FHIR Resource to use for wounds

[Sean C]

We need to know which FHIR Resource to use in order to represent a wound. In our case:

1. Each patient will have multiple unique wounds (with anatomical location, initial date). 
2. Each wound, will have separate assessment pdfs (multiple ones over time) associated to it.

From the the documentation overview on Observations  https://fhir.cerner.com/millennium/r4/diagnostic/observation/, the Document-Reference FHIR resources is the right one to use for the wound assessment pdf.  However, what resource should be used to represent the unique wound itself? As well, what is the preferred way to include a reference in the Document-Reference to its unique wound?

Thank you,

Sean

[Aaron McGinn (Cerner)]

I'm not sure I understand what you mean by "represent a wound," but you could also use Condition [1] to indicate an injury. These will typically be related to an Encounter [2], which would then also be associated to the DocumentReference you write out.

[1] https://fhir.cerner.com/millennium/r4/general-clinical/condition/

[2] https://fhir.cerner.com/millennium/r4/encounters/encounter/

-Aaron (Cerner)

[Sean C]

Thanks Aaron, that clarifies thing.

Do you know if this is generally the way a wound is recorded or represented at most facilities? Namely, are  observed wound generally recorded as a FHIR Condition resource and subsequent assessments are associated to that Condition as a FHIR Document-Reference or FHIR Observation through the use of the FHIR Encounter as linking reference?

Thanks,

Sean

[Aaron McGinn (Cerner)]

Correct, though I will mention that we currently only support writing labs and vital signs [1] in the Observation resource.

[1] https://fhir.cerner.com/millennium/r4/diagnostic/observation/#create

-Aaron (Cerner)

[Sean C]

Is there a list of wound specific systems and codes that can be used for Conditions?

Thanks,

Sean

[Aaron McGinn (Cerner)]

As we use standard codes (i.e. LOINC/SNOMED), there are a lot that we have mapped for use. Do you have some examples, and I can see if we have anything similar to what you're looking for?

-Aaron (Cerner)

[Sean C]

For each Condition, I intend to code them as wounds using the SNOMED Wound Concept (conceptId=13924000). However, I also want to include in the Condition:

1. Wound anatomical location
2. Textual description for the wound

I assume that #1 would use a subset of the SNOMED body location codes using system ""http://snomed.info/sct", however I don't see a way of inputting a textual description in #2. Could you confirm if it is correct and suggest the system+code, respectively?

Thank you,

Sean

[Aaron McGinn (Cerner)]

While a Condition would likely be documented in the chart, I'm thinking to get what you are looking for would need to be done through a clinical note through the DocumentReference resource as you mentioned above.

-Aaron (Cerner)