https://zibs.test-nictiz.nl/index.php?action=history&feed=atom&title=SOAPReport-v1.2%282022EN%29
SOAPReport-v1.2(2022EN) - Bewerkingsoverzicht
2026-04-29T10:38:38Z
Bewerkingsoverzicht voor deze pagina op de wiki
MediaWiki 1.43.0
https://zibs.test-nictiz.nl/index.php?title=SOAPReport-v1.2(2022EN)&diff=24029&oldid=prev
Update bot: Nieuwe pagina aangemaakt met '<!-- Hieronder wordt een transclude page aangeroepen --> {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.6(EN)|1|SOAPReport-v1.2(2022EN)}} <!-- Tot hier de trans...'
2022-06-10T20:18:32Z
<p>Nieuwe pagina aangemaakt met '<!-- Hieronder wordt een transclude page aangeroepen --> {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.6(EN)|1|SOAPReport-v1.2(2022EN)}} <!-- Tot hier de trans...'</p>
<p><b>Nieuwe pagina</b></p><div><!-- Hieronder wordt een transclude page aangeroepen --><br />
{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.6(EN)|1|SOAPReport-v1.2(2022EN)}}<br />
<!-- Tot hier de transclude page --><br />
==General information<!--hdGeneralInformation-->==<br />
Name<!--hdName-->: '''nl.zorg.SOAPReport''' [[Bestand:NL.png|link=SOEPVerslag-v1.2(2022NL)]]<BR><br />
Version<!--hdVersion-->: '''1.2''' <br><br />
HCIM Status<!--hdStatus-->:Final<br><br />
Release<!--hdPublication-->: '''2022''' <br><br />
Release status<!--hdPublicationStatus-->: Prepublished<br><br />
Release date<!--hdPublicationDate-->: 10-06-2022<br />
<!-- Aanroep Errata transclude page --><br />
{{ErrataEN<!--hdErrata-->|2022|{{PAGENAME}}}}<br />
<!-- tot hier --><br />
-----<br />
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2022(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2022(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div><br />
<br />
==Metadata==<br />
{| class="wikitable" style="font-size:90%; width: 750px"<br />
|- <br />
|style="width:250px; "|DCM::CoderList||<br />
|- <br />
|style="width:250px; "|DCM::ContactInformation.Address||*<br />
|- <br />
|style="width:250px; "|DCM::ContactInformation.Name||*<br />
|- <br />
|style="width:250px; "|DCM::ContactInformation.Telecom||*<br />
|- <br />
|style="width:250px; "|DCM::ContentAuthorList||<br />
|- <br />
|style="width:250px; "|DCM::CreationDate||25-5-2020<br />
|- <br />
|style="width:250px; "|DCM::DescriptionLanguage||nl<br />
|- <br />
|style="width:250px; "|DCM::EndorsingAuthority.Address||<br />
|- <br />
|style="width:250px; "|DCM::EndorsingAuthority.Name||PM<br />
|- <br />
|style="width:250px; "|DCM::EndorsingAuthority.Telecom||<br />
|- <br />
|style="width:250px; "|DCM::Id||2.16.840.1.113883.2.4.3.11.60.40.3.13.6<br />
|- <br />
|style="width:250px; "|DCM::KeywordList||Notitie, Verslag, SOEP<br />
|- <br />
|style="width:250px; "|DCM::LifecycleStatus||Final<br />
|- <br />
|style="width:250px; "|DCM::ModelerList||Zib centrum<br />
|- <br />
|style="width:250px; "|DCM::Name||nl.zorg.SOEPVerslag<br />
|- <br />
|style="width:250px; "|DCM::PublicationDate||10-06-2022<br />
|- <br />
|style="width:250px; "|DCM::PublicationStatus||Prepublished<br />
|- <br />
|style="width:250px; "|DCM::ReviewerList||<br />
|- <br />
|style="width:250px; "|DCM::RevisionDate||10-05-2022<br />
|- <br />
|style="width:250px; "|DCM::Supersedes||nl.zorg.SOEPVerslag-v1.1<br />
|- <br />
|style="width:250px; "|DCM::Version||1.2<br />
|- <br />
|style="width:250px; "|HCIM::PublicationLanguage||EN<br />
|}<br />
<br />
==Revision History==<br />
<div class="mw-collapsible mw-collapsed"><br />
'' Only available in Dutch<!--noTranslation-->''<br />
<br />
<u>Publicatieversie 1.0</u> (01-09-2020)<br />
<br />
Publicatieversie <u>1.1</u> (01-12-2021)<br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues500_2#ZIB-1418 | ZIB-1418 ]]<br />
|Terminologiekoppeling SOAPReport<br />
|-<br />
|style="width:75px; "|[[ZIBIssues500_2#ZIB-1473 | ZIB-1473 ]]<br />
|SOEP is SOAP in het Engels: vertaling klopt niet<br />
|}<br />
<br />
Publicatieversie <u>1.2</u> (10-06-2022)<br />
{|<br />
|-<br />
|style="width:75px; "|[[ZIBIssues500_2#ZIB-1474 | ZIB-1474 ]]<br />
|SOEPVerslag = Contactverslag of Deelcontactverslag<br />
|}<br />
</div><br />
<br />
==Concept==<br />
A SOAP report is a textual report of (partial)contact of the consultation with regard tto one problem according to the SOAP method. SOAP (acronym for subjective, objective, assessment, plan) is a method used by health professionals to structurally record information that comes up during contact between the patient and a health professionals in the patient's record.The following standardized format is used for reporting:<BR><br />
