", "description": "The reason why the person has been offered the service", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Contact type", "description": "Type of contact e.g. GP consultation, outpatient attendance", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Person accompanying patient", "implamentationGuidance": "<p>Could be a chaperone if appropriate </p>", "description": "Identify, where clinically relevant, others accompanying the patient, e.g. parent, relative, friend. Includes: Name, Relationship, role (e.g. informal carer).", "valueSets": "NHS data dictionary : -  <a href=\"https://datadictionary.nhs.uk/data_elements/person_full_name.html?hl=person%2Cfull%2Cname\" target=\"\" title=\"\">Person full name</a> \n                        ", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Wound assessment", "implamentationGuidance": "<p>This section makes provision for all assessments, with the initial (primary) assessment identified</p>", "description": "\n                         <p>Periodic assessments, both structured and unstructured, as recommended by best clinical practice (NWCSP)</p> \n                    ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Initial (Primary) Wound Assessment", "implamentationGuidance": "<p>This is a flag to indicated whether or not the wound assessment is the primary (or initial) assessment of the wound, There should only be one primary assessment for each wound episode of care</p>", "description": "<p>Boolean indicating whether (or not) this assessment is a initial (or primary) assessment</p>", "valueSets": "<p>Initial assessment or not initial assessment </p>", "valueDomain": [{"type": "boolean", "example": [{"type": "neutral", "#text": "yes / no"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment", "implamentationGuidance": "<p>The structured assessment includes any assessment that is relevant to the patient / wound, it could include any NICE recommended assessment such as TIMES, SINBAD etc or a patient based assessment, such as a frailty assessment </p>", "description": "Details of the structured assessment.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment name", "implamentationGuidance": "<p>The structured assessment data concept can be used to record a range of assessments applicable to wound care. The SNOMED CT terminology associated with wound care assessments is available on the PRSB website here [DN need to include a hyperlink to the document at this point]</p>     <p>The linked document includes terminology for the following\n                                    assessments</p>     <ul><li><p>Braden Scale</p></li><li><p>Norton Scale</p></li><li><p>NPUAP/AHCP R staging system</p></li><li><p>PEDIS Score for Diabetic Foot Ulcers</p></li><li><p>Pressure Ulcer Scale for Healing (PUSH)</p></li><li><p>PURPOSE-T</p></li><li><p>Rockwood frailty Score</p></li><li><p>SINBAD</p></li><li><p>TEXAS</p></li><li><p>Waterlow\n                                    Scale</p></li></ul>     <p>SNOMED CT terminology does not exist for the following assessment frameworks, these can be recorded using the text options in the information model. SNOMED CT terminology has been applied for and the reference document (and this guidance) will be updated once these terms have been released</p>     <ul><li><p>Pressure Sore Status Tool\n                                            (PSST)Sussman Wound Healing Tool</p></li><li><p>Therapeutic Index for Local Infection (TiLi)</p></li><li><p>TIME</p></li><li><p>TIME(S)</p></li><li><p>WiFi</p></li><li><p>Wound Healing Scale (WHS)</p></li></ul>     <p/>", "description": "Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for structured assessment name.\u00a0", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=273249006&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 273249006 |Assessment scales\n                                            (assessment scale)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment result", "description": "The structured assessment result. This is the overall result for the assessment.\u00a0", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Assessment score", "description": "The overall structured assessment score.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for assessment score.\u00a0", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=363787002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 363787002 |Observable entity\n                                                (observable entity)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Value", "description": "The numerical value for the assessment result.\u00a0", "valueSets": "Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Units of measure", "description": "The units of measure for the assessment result.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Ordinal", "description": "The ordinal result of the assessment e.g. mild, moderate, severe.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the ordinal result.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Subscale result", "description": "The subscale result for the structured assessment. This includes the result for individual questions or subsections.", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Subscale score", "description": "The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Coded value", "description": "The coded value for subscale item.", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=363787002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 363787002 |Observable entity\n                                                (observable entity)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Value", "description": "The numerical value for the subscale assessment result.\u00a0", "valueSets": "Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Units of measure", "description": "The units of measure for the assessment subscale result.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Ordinal", "description": "The ordinal result of the subscale assessment e.g. mild, moderate, severe.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the ordinal result.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Wound length, width and depth ", "implamentationGuidance": "\n                                   <p>Area if possible. (Area of an ellipse A=\u03c0ab might be most appropriate? Software might apply this)</p>   \n                            ", "description": "\n                             <p>The shape and size of the wound</p> \n                        ", "informationType": "\n                             &lt;p&gt;Event.Record&lt;/p&gt; \n                        ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Wound dimension", "implamentationGuidance": "<p>Group defining which dimension of wound (or wound undermining) is being measured </p>     <p>Length, width or depth of wound</p>     <p/>", "description": "<p>Group to hold t length, width and depth of a wound and of any undermining or tunnelling </p>", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dimension type", "implamentationGuidance": "<p>Length, width or depth of wound</p>     <p>&lt;364554009 |Wound observable (observable entity)|</p>     <ul><li><p>401238003 |Length of wound (observable entity)|</p></li><li><p>401239006 |Width of wound (observable entity)|</p></li><li><p>425094009 |Depth of wound (observable entity)|</p></li><li><p>1361000124101 |Depth of wound undermining\n                                            (observable entity)|</p></li><li><p>1351000124103 |Length of wound undermining (observable entity)|</p></li><li><p>1321000124107 |Length of wound tunneling (observable entity)|</p></li></ul>", "description": "<p>To specify which dimension this is a measurement of, one of</p> <ul><li><p>Length of wound</p></li><li><p>Width of wound</p></li><li><p>Depth of wound</p></li><li><p>Depth of wound undermining</p></li><li><p>Length of wound undermining</p></li><li><p>Length of wound tunneling</p></li></ul>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value of the wound dimension</p>", "valueSets": "<p>SNOMED CT &lt;364554009 |Wound observable (observable entity)</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to use if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dimension value", "description": "<p>Group containing the measurement, numerical value, of the wound dimension</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Measurement value", "description": "<p>The numerical value for the measurement</p>", "valueSets": "<p>decimal number</p>", "valueDomain": [{"type": "decimal"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "<p>The units of measure for the wound dimension</p>", "valueSets": "<p>SNOMED CT 258667005 |Unit of length (qualifier value)|</p>"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Point of reference", "implamentationGuidance": "<p>Point of reference for the wound dimensions</p>", "description": "\n                                 <p>Point of reference for measurements </p> \n                            ", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Wound and surrounding skin description", "implamentationGuidance": "\n                                   <p>TIME(S)</p>   \n                            ", "description": "\n                             <p>Group containing health care professional observations on the wound </p> \n                        ", "informationType": "\n                             &lt;p&gt;Event.Record&lt;/p&gt; \n                        ", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Wound margin and edge description", "description": "<p>Description of the edge and margins of the wound</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "<p>&lt;449747006 |Wound edge finding (finding)|</p>", "description": "<p>The coded value of the wound margin / edge description</p>", "valueSets": "<p>SNOMED CT &lt;449747006 |Wound edge finding (finding)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to use if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Limb shape", "implamentationGuidance": "\n                                   <p>Will inform off loading </p>   \n                            ", "description": "<p>A free text description of the shape of the limb</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "200"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Foot shape", "implamentationGuidance": "<p>Main issue would be presence of Charcot and/ or bony prominences and interaction with footwear. Will inform off-loading outcome</p>", "description": "<p>A free text description of the shape of the foot</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "200"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound bed tissue type", "description": "<p>Description of the bed of the wound</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "<p>&lt;225552003 |Wound finding (finding)</p>", "description": "<p>The coded value describing the wound bed tissue type</p>", "valueSets": "<p>SNOMED CT &lt;225552003 |Wound finding (finding)</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Surrounding skin condition", "description": "\n                                 <p>Description of the surround skin condition</p> \n                            ", "valueSets": "<p>Free Text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "200"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Skin colour", "implamentationGuidance": "<p>The colour of the skin surrounding the wound</p>     <p>&lt;276323006 |Finding of color of skin (finding)|</p>", "description": "<p>The colour of the surrounding skin</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Coded value", "description": "<p>Coded value of the colour of the surrounding skin</p>", "valueSets": "<p>SNOMED CT &lt;225552003 |Wound finding (finding)</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Image of wound", "description": "This is the documents record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Documentation location", "description": "The location of the document", "valueSets": "Free text or URL", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Confidentiality", "description": "The code specifying the level of confidentiality of the document.", "valueSets": "\n                             <p>FHIR value set : - <a class=\"\" href=\"https://www.hl7.org/fhir/v3/ConfidentialityClassification/vs.html\" target=\"\" title=\"\">Confidentiality</a>\n                            </p> \n                        "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Class", "description": "The document type e.g. report, summary, images, treatment plan, patient preferences, workflow", "valueSets": "Free text.", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Document title", "description": "The title of the document.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Document name", "description": "The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure\n                            with which the document is associated. Values may be found in a suitable DICOM browser", "valueSets": "SNOMED CT: - As per the  <a class=\"\" href=\"https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf\">https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf</a> \n                        "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Document MIME type", "description": "MIME type of the document e.g. application, pdf, audio, jpeg", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Comments", "description": "Comments associated with the document.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Wound complications", "implamentationGuidance": "<p>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</p>     <p>&lt;225552003 |Wound finding (finding)|</p>     <p>449752001 |Wound tissue undermining\n                                    (finding)|</p>     <p>866166001 |Wound tunneling (finding)|</p>     <h3/>", "description": "\n                             <p>Clinical complications which affect the healing of the wound</p> \n                        ", "informationType": "\n                             &lt;p&gt;Event.Record&lt;/p&gt; \n                        ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list", "implamentationGuidance": "<p>This instance of problem list is used to record and code wound complications</p>     <table><tbody><tr><td><p><strong>Requirement</strong></p></td><td><p><strong>SNOMED CT ECL</strong></p></td><td><p><strong>Comment</strong></p></td></tr><tr><td><p>Vascular (Ischaemia; venous insufficiency),\u00a0</p></td><td><p>&lt;&lt;86341008 |Vascular\n                                                    insufficiency (disorder)|</p></td><td><p/></td></tr><tr><td><p>lymphoedema,\u00a0</p></td><td><p>&lt;&lt;234097001 |Lymphedema (disorder)|</p></td><td><p/></td></tr><tr><td><p>Infection (IDSA - none, mild, moderate, severe infection),\u00a0</p></td><td><p>&lt;&lt;76844004 |Local infection of wound (disorder)|<br/>405009004 |Infection status (observable\n                                                    entity)|</p></td><td><p/></td></tr><tr><td><p>Neuropathy,\u00a0</p></td><td><p>&lt;&lt;386033004 |Neuropathy (disorder)|</p></td><td><p/></td></tr><tr><td><p>Pressure - dynamic or static (PURPOSE-T for static, dynamic = walking/ movement causing pressure),\u00a0</p></td><td colspan=\"2\"><p>1077741000000109 |PURPOSE T (Pressure Ulcer Risk Primary or\n                                                    Secondary Evaluation Tool) pathway decision (observable entity)|</p></td></tr><tr><td><p>Dermatology concerns,\u00a0</p></td><td><p/></td><td><p>Such as? Requirement needs more focus.</p></td></tr><tr><td><p>Acute infection of leg or foot (e.g. increasing unilateral redness, swelling, pain, pus, heat).</p></td><td><p>&lt;&lt;449710006 |Cellulitis of\n                                                    lower limb (disorder)|</p></td><td><p>?Cellulitis. Other symptoms should be coded individually.<br/>125115006 |Acute erythema (finding)|<br/>846694002 |Acute edema (finding)|<br/>&lt;&lt;10601006 |Pain in lower limb (finding)|<br/>822960006 |Temperature of skin over lesion warm (finding)|<br/>225550006 |Purulent discharge from wound\n                                                    (finding)|</p></td></tr><tr><td><p>Symptoms of sepsis</p></td><td><p>859701000000104 |Suspected sepsis (situation)|</p></td><td><p>1104321000000108 |Royal College of Physicians National Early Warning Score 2 - oxygen saturation scale 2 score (observable entity)|<br/>1239211000000103 |4 A's Test for delirium and cognitive impairment score\n                                                    (observable entity)|<br/>1104341000000101 |Royal College of Physicians National Early Warning Score 2 - systolic blood pressure score (observable entity)|<br/>1144798005 |Verbal Rating Scale pain intensity score (observable entity)|<br/>1104361000000100 |Royal College of Physicians National Early Warning Score 2 - consciousness score (observable\n                                                    entity)|<br/>1104311000000102 |Royal College of Physicians National Early Warning Score 2 - oxygen saturation scale 1 score (observable entity)|<br/>763264000 |Canadian Study of Health and Aging Clinical Frailty Scale score (observable entity)|<br/>1104331000000105 |Royal College of Physicians National Early Warning Score 2 - air or oxygen score\n                                                    (observable entity)|<br/>1104351000000103 |Royal College of Physicians National Early Warning Score 2 - pulse score (observable entity)|<br/>1104301000000104 |Royal College of Physicians National Early Warning Score 2 - respiration rate score (observable entity)|<br/>1104371000000107 |Royal College of Physicians National Early Warning Score 2 -\n                                                    temperature score (observable entity)|<br/>1104051000000101 |Royal College of Physicians National Early Warning Score 2 total score (observable entity)|</p></td></tr><tr><td><p>Acute or chronic limb threatening ischaemia (e.g., PAD with rest pain, gangrene,)</p></td><td><p>&lt;&lt;233961000 |Lower limb ischemia (disorder)| OR &lt;&lt;840580004\n                                                    |Peripheral arterial disease (disorder)| OR `&lt;&lt;102631000119103 |Gangrene due to peripheral vascular disease (disorder)|</p></td><td><p>Note: subsumes &lt;&lt;233962007 |Critical lower limb ischemia (disorder)|<br/>Need refinement of requirement</p></td></tr><tr><td><p>Suspected acute deep vein thrombosis (DVT).</p></td><td><p>432805000\n                                                    |Suspected deep vein thrombosis (situation)|</p></td><td><p/></td></tr><tr><td><p>Suspected skin cancer.</p></td><td><p>315276005 |Suspected skin cancer (situation)|</p></td><td><p/></td></tr><tr><td><p>Bleeding varicose veins</p></td><td><p>&lt;&lt;266330004 |Ruptured varicose veins\n                                                (disorder)|</p></td><td><p/></td></tr><tr><td><p>Charcot</p></td><td><p>&lt;&lt;359554008 |Charcot's arthropathy (disorder)|</p></td><td><p>Assuming arthropathy - ankle? Foot? Any?</p></td></tr><tr><td><p>Skin tear</p></td><td><p>&lt;&lt;428220001 |Traumatic tear of skin\n                                                    (disorder)|</p></td><td><p/></td></tr><tr><td><p>Laceration</p></td><td><p>&lt;&lt;312608009 |Laceration - injury (disorder)|</p></td><td><p/></td></tr><tr><td><p>Haemorrhage / Catastrophic dehiscence</p></td><td><p>&lt;&lt;131148009 |Bleeding (finding)|<br/>371052003 |Traumatic wound dehiscence (disorder)|</p></td><td><p>Both terms? What is\n                                                    \"catastrophic\"?