ARCHETYPE Waterlow score (openEHR-EHR-OBSERVATION.waterlow_score.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.waterlow_score.v0
ConceptWaterlow score
DescriptionThe Waterlow Score, Pressure Ulcer Risk Assessment Tool.
UseUse to record details of a Waterlow score, normally in conjunction which a more general clinical assessment of pressure sore risk. Users and implenters should familiarise themselves with the Guidance Notes. For some categries of recording e.g Build - weight for height, only a single score can be selected. For others e.g. Skin type Visual Risk areas, more than one risk can be entered to contribute to the overall score. Some categories have overall limits e.g. although mutiple Neurological deficits can be recorded , the total score for all such risks cannot exceed 6. Some centres expect only a total to be recorded for a whole category in which case, individual risk elements should not be captured.
MisuseThe Waterlow score is Copyright Protected © 2005-2007 judy-waterlow.co.uk and should not be used outside the terms of the copyright.
PurposeTo record the individual elements and overall score of the Waterlow Score (or Scale), for the purpose of estimating the risk of a patient developing a pressure sore or ulcer.
ReferencesThe Waterlow Score [Internet];[cited 2011 Aug 1] Available from: http://www.judy-waterlow.co.uk/waterlow_score.htm
The Waterlow Score Card [Internet];[cited 2011 Aug 1] Available from: http://www.judy-waterlow.co.uk/downloads/Waterlow%20Score%20Card-front.pdf
Ferguson ML, Bauer J, Gallagher B,Capra S, Christie DRH, Mason BR. Validation of a malnutrition screening tool for patients receiving radiotherapy. Australasian Radiology. 1999;43:325–327
Copyright© openEHR Foundation
AuthorsAuthor name: Dr Ian McNicoll
Organisation: Ocean Informatics, United Kingdom
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2011-08-01
Other Details LanguageAuthor name: Dr Ian McNicoll
Organisation: Ocean Informatics, United Kingdom
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2011-08-01
OtherDetails Language Independent{custodian_organisation=Ocean Informatics, references=The Waterlow Score [Internet];[cited 2011 Aug 1] Available from: http://www.judy-waterlow.co.uk/waterlow_score.htm The Waterlow Score Card [Internet];[cited 2011 Aug 1] Available from: http://www.judy-waterlow.co.uk/downloads/Waterlow%20Score%20Card-front.pdf Ferguson ML, Bauer J, Gallagher B,Capra S, Christie DRH, Mason BR. Validation of a malnutrition screening tool for patients receiving radiotherapy. Australasian Radiology. 1999;43:325–327, current_contact=Dr Ian McNicoll, Ocean Informatics, United Kingdom, ian.mcnicoll@oceaninformatics.com, original_namespace=com.oceaninformatics, original_publisher=Ocean Informatics, custodian_namespace=com.oceaninformatics, MD5-CAM-1.0.1=F86256A47BC1C240D92E52A3DA2DECD1, build_uid=8646b48c-6236-44c6-8793-7ad0e620ac41, revision=0.0.1-alpha}
Keywordspressure, ulcer, risk, sore, scale, skin
Lifecyclein_development
UID280e2976-c3fb-4678-a15c-8b2d3d7001fd
Language useden
Citeable Identifier1013.1.1600
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=The Waterlow Score, Pressure Ulcer Risk Assessment Tool., archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=2, text=Any event, description=Any event., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=null, extendedValues=null]], context=[], capabilities=[], activities=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0132]/items[at0133], code=at0133, itemType=ELEMENT, level=2, text=Score version, description=The version of the score used, normally recorded as the year., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], identities=[], source=[], credentials=[], state=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/state[at0071]/items[at0072], code=at0072, itemType=ELEMENT, level=4, text=Confounding factors, description=Issues that may affect interpretation of the score., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], items=[], contacts=[], target=[], relationships=[], description=[], ism_transition=[], content=[], details=[], other_participations=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Sex, description=Risk conferred by the sex of the subject., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Male [The subject is male.]
2: Female [The subject is female.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Age group, description=Risk conferred by the age range of the subject., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Less than 14 years [The subject is under 14 years old.]
1: 14-49 [The subject is aged between 14-49.]
2: 50-64 [The subject is aged between 50-64.]
3: 65-74 [The subject is aged between 65-74.]
4: 75-80 [The subject is aged between 75-80.]
5: 80+ [The subject is aged over 80.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Build/weight for height, description=Risk conferred by the subject's build, based on a BMI calculation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Average [The subject's build is average : BMI 20-24.9 .]
1: Above average [The subject's build is above average : BMI 25-29.9 .]
2: Obese [The subject is obese : BMI over 30 .]
3: Below average [The subject's build is below average : BMI below 20 .]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Continence, description=Risk conferred by the subject's degree of continence., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Complete / catheterised [The subject is completely continent or catheterised.]
1: Urinary incontinence [The subject is incontinent of urine.]
2: Faecal incontinence [The subject is incontinent of faeces.]