<ul><br />
<li><ul><br />
</ul><br />
</li><br />
</ul><br />
<ul><br />
<li>Subjective: the patient's complaint and request for help and the amnesic data<BR><br />
</li><br />
<li>Objective: the findings from the physical and supplementary examination.<BR><br />
</li><br />
<li>Assessment: the working hypothesis and the thinking process, for example a differential diagnosis of the healthcare professional.<BR><br />
</li><br />
<li>Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient.<br />
<br />
==Purpose==<br />
The structure of a SOEP Report offers a care provider the opportunity to record information in a structured manner in free text about one problem and a (partial) contact with a patient. Due to the standardized method of recording SOAP reports over tim, it is also possible to follow the patient's condition and its treatment over time.<BR><br />
The SOAP report is mainly used in general practice care.<br />
<br />
==Information Model==<br />
<BR><br />
<imagemap> Bestand:SOAPReport-v1.2Model(2022EN).png | center <br />
rect 503 148 630 198 [[#SOAPLineCodeCodelist]]<br />
rect 655 137 745 207 [[#13870]]<br />
rect 360 377 450 447 [[HealthProfessional-v3.5.2(2022EN)]]<br />
rect 503 386 635 436 [[#SOAPLineHeaderCodelist]]<br />
rect 655 377 745 447 [[#13866]]<br />
rect 655 257 745 327 [[#13869]]<br />
rect 354 138 452 208 [[#13868]]<br />
rect 513 257 603 327 [[#13871]]<br />
rect 354 257 452 327 [[#13867]]<br />
desc none<br />
</imagemap><br />
<BR><br />
{| border= "1" width="1500px" style = "font-size: 9.5pt; border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px" <br />
|-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; "<br />
|style="width:30px;"|Type<!--imType-->||style="width:100px;"|Id<!--imId-->||colspan="6 " style="width:140px;"|Concept<!--imConcept-->||Card.<!--imCard-->||style="width: 600px;"|Definition<!--imDefinition-->||style="width:200px;"|DefinitionCode<!--imDefinitionCode-->||style="width:200px;"|Reference<!--imReference--><br />
|-style="vertical-align:top; background-color: #E3E3E3; "<br />
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]<br />
||NL-CM:13.6.1<br />
|colspan ="6" style ="padding-left: 0px"|<span Id=13867 Title="NL: SOEPVerslag">[[Bestand: arrowdown.png | 10px | link=]]SOAPReport</span><br />
|<br />
|Root concept of the SOAPReport information model.This root concept contains all data elements of the SOAPReport information model.<br />
|<br />
|<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: TS.png| 16px | link=]]<br />
||NL-CM:13.6.2<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=13868 Title="NL: SOEPVerslagDatumTijd">[[Bestand: arrowright.png | 10px | link=]]SOAPReportDateTime</span><br />
|0..1<br />
|Date and time when the report was recorded<br />
|<br />
|<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: Verwijzing.png| 20px | link=]]<br />
||NL-CM:13.6.3<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=13863 Title="NL: Auteur::Zorgverlener">[[Bestand: arrowright.png | 10px | link=]]Author::HealthProfessional</span><br />
|0..1<br />
|The healthcare provider who prepared the report and who is responsible for its content.<br />
|<br />
|<br />
{|<br />
|-<br />
|[[Bestand: block.png | link=HealthProfessional-v3.5.2(2022EN)]]||[[HealthProfessional-v3.5.2(2022EN) |HealthProfessional]]<br />
|}<br />
|-style="vertical-align:top; background-color: #E8D7BE; "<br />
|style = "text-align:center" |[[Bestand: folder.png| 16px | link=]]<br />
||NL-CM:13.6.4<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="5" style ="padding-left: 0px"|<span Id=13871 Title="NL: SOEPRegel">[[Bestand: arrowdown.png | 10px | link=]]SOAPLine</span><br />
|1..4<br />
|Container of the SOAPLine concept.This container contains all data elements of the SOAPLine concept.<br />
|<br />
|<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CD.png| 16px | link=]]<br />
||NL-CM:13.6.5<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: none;" |<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="4" style ="padding-left: 0px"|<span Id=13870 Title="NL: SOEPRegelCode">[[Bestand: arrowright.png | 10px | link=]]SOAPLineCode</span><br />
|0..1<br />
|Coded values can be added to a line that describe essential aspects of the line.<br />
In a SOAP report an ICPC code may be assigned, but only to the S and E line.<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: SNOMED CT; Patiëntcontactverslag (record artifact)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=11591000146107 11591000146107] Patient encounter report</span><br />
