1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2

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The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif Braden Score Observation 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2

The Braden Scale is a summated rating scale made up of six subscales scored from 1-3 or 4, for total scores that range from 6-23. The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levers of risk for pressure ulcer development. This entry shows how to record the Braden Score and its component assessment scores.


Uses

See Templates using Braden Score Observation

Specification
Braden Score Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.31'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2'/>
 <id root=' ' extension=' '/>
 <code code='38227‑5' 
       displayName='Braden scale score.total' 
       codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
   <translation code='225392000' displayName='Pressure sore risk assessment'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='SNOMED CT'/>
 </code>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='INT' value=' '/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <!-- Six entries, containing each of the assessment components -->
 <entryRelationship typeCoded='COMP'>
   <observation classCode='OBS' moodCode='EVN'>
     <tempateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3'/>
        :
   </observation>
 </entryRelationship>
</observation>


<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.31'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2'/>

These <templateId> elements identify this entry as a Braden Score Observation. Furthermore, they identify it as a CCD Result entry, and a Simple Observation. They shall be present as shown above.

<code code='38227‑5' displayName='Braden scale score.total' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
 <translation code='225392000' displayName='Pressure sore risk assessment'
  codeSystem=2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

The <code> element identifies this observation as being a Braden Scale Score. The <translation> element shall be sent to indicate that this score is an assessment of pressure sore risk.

<value xsi:type='INT' value=' '/>

The <value> element shall be present, and records the Braden Score for the patient. The value shall be within the range of 6 to 23 inclusive.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode> may be present to indicate the risk for pressure sores. It shall contain a code from the table below using SNOMED CT.

Braden Score Interpretation SNOMED CT Code SNOMED CT Description
Braden Score Interpretation Codes
19-23 No risk of pressure sores 260413007 None
15-18 Risk of pressure sores 30207005 Risk Of
13-14 Moderate risk of pressure sores 25594002 Moderate risk of
10-12 High risk of pressure sores 15508007 High risk of
6-9 Very high risk of pressure sores Not Available1 Very high risk of


1 Code value pending results of submission to SNOMED
<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
<!-- Six entries, containing each of the assessment components -->
<entryRelationship typeCoded='COMP'>
 <observation classCode='OBS' moodCode='EVN'>
  <tempateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3'/>

The Braden score is made up of six assessments. Each assessment is scored individually. The overall score indicates the patient risk for pressure sores, and the individual component scores help the reciever of the information determine the appropriate interventions. Thus, a Braden Score Observation shall always be transmitted with all of its component assessments. See Braden Score Component for details on encoding the assessment components.