SOAPReport-v1.3.1(2026-1EN) - Bewerkingsoverzicht

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Version: '''1.3.1'''
HCIM Status:Final
Release: '''2026-1'''
2026-04-18T16:31:30Z

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{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.6(EN)|1|SOAPReport-v1.3.1(2026-1EN)}}

==General information==
Name: '''nl.zorg.SOAPReport''' [[Bestand:NL.png|link=SOEPVerslag-v1.3.1(2026-1NL)]]<BR>
Version: '''1.3.1''' <br>
HCIM Status:Final<br>
Release: '''2026-1''' <br>
Release status: Prepublished<br>
Release date: 17-04-2026

{{ErrataEN|2026-1|{{PAGENAME}}}}

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<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2026-1(EN)]] [[HCIM_Release_2026-1(EN) |Back to HCIM list ]]</div>

==Metadata==
{| class="wikitable" style="font-size:90%; width: 750px"
|-
|style="width:250px; "|DCM::CoderList||
|-
|style="width:250px; "|DCM::ContactInformation.Address||*
|-
|style="width:250px; "|DCM::ContactInformation.Name||*
|-
|style="width:250px; "|DCM::ContactInformation.Telecom||*
|-
|style="width:250px; "|DCM::ContentAuthorList||
|-
|style="width:250px; "|DCM::CreationDate||25-5-2020
|-
|style="width:250px; "|DCM::DescriptionLanguage||nl
|-
|style="width:250px; "|DCM::EndorsingAuthority.Address||
|-
|style="width:250px; "|DCM::EndorsingAuthority.Name||PM
|-
|style="width:250px; "|DCM::EndorsingAuthority.Telecom||
|-
|style="width:250px; "|DCM::Id||2.16.840.1.113883.2.4.3.11.60.40.3.13.6
|-
|style="width:250px; "|DCM::KeywordList||Notitie, Verslag, SOEP
|-
|style="width:250px; "|DCM::LifecycleStatus||Final
|-
|style="width:250px; "|DCM::ModelerList||Zib centrum
|-
|style="width:250px; "|DCM::Name||nl.zorg.SOEPVerslag
|-
|style="width:250px; "|DCM::PublicationDate||17-04-2026
|-
|style="width:250px; "|DCM::PublicationStatus||Prepublished
|-
|style="width:250px; "|DCM::ReviewerList||
|-
|style="width:250px; "|DCM::RevisionDate||07-05-2025
|-
|style="width:250px; "|DCM::Supersedes||nl.zorg.SOEPVerslag-v1.3
|-
|style="width:250px; "|DCM::Version||1.3.1
|-
|style="width:250px; "|HCIM::PublicationLanguage||EN
|}

==Revision History==
<div class="mw-collapsible mw-collapsed">
'' Only available in Dutch''

<u>Publicatieversie 1.0</u> (01-09-2020)

Publicatieversie <u>1.1</u> (01-12-2021)
{|
|-
|style="width:75px; "|[[ZIBIssues500_2#ZIB-1418 | ZIB-1418 ]]
|Terminologiekoppeling SOAPReport
|-
|style="width:75px; "|[[ZIBIssues500_2#ZIB-1473 | ZIB-1473 ]]
|SOEP is SOAP in het Engels: vertaling klopt niet
|}

Publicatieversie <u>1.2</u> (10-06-2022)
{|
|-
|style="width:75px; "|[[ZIBIssues500_2#ZIB-1474 | ZIB-1474 ]]
|SOEPVerslag = Contactverslag of Deelcontactverslag
|}

Publicatieversie <u>1.3</u> (15-10-2023)
{|
|-
|style="width:75px; "|[[ZIBIssues500_3#ZIB-1841 | ZIB-1841 ]]
|Inconsistentie in zib SOEPVerslag
|-
|style="width:75px; "|[[ZIBIssues500_3#ZIB-1920 | ZIB-1920 ]]
|Tekstuele wijzigingen zib SOEPVerslag
|}

Publicatieversie <u>1.3.1</u> (24-04-2024)
{|
|-
|style="width:75px; "|[[ZIBIssues500_4#ZIB-2395 | ZIB-2395 ]]
|Referentie SNOMED besluit toevoegen en zibs uitbreiden met SNOMED
|}
</div>

==Concept==
A SOAP report is a textual report of (partial) contact of the consultation with regard to 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 professional in the patient's record.The following standardized format is used for reporting: <BR>
<ul>
<li>Subjective: the patient's complaint and request for help and the amnesic data. </li>
<li>Objective: the findings from the physical and supplementary examination. </li>
<li>Assessment: the working hypothesis and the thinking process, for example a differential diagnosis of the healthcare professional. </li>
<li>Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient.