</p></td></tr><tr><td><p>\u2018burst abdomen\u2019 with visible internal organs.</p></td><td><p>&lt;&lt;22247000 |Dehiscence of surgical wound (disorder)|<br/>297681000000107 |Abdominal organs visible (finding)|</p></td><td><p/></td></tr><tr><td><p>Systemic signs of infection/sepsis.</p></td><td><p/></td><td><p>See\n                                                    above</p></td></tr><tr><td><p>Follow NICE Guideline for Sepsis: Recognition, Diagnosis and Early Management</p></td><td><p/></td><td><p>N/A</p></td></tr><tr><td><p>Spreading cellulitis, or</p></td><td><p/></td><td><p>See above</p></td></tr><tr><td><p>Dehiscence if:</p></td><td><p/></td><td><p/></td></tr><tr><td><p>Surgery involved implants (e.g.\n                                                    mesh, prosthesis).</p></td><td><p/></td><td><p>Possible to use attribute \"Using device\" in SNOMED CT. Also &lt;&lt;363691001 |Procedure categorized by device involved (procedure)|</p></td></tr><tr><td><p>Aesthetically or functionally important surgical site (e.g. face or joints).</p></td><td><p/></td><td><p>Subjective - not supported in\n                                                    terminology.</p></td></tr><tr><td><p>Dehiscence exposing subcutaneous layers and fascia.</p></td><td><p>441737006 |Dehiscence of fascia (disorder)|</p></td><td><p/></td></tr><tr><td><p>Suspected sinus / fistula / tunnelling.</p></td><td><p>444433005 |Suspected clinical finding (situation)|</p></td><td><p>All possible with 444433005 |Suspected\n                                                    clinical finding (situation)| with post cooordination</p></td></tr></tbody></table>", "description": "A summary of the problems that require investigation or treatment.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list record entry", "description": "This is a problem list record entry.  <br clear=\"none\"/> \n                         <br clear=\"none\"/> There may be 0 to many record entries under problem list.  <br clear=\"none\"/> \n                         <br clear=\"none\"/> Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem", "description": "A condition which needs addressing and so is important for every professional to know about when seeing the person.  <br clear=\"none\"/> \n                             <br clear=\"none\"/> Problems may include diagnoses, symptoms, and social or behavioural issues", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the problem list.", "valueSets": "<div>SNOMED CT : - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=1127581000000103&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999000681000001101,999001251000000103\" target=\"_blank\" rel=\"noopener\">^1127581000000103 |Health issues simple\n                                        reference set|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Onset date", "description": "A date or estimated date that the problem began", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End Date", "description": "The date or estimated date the problem was resolved.", "valueSets": "Date and time.", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Vascular Assessment", "implamentationGuidance": "\n                                   <p>none, mild, moderate, severe - see wifi for classifications. </p>   \n                            ", "description": "\n                             <p>Assessment to determine the presence and degree of peripheral vascular disease</p> \n                        ", "informationType": "\n                             &lt;p&gt;Event.Record&lt;/p&gt; \n                        ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Arterial supply assessment", "implamentationGuidance": "\n                                   <table>\n                                    <tbody>\n                                        <tr>\n                                            <td rowspan=\"2\">\n                                                <p>Pulse palpation, Doppler insonation (mono-, bi-, tri-phasic), ABPI, TPI</p>\n                                            </td>\n                                        </tr>\n                                        <tr/>\n                                    </tbody>\n                                </table>   \n                            ", "description": "\n                                 <p>Assessment of arterial supply to an anatomical location</p> \n                            ", "informationType": "\n                                 &lt;p&gt;Event.Record&lt;/p&gt; \n                            ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment", "description": "Details of the structured assessment.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment name", "description": "Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for structured assessment name.\u00a0", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=273249006&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 273249006 |Assessment scales\n                                            (assessment scale)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment result", "description": "The structured assessment result. This is the overall result for the assessment.\u00a0", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment score", "implamentationGuidance": "\n                                   <table>\n                                    <tbody>\n                                        <tr>\n                                            <td rowspan=\"2\">\n                                                <p>Scores applicable to ABPI, TPI</p>\n                                            </td>\n                                        </tr>\n                                        <tr/>\n                                    </tbody>\n                                </table>   \n                            ", "description": "The overall structured assessment score.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for assessment score.\u00a0", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=363787002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 363787002 |Observable entity\n                                                (observable entity)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The numerical value for the assessment result.\u00a0", "valueSets": "Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The units of measure for the assessment result.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ordinal", "description": "The ordinal result of the assessment e.g. mild, moderate, severe.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the ordinal result.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Subscale result", "description": "The subscale result for the structured assessment. This includes the result for individual questions or subsections.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Subscale score", "description": "The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for subscale item.", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=363787002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 363787002 |Observable entity\n                                                (observable entity)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The numerical value for the subscale assessment result.\u00a0", "valueSets": "Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The units of measure for the assessment subscale result.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ordinal", "description": "The ordinal result of the subscale assessment e.g. mild, moderate, severe.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the ordinal result.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment", "description": "Details of the structured assessment.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment name", "description": "Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for structured assessment name.\u00a0", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=273249006&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 273249006 |Assessment scales\n                                            (assessment scale)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment result", "description": "The structured assessment result. This is the overall result for the assessment.\u00a0", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment score", "description": "The overall structured assessment score.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for assessment score.\u00a0", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=363787002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 363787002 |Observable entity\n                                                (observable entity)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The numerical value for the assessment result.\u00a0", "valueSets": "Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The units of measure for the assessment result.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ordinal", "description": "The ordinal result of the assessment e.g. mild, moderate, severe.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the ordinal result.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Subscale result", "description": "The subscale result for the structured assessment. This includes the result for individual questions or subsections.