1. 1 The Use of Clinical LOINC ® * for Practice-Based Nursing Skin Assessment * Logical Observation Identifiers Names and Codes February 5, 2010 Holly Miller Donna DuLong Luigi Sison Terminology Standards, Standards and Interoperability, Chief Health Informatics Office

2. 2 Objectives Report a current effort to use Clinical LOINC ® for representing questions in a practice-based nursing skin assessment Describe an emerging nursing skin assessment model informed by Clinical LOINC ®

3. 3 Trigger Concerns Veterans Affairs (VA) application development –Patient Assessment Template –Clinical Flow Sheet (CLIO) Commercial Off the Shelf (COTS) –Clinical Information Systems (CIS) –Anesthesia Record Keeper (ARK)

4. 4 Office of Nursing Leadership

5. 5 Example - Spreadsheet Enterprise TermCode SystemCodeDescription Q: What is the status of the tissue in the wound? (Wound Healing Status) LOINC ® 39123-5 Wound status: Finding: Point in time: Wound: Nominal A: Epithelialization SNOMED19982005 Epithelialization (morphologic abnormality) A: Eschar SNOMED8731900 Eschar (morphologic abnormality) A: Granulation SNOMED225541009 Granulation of tissue (finding) A: Hypergranulation SNOMED201072002 Other abnormal granulation tissue (disorder) A: Necrotic SNOMED44015005 Necrotic debris (morphologic abnormality) 5

6. 6 Repeatable Process Identify common observations of interest Represent observations with reference terminologies Describe the clinical knowledge about the observations using mind maps Represent clinical knowledge as comparable, implementable models Engage in dialog with standards organizations

7. 7 Skin Assessment Model 7

8. 8 Wound Model Informed by LOINC ®

9. 9 Wound Model – Practice Example

10. 10 Scales and Instruments

11. 11 Question/Answer Pairs Answers: 1.Clear 2.Green 3.White 4.Red 5.Yellow Question: “What is the color of the patient’s wound drainage?” LOINC ® 6824-7 Color – Body Fld

12. 12 Next Steps Continue to explore the use of Clinical LOINC ® for practice based Nursing Assessments Identify interested partners for further exploration of Clinical LOINC ® skin assessment for content and models

13. 13 Questions For more information, contact: Holly Miller Holly.Miller@va.govHolly.Miller@va.gov