==Purpose==
The structure of a SOAP 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 time, it is also possible to follow the patient's condition and its treatment over time.<BR>
The SOAP report is mainly used in general practice care.

==Information Model==
<BR>
<imagemap> Bestand:SOAPReport-v1.3.1Model(2026-1EN).png | center
rect 503 148 630 198 [[#SOAPLineCodeCodelist]]
rect 655 137 745 207 [[#1960]]
rect 360 377 450 447 [[HealthProfessional-v4.0.1(2026-1EN)]]
rect 503 386 635 436 [[#SOAPLineHeaderCodelist]]
rect 655 377 745 447 [[#1956]]
rect 655 257 745 327 [[#1959]]
rect 354 138 452 208 [[#1958]]
rect 513 257 603 327 [[#1961]]
rect 354 257 452 327 [[#1957]]
desc none
</imagemap>
<BR>
{| border= "1" width="1500px" style = "font-size: 9.5pt; border: solid 1px silver; border-collapse:collapse;" cellpadding = "3px" cellspacing ="0px"
|-style="background-color: #1F497D; color: white; font-weight: bold; font-variant: small-caps; "
|style="width:30px;"|Type||style="width:100px;"|Id||colspan="6 " style="width:140px;"|Concept||Card.||style="width: 600px;"|Definition||style="width:200px;"|DefinitionCode||style="width:200px;"|Reference
|-style="vertical-align:top; background-color: #E3E3E3; "
|style = "text-align:center" |[[Bestand: block.png| 20px | link=]]
||NL-CM:13.6.1
|colspan ="6" style ="padding-left: 0px"|<span Id=1957 Title="NL: SOEPVerslag">[[Bestand: arrowdown.png | 10px | link=]]SOAPReport</span>
|
|Root concept of the SOAPReport information model. This root concept contains all data elements of the SOAPReport information model.
|
|
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: TS.png| 16px | link=]]
||NL-CM:13.6.2
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Id=1958 Title="NL: SOEPVerslagDatumTijd">[[Bestand: arrowright.png | 10px | link=]]SOAPReportDateTime</span>
|0..1
|Date and time when the report was recorded.
|
|
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: Verwijzing.png| 20px | link=]]
||NL-CM:13.6.3
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Id=1953 Title="NL: Auteur::Zorgverlener">[[Bestand: arrowright.png | 10px | link=]]Author::HealthProfessional</span>
|0..1
|The healthcare professional who prepared the report and who is responsible for its content.
|
|
{|
|-
|[[Bestand: block.png | link=HealthProfessional-v4.0.1(2026-1EN)]]||[[HealthProfessional-v4.0.1(2026-1EN) |HealthProfessional]]
|}
|-style="vertical-align:top; background-color: #E8D7BE; "
|style = "text-align:center" |[[Bestand: folder.png| 16px | link=]]
||NL-CM:13.6.4
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="5" style ="padding-left: 0px"|<span Id=1961 Title="NL: SOEPRegel">[[Bestand: arrowdown.png | 10px | link=]]SOAPLine</span>
|1..4
|Container of the SOAPLine concept. This container contains all data elements of the SOAPLine concept.
|
|
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: CD.png| 16px | link=]]
||NL-CM:13.6.5
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: none;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="4" style ="padding-left: 0px"|<span Id=1960 Title="NL: SOEPRegelCode">[[Bestand: arrowright.png | 10px | link=]]SOAPLineCode</span>
|0..1
|Coded values can be added to a line that describe essential aspects of the line.
In a SOAP report an ICPC code may be assigned, but only to the S and A line.
|
{|
|-
|<span title = "Codesystem: SNOMED CT; Patiëntcontactverslag (record artifact)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=11591000146107 11591000146107] Patient encounter report</span>
|}
|
{|
|-
|[[Bestand: List2.png | link=#SOAPLineCodeCodelist]]||[[#SOAPLineCodeCodelist|SOAPLineCodeCodelist]]
|}
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: CD.png| 16px | link=]]
||NL-CM:13.6.6
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: none;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="4" style ="padding-left: 0px"|<span Id=1956 Title="NL: SOEPRegelNaam">[[Bestand: arrowright.png | 10px | link=]]SOAPLineHeader</span>
|1
|The name of the SOAP line as a coded description. In a SOAP report this can be one of the following: subjective, objective, assessment or plan.
|
|
{|
|-
|[[Bestand: List2.png | link=#SOAPLineHeaderCodelist]]||[[#SOAPLineHeaderCodelist|SOAPLineHeaderCodelist]]
|}
|-style="vertical-align:top; background-color: transparent; "
|style = "text-align:center" |[[Bestand: ST.png| 16px | link=]]
||NL-CM:13.6.7
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: none;" |
|style = "width: 7px; padding-left: 0px; padding-right: 0px; border-left: none; border-right: 1px dotted silver;" |
|colspan ="4" style ="padding-left: 0px"|<span Id=1959 Title="NL: SOEPRegelTekst">[[Bestand: arrowright.png | 10px | link=]]SOAPLineText</span>
|1
|The actual content of the section as free formatted text.
|
{|
|-
|<span title = "Codesystem: SNOMED CT; Gedeelte in status (record artifact)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=422813005 422813005] Document section</span>
|}
|
|}
Columns Concept and DefinitionCode: hover over the values for more information<BR>
For explanation of the symbols, please see the legend page [[Bestand:list2.png|link=Legend]]