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Subscale score", "description": "The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for subscale item.", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=363787002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 363787002 |Observable entity\n                                                (observable entity)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The numerical value for the subscale assessment result.\u00a0", "valueSets": "Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The units of measure for the assessment subscale result.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Ordinal", "description": "The ordinal result of the subscale assessment e.g. mild, moderate, severe.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the ordinal result.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ankle\u2013brachial pressure index", "description": "<p>The <strong>ankle-brachial pressure index</strong> (<strong>ABPI</strong>) or <strong>ankle-brachial index</strong> (<strong>ABI</strong>) is the ratio of the <a href=\"https://en.wikipedia.org/wiki/Blood_pressure\" rel=\"noopener noreferrer nofollow\">blood pressure</a> at the <a href=\"https://en.wikipedia.org/wiki/Ankle\" rel=\"noopener noreferrer nofollow\">ankle</a> to the blood pressure in the <a href=\"https://en.wikipedia.org/wiki/Arm\" rel=\"noopener noreferrer nofollow\">upper arm</a>(brachium). Compared to the arm, lower blood pressure in the leg suggests blocked arteries due to <a href=\"https://en.wikipedia.org/wiki/Peripheral_artery_disease\" rel=\"noopener noreferrer nofollow\">peripheral artery disease</a> (PAD). The ABPI is calculated by dividing the <a href=\"https://en.wikipedia.org/wiki/Systole_(medicine)\" rel=\"noopener noreferrer nofollow\">systolic</a>\n                                    <a href=\"https://en.wikipedia.org/wiki/Blood_pressure\" rel=\"noopener noreferrer nofollow\">blood pressure</a> at the ankle by the systolic blood pressure in the arm.<a href=\"https://en.wikipedia.org/wiki/Ankle%E2%80%93brachial_pressure_index#cite_note-Review09-1\" rel=\"noopener noreferrer nofollow\"><sup>[1]</sup></a></p> <ul><li><p><strong>Less than\n                                            0.5</strong>\u00a0suggests severe arterial disease.</p><ul><li><p>Compression treatment is contraindicated.\u00a0</p></li><li><p><a href=\"https://cks.nice.org.uk/topics/leg-ulcer-venous/management/venous-leg-ulcers/#when-to-refer\" rel=\"noopener noreferrer nofollow\"><u>Refer</u></a> the person urgently for specialist vascular\n                                                assessment.\u00a0</p></li></ul></li><li><p><strong>Greater than 0.5 to</strong>\u00a0<strong>less than 0.8</strong>\u00a0suggests the presence of arterial\u00a0disease or mixed arterial/venous disease.</p><ul><li><p>Compression should generally be avoided. However, reduced compression can be used under specialist advice and with strict supervision.</p></li><li><p><a href=\"https://cks.nice.org.uk/topics/leg-ulcer-venous/management/venous-leg-ulcers/#when-to-refer\" rel=\"noopener noreferrer nofollow\"><u>Refer</u></a> the person for specialist vascular assessment.\u00a0</p></li></ul></li><li><p><strong>Between 0.8 and 1.3</strong>\u00a0suggests no evidence of significant arterial disease.</p><ul><li><p>Compression may\n                                                    be safely applied in most people.\u00a0</p></li><li><p>For people with cardiac failure, consider seeking specialist advice as there may be a risk of fluid overload if not closely monitored.\u00a0</p></li></ul></li><li><p><strong>Greater than 1.3</strong>\u00a0may suggest the presence of arterial calcification, such as in some people with diabetes,\u00a0rheumatoid\n                                            arthritis, systemic vasculitis, atherosclerotic disease, and advanced chronic renal failure.\u00a0For values above 1.5, the vessels are likely to be incompressible, and the result cannot be relied on to guide clinical decisions.</p><ul><li><p>Care must be taken in interpreting ABPI results in people with these conditions,\u00a0as they may be misleadingly\n                                                high.</p></li><li><p>Compression therapy should be used with caution in people with diabetes, who may have unreliable ABPIs\u00a0due to arterial calcification as well as an underlying sensory neuropathy.</p></li><li><p><a href=\"https://cks.nice.org.uk/topics/leg-ulcer-venous/management/venous-leg-ulcers/#when-to-refer\" rel=\"noopener noreferrer nofollow\"><u>Refer</u></a> to a vascular service as further assessments may be required to determine the person's suitability for compression therapy.</p></li></ul></li></ul>", "valueSets": "<p>Ratio of blood pressure at ankle : blood pressure in upper arm </p>", "valueDomain": [{"type": "decimal"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Toe pressure index", "description": "\n                                 <p>Commonly used in patients with diabetes and peripheral arterial disease, a toe brachial pressure index (TBPI) is <strong>a noninvasive way of determining arterial perfusion in feet and toes</strong>. A Doppler device and a sphygmomanometer are used to measure systolic pressure in the arm and the great toe.</p> \n                            ", "valueSets": "<p/> <p><strong> ratio between the systolic blood pressure in the right or left toe and the higher of the systolic pressure in the right or left arms</strong>.</p>", "valueDomain": [{"type": "decimal"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pressure ulcer category", "description": "\n                             <p>Formal grading of pressure ulcers</p> \n                        ", "informationType": "\n                             &lt;p&gt;Event.Record&lt;/p&gt; \n                        ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Structured assessment", "description": "Details of the structured assessment.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment name", "description": "Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for structured assessment name.\u00a0", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=273249006&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 273249006 |Assessment scales\n                                            (assessment scale)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment result", "description": "The structured assessment result. This is the overall result for the assessment.\u00a0", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment score", "description": "The overall structured assessment score.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for assessment score.\u00a0", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=363787002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 363787002 |Observable entity\n                                                (observable entity)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Value", "description": "The numerical value for the assessment result.\u00a0", "valueSets": "Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Units of measure", "description": "The units of measure for the assessment result.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Ordinal", "description": "The ordinal result of the assessment e.g. mild, moderate, severe.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the ordinal result.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "name": "Subscale result", "description": "The subscale result for the structured assessment. This includes the result for individual questions or subsections.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Subscale score", "description": "The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for subscale item.", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=363787002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt; 363787002 |Observable entity\n                                                (observable entity)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Value", "description": "The numerical value for the subscale assessment result.\u00a0", "valueSets": "Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Units of measure", "description": "The units of measure for the assessment subscale result.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Ordinal", "description": "The ordinal result of the subscale assessment e.g. mild, moderate, severe.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Coded value", "description": "The coded value for the ordinal result.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Subscale score", "description": "The subscale score of the structured assessment.", "valueSets": "Free text."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Subscale value", "description": "The subscale value of the structured assessment.", "valueSets": "Numeric", "valueDomain": [{"type": "quantity"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Surgical specific", "description": "<p>This section holds assessment details that are specific to surgical wounds</p>", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Approximation of wound edges", "implamentationGuidance": "<p><strong>Wounds that fit neatly together</strong> are referred to as \u201cwell approximated.\u201d This is when the edges of a wound fit neatly together, such as a surgical incision, and can close easily.