1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3
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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
<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'/> <text><reference value='#xxx'/></text> <statusCode code='completed'/> |
<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.
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.
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.