|}<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#SOAPLineCodeCodelist]]||[[#SOAPLineCodeCodelist|SOAPLineCodeCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: CD.png| 16px | link=]]<br />
||NL-CM:13.6.6<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: none;" |<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="4" style ="padding-left: 0px"|<span Id=13866 Title="NL: SOEPRegelNaam">[[Bestand: arrowright.png | 10px | link=]]SOAPLineHeader</span><br />
|1<br />
|The name of the SOAP line as an coded description. In a SOAP report this can be one of the following: subjective, objective, assessment or plan.<br />
|<br />
|<br />
{|<br />
|-<br />
|[[Bestand: List2.png | link=#SOAPLineHeaderCodelist]]||[[#SOAPLineHeaderCodelist|SOAPLineHeaderCodelist]]<br />
|}<br />
|-style="vertical-align:top; background-color: transparent; "<br />
|style = "text-align:center" |[[Bestand: ST.png| 16px | link=]]<br />
||NL-CM:13.6.7<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: none;" |<br />
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |<br />
|colspan ="4" style ="padding-left: 0px"|<span Id=13869 Title="NL: SOEPRegelTekst">[[Bestand: arrowright.png | 10px | link=]]SOAPLineText</span><br />
|1<br />
|The actual content of the section as free formatted text.<br />
|<br />
{|<br />
|-<br />
|<span title = "Codesystem: SNOMED CT; Gedeelte in status (record artifact)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=422813005 422813005] Document section</span><br />
|}<br />
|<br />
|}<br />
Columns Concept and DefinitionCode: hover over the values for more information<!--imHover--><BR><br />
For explanation of the symbols, please see the legend page<!--imLegend--> [[Bestand:list2.png|link=Legend<!--wikiLegend-->]]<br />
<br />
==Example Instances==<br />
''Only available in Dutch<!--noTranslation-->''<br />
<br />
{|class="wikitable" width="623px" style= "font-size: 9.5pt;"<br />
|-style=vertical-align:top;<br />
|colspan="2" style="background-color: #1F497D; width: 100%; "|<font color=#FFFFFF><b>SOEP Verslag</b></font><br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPVerslagDatumTijd<br />
| style="width: 66%; "|21-07-2019<br />
|-style=vertical-align:top;<br />
|colspan="2" style="background-color: #BFBFBF; width: 100%; "|Auteur<br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|Medewerkerscode<br />
| style="width: 66%; "|01299<br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|AGBCode<br />
| style="width: 66%; "|01999999<br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|Initialen<br />
| style="width: 66%; "|H.A<br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|Geslachtsnaam<br />
| style="width: 66%; "|Janszens<br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|ZorgverlenersRol<br />
| style="width: 66%; "|Huisarts<br />
|-style=vertical-align:top;<br />
|colspan="2" style="background-color: #4F81BD; width: 100%; "|<font color=#FFFFFF><b>S</b></font><font color=#FFFFFF><b>OEPRegel</b></font><br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPRegelNaam<br />
| style="width: 66%; "|S<br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPRegelTekst<br />
| style="width: 66%; "|Sinds 2 maanden hoesten. Begonnen na start enalapril. Een weekje gestopt, klachten toen weg. Na hervatten klachten weer terug gekomen.<br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPRegelCode<br />
| style="width: 66%; "|<font color=#292929>Hoesten, ICPC code R05</font><br />
|-style=vertical-align:top;<br />
|colspan="2" style="background-color: #4F81BD; width: 100%; "|<font color=#FFFFFF><b>SOEPRegel</b></font><br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPRegelNaam<br />
| style="width: 66%; "|O<br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPRegelTekst<br />
| style="width: 66%; "|Keelinspectie geen bijzonderheden, pulmonaal vesiculair ademgeruis (VAG)<br />
|-style=vertical-align:top;<br />
|colspan="2" style="background-color: #4F81BD; width: 100%; "|<font color=#FFFFFF><b>SOEPRegel</b></font><br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPRegelNaam<br />
| style="width: 66%; "|E<br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPRegelTekst<br />
| style="width: 66%; "|<font color=#292929>bijwerking</font><font color=#292929> ACE-remmer</font><br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPRegelCode<br />