</p>     <p>449741007 |Wound edges approximated (finding)|</p>", "description": "<p>fully approximated, fully approximated but with tension on incision line, edges not approximated with tension on the incision line</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>Coded value for wound edge approximation</p>", "valueSets": "<p>SNOMED CT &lt;449741007 |Wound edges approximated (finding)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be if no code is available </p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound observations", "implamentationGuidance": "\n                                   <p>The wound observations section includes observations that care professionals make on the wound at any visit to, or contact with, the person, there is also provision for recording persons observations</p>   \n                            ", "description": "\n                         <p>Observations relating to the wound care episode</p> \n                    ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Clinical observations", "description": "\n                             <p>Observations that health care professionals make </p> \n                        ", "informationType": "\n                             &lt;p&gt;Event.Record&lt;/p&gt; \n                        ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pain score", "implamentationGuidance": "<p>Use the most appropriate scale for wound care, either 7 point likert or 10 point VAS would be appropriate</p>", "description": "The pain score for the person", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pain assessment scale", "implamentationGuidance": "<p>The pain assessment being used</p>", "description": "<p>A group specifying which pain assessment scale is being used to reflect the persons perception of pain </p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>Coded value for the pain assessment scale used</p>", "valueSets": "<p>SNOMED CT</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"minLength": "0", "maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pain value", "implamentationGuidance": "<p>The pain assessment scale value, either as coded entry or free text</p>", "description": "<p>A group for the pain value result from the assessment of the perception of pain. </p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pain Score", "description": "<p>The numeric value for the pain score.\u00a0</p>", "valueDomain": [{"type": "decimal"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "<p>Free text field to be used if no code is available.</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound pain frequency", "implamentationGuidance": "<p>&lt;298011007 |Finding of sensation of wound (finding)| OR &lt;&lt;81765008 |No pain (situation)| OR &lt;33653009 |Absence of sensation (finding)|</p>     <p>700469003 |Frequency of pain symptom (observable entity)|</p>", "description": "<p>The frequency of the wound pain, is it painful all the time, or at specific times or with specific movements or activities </p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value of the wound pain frequency</p>", "valueSets": "<p>SNOMED CT &lt;298011007 |Finding of sensation of wound (finding)| OR &lt;&lt;81765008 |No pain (situation)| OR &lt;33653009 |Absence of sensation (finding)| 700469003 |Frequency of pain symptom (observable entity)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Signs and symptoms of infections", "implamentationGuidance": "<p>1382461000000108 |Emergency care coded observations simple reference set (foundation metadata concept)|</p>     <ul><li><p>72313002 |Systolic arterial pressure (observable entity)|</p></li><li><p>86290005 |Respiratory rate (observable entity)|</p></li><li><p>78564009 |Heart rate measured at systemic artery (observable\n                                            entity)|</p></li><li><p>1104441000000107 |Alert Confusion Voice Pain Unresponsive scale score (observable entity)|</p></li><li><p>103228002 |Hemoglobin saturation with oxygen (observable entity)|</p></li><li><p>276885007 |Core body temperature (observable entity)|</p></li></ul>     <p>&lt;&lt;91302008 |Sepsis (disorder)|</p>     <p>&lt;&lt;2106076001 |Skin finding\n                                    (finding)|</p>", "description": "<p>Is infection present - SSI</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value for signs and symptoms of infection</p>", "valueSets": "<p>SNOMED CT</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Swab for investigation", "implamentationGuidance": "<p>225997002 |Taking wound swab (procedure)|</p>", "description": "<p>Group for recording that a swab has been taken and sent for investigation </p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded Value", "valueSets": "<p>SNOMED CT 225997002 |Taking wound swab (procedure)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>For use if coded value is not available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigations requested", "description": "Details of any investigations requested", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigations requested record entry", "description": "This is an investigation requested record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation requested", "description": "The investigation that is requested. The investigation may refer to an individual test or a group of related tests or broader investigation required (so the investigator can determine the appropriate tests)", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for Investigation requested", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=71388002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;71388002 |Procedure\n                                (procedure)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status of request", "description": "The status of the investigation request.", "valueSets": "Code : - draft | active | suspended | completed | entered-in-error | cancelled", "valueDomain": [{"type": "string", "property": [{"maxLength": "16"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for request", "description": "An explanation or justification for why this investigation is being requested.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Request priority", "description": "The urgency of the investigation requested.", "valueSets": "Code : - routine | urgent | asap | stat", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Exudate", "description": "\n                                 <p>Record of discharge from the wound</p> \n                            ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Exudate amount", "implamentationGuidance": "<p>441281002 |Amount of exudate (observable entity)|</p>", "description": "<p>The observed quantity of exudate</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value for exudate amount</p>", "valueSets": "<p>SNOMED CT 441281002 |Amount of exudate (observable entity)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Exudate consistency", "implamentationGuidance": "<p>viscosity: none, low, moderate, high</p>     <p>&lt;&lt;239164002 |Wound discharge (finding)|</p>", "description": "<p>The consistency of the discharge</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value of the exudate consistency</p>", "valueSets": "<p>SNOMED CT &lt;&lt;239164002 |Wound discharge (finding)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Exudate type", "implamentationGuidance": "<p>&lt;&lt;239164002 |Wound discharge (finding)|</p>", "description": "<p>The type of discharge that is coming from the wound</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value of the type of exudate</p>", "valueSets": "<p>SNOMED CT &lt;&lt;239164002 |Wound discharge (finding)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Exudate colour", "implamentationGuidance": "<p>&lt;&lt;239164002 |Wound discharge (finding)|</p>", "description": "<p>The colour of the discharge</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value of the exudate colour </p>", "valueSets": "<p>SNOMED CT &lt;&lt;239164002 |Wound discharge (finding)</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code is available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound care product performance", "description": "\n                                 <p>Care professionals assessment on how the wound care product (for example dressing) is performing</p> \n                            ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Dressing performance", "description": "\n                                     <p>is the dressing in use effective</p> \n                                ", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Odour intensity", "implamentationGuidance": "<p>&lt;&lt;445916002 |Wound odor (finding)|</p>     <p>odour present before dressing removal, at dressing removal, not present. Pt reported odour but not observed?</p>", "description": "<p>Presence and degree of odour</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value of the odour intensity</p>", "valueSets": "<p>SNOMED CT &lt;&lt;445916002 |Wound odor (finding)</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Examination type", "implamentationGuidance": "\n                                   <p>Other wound care examinations</p>   \n                            ", "description": "The type of examination performed.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for examination type.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Examination findings", "description": "The record of findings from the examinations performed.