==Example Instances==
''Only available in Dutch''

{|class="wikitable" width="623px" style= "font-size: 9.5pt;"
|-style=vertical-align:top;
|colspan="2" style="background-color: #1F497D; width: 100%; "|<font color=#FFFFFF><b>SOEP Verslag</b></font>
|-style=vertical-align:top;
| style="width: 34%; "|SOEPVerslagDatumTijd
| style="width: 66%; "|21-07-2019
|-style=vertical-align:top;
|colspan="2" style="background-color: #BFBFBF; width: 100%; "|Auteur
|-style=vertical-align:top;
| style="width: 34%; "|Medewerkerscode
| style="width: 66%; "|01299
|-style=vertical-align:top;
| style="width: 34%; "|AGBCode
| style="width: 66%; "|01999999
|-style=vertical-align:top;
| style="width: 34%; "|Initialen
| style="width: 66%; "|H.A
|-style=vertical-align:top;
| style="width: 34%; "|Geslachtsnaam
| style="width: 66%; "|Janszens
|-style=vertical-align:top;
| style="width: 34%; "|ZorgverlenersRol
| style="width: 66%; "|Huisarts
|-style=vertical-align:top;
|colspan="2" style="background-color: #4F81BD; width: 100%; "|<font color=#FFFFFF><b>S</b></font><font color=#FFFFFF><b>OEPRegel</b></font>
|-style=vertical-align:top;
| style="width: 34%; "|SOEPRegelNaam
| style="width: 66%; "|S
|-style=vertical-align:top;
| style="width: 34%; "|SOEPRegelTekst
| style="width: 66%; "|Sinds 2 maanden hoesten. Begonnen na start enalapril. Een weekje gestopt, klachten toen weg. Na hervatten klachten weer terug gekomen.
|-style=vertical-align:top;
| style="width: 34%; "|SOEPRegelCode
| style="width: 66%; "|<font color=#292929>Hoesten, ICPC code R05</font>
|-style=vertical-align:top;
|colspan="2" style="background-color: #4F81BD; width: 100%; "|<font color=#FFFFFF><b>SOEPRegel</b></font>
|-style=vertical-align:top;
| style="width: 34%; "|SOEPRegelNaam
| style="width: 66%; "|O
|-style=vertical-align:top;
| style="width: 34%; "|SOEPRegelTekst
| style="width: 66%; "|Keelinspectie geen bijzonderheden, pulmonaal vesiculair ademgeruis (VAG)
|-style=vertical-align:top;
|colspan="2" style="background-color: #4F81BD; width: 100%; "|<font color=#FFFFFF><b>SOEPRegel</b></font>
|-style=vertical-align:top;
| style="width: 34%; "|SOEPRegelNaam
| style="width: 66%; "|E
|-style=vertical-align:top;
| style="width: 34%; "|SOEPRegelTekst
| style="width: 66%; "|<font color=#292929>bijwerking</font><font color=#292929> ACE-remmer</font>
|-style=vertical-align:top;
| style="width: 34%; "|SOEPRegelCode
| style="width: 66%; "|<font color=#292929>Geneesmiddelbijwerking</font><font color=#292929>, ICPC code A85</font>
|-style=vertical-align:top;
|colspan="2" style="background-color: #4F81BD; width: 100%; "|<font color=#FFFFFF><b>SOEPRegel</b></font>
|-style=vertical-align:top;
| style="width: 34%; "|SOEPRegelNaam
| style="width: 66%; "|P
|-style=vertical-align:top;
| style="width: 34%; "|SOEPRegelTekst
| style="width: 66%; "|Overzetten van enalapril naar telmisartan. Evaluatie over 2 weken.
|}