3: Urinary and faecal incontinence [The subject is incontinent of urine and faeces.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Mobility, description=Risk conferred by the mobility level of the subject., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Fully mobile [The subject is fully mobile.]
1: Restless/ fidgety [The subject is restless and fidgety.]
2: Apathetic [The subject is apathetic.]
3: Restricted [The subject's mobility is restricted.]
4: Bedbound [The subject is confined to bed e.g by traction.]
5: Chairbound [The subject is confined to a chair or wheelchair.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0129], code=at0129, itemType=CLUSTER, level=4, text=Nutritional risk, description=An estimate of nutritional risk based on the MST nutritional score but can make use of another compatible nutritional score., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0129]/items[at0054], code=at0054, itemType=ELEMENT, level=5, text=Weight loss, description=Risk conferred by recent weight loss., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No recent weight loss [The subject has not recently lost weight.]
1: 0.5-5kg [The subject has recently lost 0.5-5kg in weight.]
2: 5-10kg (or Amount unsure) [The subject has recently lost 5-10kg in weight.]
3: 10-15kg [The subject has recently lost 10-15kg in weight or the amount of weight loss is unknown.]
4: Over 15kg [The subject has recently lost over 15kg in weight.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0129]/items[at0044], code=at0044, itemType=ELEMENT, level=5, text=Appetite, description=Risk conferred by the subject's appetite and eating habit., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Average [The subject is eating normally and has a normal appetite.]
1: Poor [The subject is eating poorly or has a poor appetite.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0129]/items[at0130], code=at0130, itemType=ELEMENT, level=5, text=Nutritional score, description=The nutritional score total, derived from Appetite and Weight loss scores or recorded directly from another compatible nutritional scoring system., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <=5

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0066], code=at0066, itemType=CLUSTER, level=4, text=Skin type visual risk areas, description=Category of risks assessed by skin inspection., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0066]/items[at0116], code=at0116, itemType=ELEMENT, level=5, text=Healthy, description=The skin appears healthy., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Healthy [The skin appears healthy.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0066]/items[at0117], code=at0117, itemType=ELEMENT, level=5, text=Tissue-paper, description=The skin has a tissue-paper quality., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Tissue-paper [The skin has a tissue-paper quality.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0066]/items[at0118], code=at0118, itemType=ELEMENT, level=5, text=Dry, description=The skin is dry., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Dry [The skin is dry.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0066]/items[at0119], code=at0119, itemType=ELEMENT, level=5, text=Oedematous, description=The skin is oedematous., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Oedematous [The skin is oedematous.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0066]/items[at0120], code=at0120, itemType=ELEMENT, level=5, text=Clammy, pyrexia, description=The aptient appears clammy or pyrexic., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Clammy, pyrexia [The aptient appears clammy or pyrexic.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0066]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Discoloured - Stage 1, description=The skin is dicoloured - Pressure sore - Grade 1., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=2: Discoloured - Stage 1 [The skin is dicoloured - Pressure sore - Grade 1.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0066]/items[at0122], code=at0122, itemType=ELEMENT, level=5, text=Pressure ulcer - Stage 2-4, description=The skin has a frank pressure sore - Stage 2-4., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=2: Pressure ulcer - Stage 2-4 [The skin has a frank pressure sore - Stage 2-4.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0070], code=at0070, itemType=CLUSTER, level=4, text=Tissue malnutrition, description=Category of risks conferred by tissue malnutrition., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0070]/items[at0123], code=at0123, itemType=ELEMENT, level=5, text=Terminal cachexia, description=The subject is terminally-ill and shows significant weight-loss., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=8: Terminal cachexia [The subject is terminally-ill and shows significant weight-loss.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0070]/items[at0124], code=at0124, itemType=ELEMENT, level=5, text=Single organ failure, description=The patent has single organ/system failure e.g. respiratory, cardiac, liver, renal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=5: Single organ failure [The patent has single organ/system failure e.g. respiratory, cardiac, liver, renal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0070]/items[at0125], code=at0125, itemType=ELEMENT, level=5, text=Multiple organ failure, description=The subject has multiple organ/system failure., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=8: Multiple organ failure [The subject has multiple organ/system failure.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0070]/items[at0126], code=at0126, itemType=ELEMENT, level=5, text=Peripheral vascular disease, description=The subject has peripheral vascular disease., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=5: Peripheral vascular disease [The subject has peripheral vascular disease.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0070]/items[at0127], code=at0127, itemType=ELEMENT, level=5, text=Anaemia (Hb < 8 g/dl), description=The subject is significantly anaemic. Hb less than 8 mg/dl., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=2: Anaemia (Hb < 8 g/dl) [The subject is significantly anaemic. Hb less than 8 mg/dl.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0070]/items[at0128], code=at0128, itemType=ELEMENT, level=5, text=Smoking, description=The subject is a smoker., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Smoking [The subject is a smoker.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0073], code=at0073, itemType=CLUSTER, level=4, text=Neurological deficit, description=Risk conferred by neurological deficit. Each identified risk can be scored between 4-6 but a maximum of 6 only can be given for the whole neurological deficit category., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0073]/items[at0150], code=at0150, itemType=ELEMENT, level=5, text=Diabetes, MS, CVA, description=The subject has diabetes, multiple sclerosis or has had a stroke., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No neurological deficit [The subject has no overall neurological deficit.]
