1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3

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Trial.gif Braden Score Component 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3

This entry supports the recording of the observations from the six subscales of the Braden Score. These scales are scored from 1-3 or 4. The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. This entry shows how to record the assessment scores Braden Score components.


Uses

See Templates using Braden Score Component

Specification
Braden Score Component 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='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3'/>
 <id root=' ' extension=' '/>
 <code code='38222‑6|38229‑1|38223‑4|38224‑2|38225‑9|38226‑7' 
       displayName=' ' 
       codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
   <translation code=' ' displayName=' ' 
     codeSystem='2.16.840.1.113883.6.96' 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=' '/>
</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='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3'/>

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

<code code='38222‑6|38229‑1|38223‑4|38224‑2|38225‑9|38226‑7'
 displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
 <translation code=' ' displayName=' '
  codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

The <code> element identifies which component of the Braden Scale is being assessed in this observation. The valid LOINC codes are listed in the second column of the table below.

Braden Component Score Codes
Component LOINC Code SNOMED CT Code SNOMED CT Description
Sensory Perception 38222-6 248240001 response to pain
Moisture Exposure 38229-1 364532007 moistness of skin
Physical Mobility 38224-2 249864002 ability to assume and maintain a position
Physical Activity 38223-4 68130003 physical activity
Nutrition Intake Pattern 38225-9 87276001 nutritional status
Friction and Shear 38226-7 301438001 ability to mobilize

The translation element should be sent to provide a translation of the measure to the SNOMED CT coding system. The code attribute of the translation element shall contain the matching SNOMED CT code from column three in the table above. The displayName attribute may be present, and should contain text similar to the matching description from column four of the table above.

<effectiveTime value=' '/>

The <effectiveTime> element need not be present, as it is already recorded in the observation for which this is a component.

<value xsi:type='INT' value=' '/>

The <value> element shall be present, and records the Braden Score for the component assessed. The value shall be within the range of 1 to 4 inclusive for all components except the Friction/Shear score, which shall be within the range of 1 to 3 inclusive.

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

The <interpretationCode> may be present to interpret the score value using SNOMED CT. Interpretations for each of the scores for each assessment component are shown in the table below. When the <interpretionCode> element is present, the <translation> element described above shall be present. These interpretations are provided to assist decision support systems that are making secondary use of the assessment information, and are not intended to replace the score values.

Braden Component Score Interpretation Codes
Component LOINC
Code
Score SNOMED CT
Interpretation Code
SNOMED CT
Description
Sensory Perception 38222-6 1 42341009 Agnosia
2 425403003 Limited sensory perception
3
4 247700009 Normal perception
Moisture Exposure 38229-1 1 255238004 Continuous
2 70232002 Frequent
3 84638005 Occasional
4 89292003 Rare
Physical Mobility 38224-2 1 302045007 Does not mobilize
2 160692006 Mobility very poor
3 8510008 Reduced mobility
4 302042005 Able to mobilize
Physical Activity 38223-4 1 160685001 Bed-ridden
2 160684002 Confined to chair
3 84638005 Occasional
4 70232002 Frequent
Nutrition Intake Pattern 38225-9 1 255351007 Poor
2 71978007 Inadequate
3 88323005 Adequate
4 425405005 Excellent
Friction and Shear 38226-7 1 301684000 Does not move in bed
2 301697003 Difficulty moving up and down bed
3 301693004 able to move up and down bed


<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <methodCode> and <targetSiteCode> elements shall not be used.