1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2

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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'/> <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'/>

The <code> element identifies this observation as being a Braden Scale Score.

For Public Comment

Both LOINC and SNOMED CT support identification of the Braden Scale Score. Should we select one (e.g. LOINC as shown) or the other, require the use of both, allow the sender to choose which coding system to use?

<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.

For Public Comment

This is a CE data type, which means that it must use a coding system that does not use qualifiers to assess risk. Should we ask SNOMED for a set of concepts that can be used here?

<!-- 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.