4: Mild neurological deficit [The subject has a mild overall neurological deficit.]
5: Moderate neurological deficit [The subject has a moderate overall neurological deficit.]
6: Severe neurological deficit [The subject has a severe overall neurological deficit.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0073]/items[at0151], code=at0151, itemType=ELEMENT, level=5, text=Motor / sensory deficit, description=The subject has a motor or sensory deficit., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No neurological deficit [The subject has no overall neurological deficit.]
4: Mild neurological deficit [The subject has a mild overall neurological deficit.]
5: Moderate neurological deficit [The subject has a moderate overall neurological deficit.]
6: Severe neurological deficit [The subject has a severe overall neurological deficit.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0073]/items[at0152], code=at0152, itemType=ELEMENT, level=5, text=Paraplegia, description=The subject has a paraplegia., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No neurological deficit [The subject has no overall neurological deficit.]
4: Mild neurological deficit [The subject has a mild overall neurological deficit.]
5: Moderate neurological deficit [The subject has a moderate overall neurological deficit.]
6: Severe neurological deficit [The subject has a severe overall neurological deficit.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0073]/items[at0135], code=at0135, itemType=ELEMENT, level=5, text=Combined neurological deficit, description=An overall estimate of neurological deficit. Should not be used if individual neurological deficit risks are recorded., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No neurological deficit [The subject has no overall neurological deficit.]
4: Mild neurological deficit [The subject has a mild overall neurological deficit.]
5: Moderate neurological deficit [The subject has a moderate overall neurological deficit.]
6: Severe neurological deficit [The subject has a severe overall neurological deficit.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0068], code=at0068, itemType=CLUSTER, level=4, text=Major surgery or trauma, description=Risk associated with major surgery or trauma., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0068]/items[at0114], code=at0114, itemType=ELEMENT, level=5, text=Orthopaedic /spinal, description=Risks related to orthopaedic or spinal surgery., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No orthopaedic / spinal surgery [The subject has no risk related to spinal / orthopaedic surgery.]
5: Orthopaedic /spinal surgery [The subject has undergone orthopaedic or spinal surgery.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0068]/items[at0144], code=at0144, itemType=ELEMENT, level=5, text=Duration of surgery, description=Risks imparted by length of surgery., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: On table < 2 hrs or not in ast 48 hrs [The subject has had surgery more than 48 hrs ago or lasting for less than 2 hours.]
5: On table > 2 hrs (Past 48 hrs) [The subject has had surgery within the past 48 hours lasting over 2 hours.]
8: On table > 6 hrs (Past 48 hrs) [The subject has had surgery within the past 48 hours lasting over 6 hours.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0067], code=at0067, itemType=CLUSTER, level=4, text=Medication, description=Risk associated with medication. Each medication can be scored between 0-4 but a total of 4 only can be given by all risks in the Medication category., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0067]/items[at0106], code=at0106, itemType=ELEMENT, level=5, text=Cytotoxics, description=The subject is receiving cytotoxic medication., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No medication risk [The subject has no risk related to medication.]
4: Significant medication risk [The subject has significant risk related to medication.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0067]/items[at0107], code=at0107, itemType=ELEMENT, level=5, text=Steroids, description=The subject is receiving high-dose or long-term steroid medication., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No medication risk [The subject has no risk related to medication.]
4: Significant medication risk [The subject has significant risk related to medication.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0067]/items[at0108], code=at0108, itemType=ELEMENT, level=5, text=Anti-inflammatories, description=The subject is receiving anti-inflammatory medication., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No medication risk [The subject has no risk related to medication.]
4: Significant medication risk [The subject has significant risk related to medication.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0067]/items[at0140], code=at0140, itemType=ELEMENT, level=5, text=Combined medication risk, description=Overall pressure ulcer risk related to medication. Should not be recorded if individual medication risks are used., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No medication risk [The subject has no risk related to medication.]
4: Significant medication risk [The subject has significant risk related to medication.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=Waterlow score, description=The total summed score of all recorded individual risks., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=1

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0015], code=at0015, itemType=ELEMENT, level=4, text=Overall risk grade, description=Overall Waterlow Score., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=10: 10+ At risk [The subject is at risk of developing a pressure ulcer.]
15: 15+ High risk [The subject is at high risk of developing a pressure ulcer.]
20: 20+ Very high risk [The subject is at very high risk of developing a pressure ulcer.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0019], code=at0019, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative comment about the Score., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], provider=[]}, topLevelItems={state=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/state[at0071], code=at0071, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0132], code=at0132, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0132]/items[at0133], code=at0133, itemType=ELEMENT, level=2, text=Score version, description=The version of the score used, normally recorded as the year., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]