==Instructions==
Valuesets from this zib may be deprecated when the SNOMED decision comes into force in the Netherlands. More information on the SNOMED decision and what its implementation means for zibs can be found at https://zibs.nl/wiki/SNOMEDbesluit. (Dutch)

==Traceability to other Standards==
This health and care information model is based on the information model template ClinicalNote-v1.0.

== Valuesets ==
=== SOAPLineCodeCodelist===
{| class="wikitable" width="60%"
|-style='vertical-align:top; background-color: #E8D7BE;'
|Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.6.1
|Binding: Required
|Status: Active
|}
{| class="wikitable" width="60% "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|Conceptname
|Codesystem name||Codesystem OID
|-style="vertical-align:top; "
|All values
|ICPC-1 NL
|2.16.840.1.113883.2.4.4.31.1
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|colspan="3"|
|-style="vertical-align:top; background-color: #EBF5FB;"
|colspan="3"|Value Other (OTH) from codesystem NullFlavor (OID: 2.16.840.1.113883.5.1008) is allowed in this valueset.
|}
=== SOAPLineHeaderCodelist===
{| class="wikitable" width="60%"
|-style='vertical-align:top; background-color: #E8D7BE;'
|Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2
|Binding: Required
|Status: Active
|}
{| class="wikitable" width="60% "
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|Conceptname
|Conceptcode
|Codesystem name||Codesystem OID
|Description
|-style="vertical-align:top; "
|<span title = "Subjectieve waarneming (qualifier value)">Subjective</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=255362007 255362007]
|SNOMED CT
|2.16.840.1.113883.6.96
|Subjectief, (S)
|-style="vertical-align:top; "
|<span title = "Objectieve waarneming (qualifier value)">Objective</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=260224007 260224007]
|SNOMED CT
|2.16.840.1.113883.6.96
|Objectief, (O)
|-style="vertical-align:top; "
|<span title = "Evaluatie (qualifier value)">Evaluation - action</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=129265001 129265001]
|SNOMED CT
|2.16.840.1.113883.6.96
|Evaluatie, (E)
|-style="vertical-align:top; "
|<span title = "Beleid (qualifier value)">Management - action</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=129271007 129271007]
|SNOMED CT
|2.16.840.1.113883.6.96
|Plan, (P)
|-style="background-color: #1F497D; color: white; font-weight: bold; "
|colspan="5"|
|-style="vertical-align:top; background-color: #EBF5FB;"
|colspan="5"|Other values are not allowed
|}

==This information model in other releases==

{{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.6(EN)|2|2026-1}}

==Information model references==
====This information model refers to====
*[[HealthProfessional-v4.0.1(2026-1EN)|HealthProfessional-v4.0.1]]
====This information model is used in====
:--
==Technical specifications in HL7v3 CDA and HL7 FHIR==
To exchange information based on health and care information models, additional, more technical specifications are required.<BR>
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:
<ul>
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment {{ArtDecorLinks|2026-1|13.6}}</li>
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR {{SimplefierLinks|2026-1|SOEPVerslag}}</li>
</ul>
==Downloads==
This information model is also available as [[Media:nl.zorg.SOAPReport-v1.3.1(2026-1EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.SOAPReport-v1.3.1(2026-1EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]
==About this information==
The information in this wikipage is based on prerelease 2026-1 <BR>
SNOMED CT and LOINC codes are based on:
<ul>
<li>SNOMED Clinical Terms versie: 20260331 [R] (maart 2026-editie)</li>
<li>LOINC version 2.81</li>
</ul>
Conditions for use are located on the mainpage [[Bestand:list2.png|link=HCIM_Mainpage]]<BR>
This page is generated on 18/04/2026 18:14:24 with ZibExtraction v. 10.0.9604.31200 <BR>
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<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release_2026-1(EN)]] [[HCIM_Release_2026-1(EN) |Back to HCIM list ]]</div>