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for examination findings.", "valueSets": "<div>SNOMED CT : - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=1127601000000107&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">^1127601000000107 |Healthcare matters\n                                        simple reference set (foundation metadata concept)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no coded text available", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pulse sounds", "implamentationGuidance": "<p>On a handheld Doppler - tri-,bi-,mono-phasic or multi-phasic (means both tri and bi- phasic)</p>", "description": "<p>The sound of a pulse</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value for the sound of the pulse</p>", "valueSets": "<p>SNOMED CT</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code available</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Joint mobility", "implamentationGuidance": "\n                                   <p>Anatomical site should come first. Hyper-mobility, normal range of motion, reduced mobility, no range of motion</p>   \n                            ", "description": "\n                                 <p>Is the joint mobile</p> \n                            ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Anatomical site", "description": "The body site of the procedure", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of the anatomical site.", "valueSets": "<div>SNOMED CT :- <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=123037004&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;123037004 |Body structure (body\n                                        structure)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Mobility assessment", "implamentationGuidance": "\n                                   <p>Ability to mobilise is perhaps more relevant as per PURPOSE-T assessment. Foot off-loading on walking is important to this section</p>   \n                            ", "description": "\n                                     <p>Degree of mobility in the joint</p> \n                                ", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Posture and positioning", "description": "\n                                 <p>Position that the limb is in</p> \n                            ", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Lower limb oedema", "implamentationGuidance": "\n                                   <p>Level of oedema may be relevant, there are guideline terms of mild, moderate, severe and ankle, leg, thigh, etc</p>   \n                            ", "description": "\n                                 <p><strong>Swelling in the ankles, feet and legs is often caused by a build-up of fluid in these areas, called oedema</strong>. Oedema is usually caused by: standing or sitting in the same position for too long. eating too much salty food.</p> \n                            ", "valueSets": "<p>SNOMED CT 102572006 |Edema of lower extremity (finding)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Sensitivity and sensation", "description": "\n                                 <p>The sensitivity and reported sensation </p> \n                            ", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Temperature", "implamentationGuidance": "\n                                   <p>Temperature of wound </p>   \n                                   <p>Not collected as standard in wound care. Is it relevant as it is changeable. Important for sepsis assessment</p>   \n                            ", "description": "The measurement of the person's temperature in Celsius (OC) <br clear=\"none\"/> \n                            ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value for temperature</p>", "valueSets": "SNOMED CT : -&lt;&lt;386725007 |Body temperature (observable entity)| <br clear=\"none\"/> \n                                "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Value", "description": "<p>The value of the person temperature</p>", "valueSets": "Numeric", "valueDomain": [{"type": "quantity", "property": [{"minInclude": "1", "maxInclude": "2"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "<p>The units of measure for the persons temperature </p>", "valueSets": "UCUM code"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Observations record entry", "description": "This is an observations record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for observations", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=363787002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;363787002 | Observable entity\n                                            (observable entity) |</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Value", "description": "The measured value of the observations", "valueSets": "Enumerated value e.g. numeric, natural numbers, mild, moderate", "valueDomain": [{"type": "quantity"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observed nutritional status", "description": "\n                                 <p>The nutritional status of the person</p> \n                            ", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observed hydration status", "description": "<p>Allows the recording of the amount of water per KG of body weight with reference to NICE guielines 2006</p> <p/>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Surgical Wound Specific symptoms and observations", "description": "<p>Clinical observations and symptoms that relate to surgical wounds</p>", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dehiscence", "description": "<p>Group of items relating to wound dehiscence</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound dehiscence", "description": "<p>How many areas of dehiscence are there</p>", "valueSets": "<p>Numeric</p>", "valueDomain": [{"type": "quantity"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dehiscence Details", "implamentationGuidance": "<p>&lt;&lt;225553008 |Wound dehiscence (disorder)|</p>     <p/>", "description": "<p>A group containing details about individual areas of dehiscence </p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dehiscence Length", "description": "<p>The length of an area of wound dehiscence</p>", "valueSets": "<p>Decimal number</p>", "valueDomain": [{"type": "decimal"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dehiscence Depth", "description": "<p>The depth of an area of dehiscence</p>", "valueSets": "<p>Decimal Number</p>", "valueDomain": [{"type": "decimal"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "<p>The units of measure for the wound dimension</p>", "valueSets": "<p>SNOMED CT 258667005 |Unit of length (qualifier value)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dehiscence Description", "description": "<p>A description of the area of dehiscence, detailing any exposure of organs/bone/implant</p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "string"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Crepitus Present", "implamentationGuidance": "<p>271776004 |Soft tissue crepitus (finding)|</p>", "description": "<p>Is crepitus present</p> <p>crepitus describes <strong>a popping, clicking or crackling sound in a joint</strong>. Joint popping sounds \u2013 what some may call bone cracking \u2013 may mean that air is moving in the joint, which is usually harmless.</p>", "valueSets": "<p>Yes / No indicating whether or not Crepitus is present</p>", "valueDomain": [{"type": "boolean"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Healing ridge present", "implamentationGuidance": "<p>&lt;298005009 |Finding of wound healing (finding)|</p>", "description": "<p>Is there a healing ridge</p> <p>A healing ridge of thickened tissue indicating newly formed collagen can be felt about 1cm either side of the incision along its length, and persists into the remodelling phase</p>", "valueSets": "<p>Yes / No indicating the presence of a healing ridge</p>", "valueDomain": [{"type": "boolean"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Person observations", "description": "\n                             <p>Observations noted and reported by the person</p> \n                        ", "informationType": "\n                             &lt;p&gt;Record&lt;/p&gt; \n                        ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "description": "<p>The record of person reported observations e.g pulse, blood pressure, oxygen saturation/capnography, temperature, pain score, respiration rate, level of consciousness or new confusion. </p>", "valueSets": "<p>Free text recording of patient reported observations</p>", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound and skin care treatment", "implamentationGuidance": "\n                                   <p>This section allows for the recording of any wound treatments that the care professional delivers to the person. This includes:</p>   \n                                   <ul>\n                                    <li>\n                                        <p>the application of wound care products (dressings, lotions etc.),</p>\n                                    </li>\n                                    <li>\n                                        <p> the prescription of medications, </p>\n                                    </li>\n                                    <li>\n                                        <p>any procedures undertaken, such as debridement</p>\n                                    </li>\n                                    <li>\n                                        <p>any therapies provided</p>\n                                    </li>\n                                    <li>\n                                        <p>requests for investigations</p>\n                                    </li>\n                                    <li>\n                                        <p>details of referrals to other services </p>\n                                    </li>\n                                    <li>\n                                        <p>advice and guidance given</p>\n                                    </li>\n                                </ul>   \n                            ", "description": "\n                         <p>Treatments that are peculiar to wound care</p> \n                    ", "informationType": "\n                         &lt;p&gt;Event.Record&lt;/p&gt; \n                    ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Wound care products", "implamentationGuidance": "\n                                   <p>Off-loading and compression therapy need covering for lower limb wounds</p>   \n                            ", "description": "\n                             <p>Dressing applied to wound</p> \n                        ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item entry", "implamentationGuidance": "\n                                   <p>Dressings, lotions etc</p>   \n                            ", "description": "All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item cluster", "description": "Medication item cluster", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Medication prescribed by", "description": "The type of organisation responsible for authorising and issuing the medication e.g. GP <br clear=\"none\"/> \n                            ", "valueSets": "\n                                 <div>FHIR value set : - <a href=\"https://simplifier.net/hl7fhirukcorer4/ukcore-medicationprescribingagency-duplicate-2\" target=\"_blank\" rel=\"noopener\">Medication prescribing agency</a></div> \n                            "}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Medication name", "description": "May be generic name or brand name.", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for medication name", "valueSets": "dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes"}, {"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Medication trade family", "description": "The trade family or brand of the medication prescribed.", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for medication trade family or brand.", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=999000631000001100&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">^999000631000001100 |National\n                                            Health Service dictionary of medicines and devices trade family simple reference set (foundation metadata concept)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Form", "description": "The form of the medication e.g. capsule, drops, tablet, lotion etc.", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for form.", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=999000781000001107&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">^999000781000001107 | National\n                                            Health Service dictionary of medicines and devices dose form simple reference set (foundation metadata concept) |</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Quantity supplied", "description": "The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person. This may be dispensed by the pharmacy or on the ward. Record in a structured format i.e. value and a unit", "valueSets": "Free text", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The value of the quantity supplied", "valueSets": "Enumerated value", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "\n                                     <div>Units of measure of quantity supplied</div> \n                                ", "valueSets": "UCUM code"}]}, {"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Date supplied", "description": "The date/time the medication was supplied.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Site", "description": "The anatomical site at which the medication is to be administered.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for site", "valueSets": "<div>SNOMED CT: - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=442083009&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;442083009 | Anatomical or acquired body\n                                            structure (body structure) |</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used when code is not available", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Method", "description": "The technique or method by which the medication is to be administered.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for method", "valueSets": "<div>SNOMED CT : - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=999000041000001103&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">^999000041000001103 |\n                                            ePrescribing method simple reference set (foundation metadata concept) |</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no coded text available", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Supply type", "description": "A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Batch number", "description": "The batch number of the product.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the batch number", "valueSets": "FMD code : - Derived from Falsified medicines directive"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Additional instructions", "description": "Allows for: requirements for adherence support, e.g. compliance aids, prompts and packaging requirements, additional information about specific medicines e.g. where specific brand required, person requirements, e.g. unable to swallow tablets.", "valueSets": "FHIR value set : -  <a href=\"http://hl7.org/fhir/stu3/valueset-additional-instruction-codes.html\" target=\"\" title=\"\">Additional instruction</a> \n                            "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Request for advice", "description": "Request for advice and recommendation about medication", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "name": "Matters identified during discussion", "description": "Matters identified during the service about the patient's experience of using the medication.", "valueSets": "\n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">Coded text using the following descriptors:</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">a. patient reports using the medicine as prescribed</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">b. patient reports not using the medicine as prescribed</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">c. patient has not started using the medicine</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">d. prescriber has stopped new medicine</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">e. patient is not using the medicine in line with the directions of the prescriber</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">f. patient reports missing a dose in the past 7 days</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">g. patient reports need for more information about the medicine</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">h. patient reports side effects</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">i. patient reports negative feelings about the medicine</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">j. patient reports uncertainty on whether the medicine is working</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">k. patient reports concern about remembering to take the medicine</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">l. patient reports difficulty using the medicine due to its pharmaceutical form/formulation</div> \n                                 <div class=\"ewa-rteLine\" style=\"font-family: Calibri, &#34;Segoe UI&#34;, Calibri, Thonburi, Arial, Verdana, sans-serif, &#34;Mongolian Baiti&#34;, &#34;Microsoft Yi Baiti&#34;, &#34;Javanese Text&#34;; font-size: 14.6667px; white-space: pre-wrap;\">i. other - free text option</div> \n                            "}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medical devices entry", "implamentationGuidance": "\n                                   <p>Off loading devices</p>   \n                            ", "description": "Medical devices", "informationType": "Record", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Medical device", "description": "Details of a medical device used by the person.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Device type", "description": "The device type.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for device type.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available.", "valueSets": "Free text.", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Device manufacturer", "description": "Name of the device manufacturer.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for device manufacturer.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Model", "description": "The model of the device.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for model.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Comments", "description": "Any information regarding the medical device.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Procedures and therapies", "description": "The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedure record entry", "description": "This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedure", "description": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, or follow-up interventions as a result of physical health checks). Complementary or alternative procedures and therapies should be recorded here.