| style="width: 66%; "|<font color=#292929>Geneesmiddelbijwerking</font><font color=#292929>, ICPC code A85</font><br />
|-style=vertical-align:top;<br />
|colspan="2" style="background-color: #4F81BD; width: 100%; "|<font color=#FFFFFF><b>SOEPRegel</b></font><br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPRegelNaam<br />
| style="width: 66%; "|P<br />
|-style=vertical-align:top;<br />
| style="width: 34%; "|SOEPRegelTekst<br />
| style="width: 66%; "|Overzetten van enalapril naar telmisartan. Evaluatie over 2 weken.<br />
|}<br />
<br />
==Traceability to other Standards==<br />
This health and care information model is based on the information model template ClinicalNote-v1.0.<br />
<br />
== Valuesets ==<br />
=== SOAPLineCodeCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.13.6.1<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|-style="vertical-align:top; "<br />
|Alle waarden<br />
|ICPC-1 NL<br />
|2.16.840.1.113883.2.4.4.31.1<br />
|}<br />
=== SOAPLineHeaderCodelist===<br />
{| class="wikitable" width="60%" <br />
|-style='vertical-align:top; background-color: #E8D7BE;'<br />
|Valueset OID<!--vsValuesetOID-->: 2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2<br />
|Binding<!--vsBindingTag-->: Required<br />
|}<br />
{| class="wikitable" width="60% "<br />
|-style="background-color: #1F497D; color: white; font-weight: bold; "<br />
|Conceptname<!--vsConceptName--><br />
|Conceptcode<!--vsConceptCode--><br />
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID--><br />
|Description<!--vsDescription--><br />
|-style="vertical-align:top; "<br />
|<span title = "(qualifier value)">Subjective</span><br />
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=255362007 255362007]<br />
|SNOMED CT<br />
|2.16.840.1.113883.6.96<br />
|Subjectief<br />
|-style="vertical-align:top; "<br />
|<span title = "(qualifier value)">Objective</span><br />
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=260224007 260224007]<br />
|SNOMED CT<br />
|2.16.840.1.113883.6.96<br />
|Objectief<br />
|-style="vertical-align:top; "<br />
|<span title = "Evaluatie (qualifier value)">Evaluation - action</span><br />
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=129265001 129265001]<br />
|SNOMED CT<br />
|2.16.840.1.113883.6.96<br />
|Evaluatie<br />
|-style="vertical-align:top; "<br />
|<span title = "Beleid (qualifier value)">Management - action</span><br />
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=129271007 129271007]<br />
|SNOMED CT<br />
|2.16.840.1.113883.6.96<br />
|Plan<br />
|}<br />
<br />
==This information model in other releases<!--ftOtherReleases-->==<br />
<!-- Hieronder wordt een transclude page aangeroepen --><br />
{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.6(EN)|2|2022}}<br />
<!-- Tot hier de transclude page --><br />
==Information model references<!--ftReferences-->==<br />
====This information model refers to<!--ftRefersTo-->====<br />
*[[HealthProfessional-v3.5.2(2022EN)|HealthProfessional-v3.5.2]]<br />
====This information model is used in<!--ftReferredBy-->====<br />
:--<br />
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==<br />
To exchange information based on health and care information models, additional, more technical specifications are required.<BR><br />
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro--><br />
<ul><br />
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> {{ArtDecorLinks|2022|13.6}}</li><br />
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2022}}</li><br />
</ul><br />
==Downloads<!--ftDownloadTitle-->==<br />
This information model is also available as [[Media:nl.zorg.SOAPReport-v1.2(2022EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.SOAPReport-v1.2(2022EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]<!--ftDownloads--><br />
==About this information<!--ftHeader2-->==<br />
The information in this wikipage is based on<!--ftInfoBase--> Pre-release 2022-1 <BR><br />
SNOMED CT and LOINC codes are based on:<br />
<ul><br />
<li>SNOMED Clinical Terms version: 20220131 [R] (January 2022 Release)</li><br />
<li>LOINC version 2.67</li><br />
</ul><br />
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR><br />
This page is generated on 10/06/2022 12:44:38 with ZibExtraction v. 8.0.8196.20371<!--ftDate--> <BR><br />
-----<br />
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2022(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2022(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div></div>
Update bot