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
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'/>
 <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'/>

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

Braden Component Score Codes
Component LOINC Code
Sensory Perception 38222-6
Moisture Exposure 38229-1
Physical Mobility 38224-2
Physical Activity 38223-4
Nutrition Intake Pattern 38225-9
Friction and Shear 38226-7


For Public Comment Both LOINC and SNOMED CT support identification of the Braden Scale Assessment panel components. 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? The LOINC codes are very specific, and identify each component as being a component of the Braden Scale, whereas the SNOMED CT codes are mappings of existing codes to Brade Scale components


<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 describe the meaning of the score value. Interpretations for each of the scores for each assessment component are shown in the table below.

Need help filling out this table with precoordinated SNOMED concepts.-->>Braden Component Score Interpretation Codes<<--
Component Code Score Interpretation Code Description
Sensory Perception 38222-6 1    
2    
3    
4    
Moisture Exposure 38229-1 1    
2    
3    
4    
Physical Mobility 38224-2 1    
2    
3    
4    
Physical Activity 38223-4 1    
2    
3    
4    
Nutrition Intake Pattern 38225-9    
2 255351007 Poor
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


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?


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

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

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