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The procedure code.", "valueSets": "<div>SNOMED CT : - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=71388002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;71388002 |Procedure|</a> OR <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=129125009&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;129125009 |Procedure with explicit context|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Anatomical site", "description": "The body site of the procedure", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of the anatomical site.", "valueSets": "<div>SNOMED CT :- <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=123037004&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;123037004 |Body structure (body\n                                        structure)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Laterality", "description": "Laterality of the procedure", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for laterality.", "valueSets": "<div>SNOMED CT:- <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=182353008&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;182353008 |Side (qualifier\n                                value)|</a></div>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "name": "Complications related to procedure", "description": "Details of any intra-operative complications encountered during the procedure, arising during the person\u2019s stay in the recovery unit or directly attributable to the procedure.", "valueSets": "\n                             <p/> \n                        ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for complications relating to procedure.", "valueSets": "<div>SNOMED CT : - <a href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=404684003&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"_blank\" rel=\"noopener\">&lt;404684003 |Clinical finding\n                                    (finding)|</a></div> <p>\u00a0</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Information and advice given", "description": "Information and advice given.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Information and advice given", "description": "<p>The oral, written, or multi-media information or advice given to the person, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an \u2018information prescription'. State here if there are concerns about\n                            the extent to which the person and/or carer understand the information provided about diagnosis, prognosis and treatment.</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for information and advice given.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Plan and requested actions", "description": "The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Plan and requested actions record entry", "description": "This is a plan and requested actions record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Actions for professionals", "description": "Including planned investigations, procedures and treatment for a person's identified conditions and priorities. For each action the following should be identified:outcome expectations, including the person\u2019s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location,\n                            strategies.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Actions for person or their carer", "description": "For each action the following should be identified:outcome expectations, including person\u2019s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Agreed with the person or their legitimate representative", "description": "Indicates whether the person or their legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments. A record of the agreement of the decisions made.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Future appointments", "description": "Details of future appointments.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Future appointments record entry", "description": "This is the future appointments record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of appointment", "description": "Date and time of future appointment.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMD"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Appointment status", "description": "The status of the appointment e.g. proposed, booked, confirmed, rejected.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for appointment", "description": "Reason this appointment is scheduled e.g. diagnosis, investigation, treatment or assessment", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Clinical urgency of appointment", "description": "Urgency of appointment.", "valueSets": "NHS data dictionary : -  <a href=\"https://datadictionary.nhs.uk/data_elements/priority_type_code.html\" target=\"\" title=\"\">Priority</a> \n                        ", "valueDomain": [{"type": "string", "property": [{"maxLength": "1"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Location of future appointment", "description": "The location of the appointment.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "\n                                 <div>NHS data dictionary : - <a href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html#:~:text=The%20Organisation%20Data%20Service%20provides,Information%20Standards%20in%20this%20area\" target=\"_blank\" rel=\"noopener\">Organisation data service</a></div> \n                            ", "valueDomain": [{"type": "string", "property": [{"minLength": "3", "maxLength": "5"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The specialty e.g. physiotherapy, oncology, mental health etc.", "valueSets": "\n                             <div>NHS data dictionary :- <a href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html\" target=\"\" title=\"\">Activity treatment function code</a>\n                            </div> \n                        ", "valueDomain": [{"type": "string", "property": [{"maxLength": "3"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service", "description": "<p>The service that was provided</p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded Value", "description": "<p>The code for service provided</p>", "valueSets": "<p>SNOMED CT :- ^1127531000000102 |Services simple reference set (foundation metadata concept)|</p>", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text", "description": "<p>Free text to be used if no code is available</p>", "valueSets": "<p>Free text</p>"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Professional to see the person", "description": "The name and role of the professional e.g. consultant, care worker, nurse consultant.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Name", "description": "The name of the professional seeing the person.", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Role", "description": "The role of the professional seeing the person.", "valueSets": "FHIR values set : -\u00a0 <a class=\"\" href=\"https://simplifier.net/HL7FHIRUKCoreR4/UKCore-PractitionerRoleCode\" target=\"_blank\" title=\"\">ukcorepractitionerrolecode</a> \n                                 <br clear=\"none\"/> \n                            "}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Consent", "description": "Legal information captured relating to patient care, such as consent.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consent relating to child", "description": "Consideration of age and competency, applying Gillick competency or Fraser guidelines. Record of person with parental responsibility or appointed guardian where child lacks competency. Record if there is disagreement between patient and parent.", "valueSets": "Free text", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consent for treatment record", "description": "Whether consent has been obtained for the treatment. May include where record of consent is located or record of consent.", "informationType": "Event.Record", "valueSets": "Free text", "valueDomain": [{"type": "string"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Deviation from plan", "description": "\n                             <p>Rationale for variation from the plan</p> \n                        ", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound care episode outcome", "implamentationGuidance": "\n                                   <p>The wound care outcome section allows the recording of the outcome of the wound care episode, this could be a healed wound, but could be when no further treatment is being delivered</p>   \n                            ", "description": "\n                         <p>Recorded outcome of the wound care episode, based on the existing clinical summary data concept </p> \n                    ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound Healed", "implamentationGuidance": "<p>&lt;298005009 |Finding of wound healing (finding)|</p>", "description": "<p>Defined as either wound remains open upon removal of closure method or full epithelialisation across 100% of wound bed </p>", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "<p>The coded value of the wound healed</p>", "valueSets": "<p>SNOMED CT &lt;298005009 |Finding of wound healing (finding)|</p>"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "<p>Free text field to be used if no code is available </p>", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Wound Healed Date", "description": "<p>The date that the wound was assessed as being healed</p>", "valueSets": "<p>Date</p>", "valueDomain": [{"type": "date"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Episode summary", "description": "<p>Summary of the episode or period of care. Where possible, very brief. This may include interpretation of findings and results; differential diagnoses, opinion and specific action(s). Planned actions should be recorded under plan and requested actions or in the personalised care and support plan.</p>", "informationType": "&lt;p&gt;Event.Record&lt;/p&gt;", "valueSets": "<p>Free text</p>", "valueDomain": [{"type": "text"}]}]}]}]}]}