SOAPReport-v1.0(2020EN): verschil tussen versies

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Geen bewerkingssamenvatting
Regel 319: Regel 319:
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
<ul>
<ul>
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2020bbr-?id=2.16.840.1.113883.2.4.3.11.60.10.4.2.13.6&effectiveDate=2020-09-01T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li>
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2020bbr-?id=2.16.840.1.113883.2.4.3.11.60.121.4.2.13.6&effectiveDate=2020-09-01T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li>
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2020}}</li>
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2020}}</li>
</ul>
</ul>
Regel 328: Regel 328:
SNOMED CT and LOINC codes are based on:
SNOMED CT and LOINC codes are based on:
<ul>
<ul>
<li>SNOMED Clinical Terms version: 20200309 [R] (March 2020 Interim Release)</li>
<li>SNOMED Clinical Terms version: 20200731 [R] (July 2020 Release)</li>
<li>LOINC version 2.67</li>
<li>LOINC version 2.67</li>
</ul>
</ul>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
This page is generated on 03/09/2020 13:50:56 with ZibExtraction v. 4.0.7551.21411<!--ftDate--> <BR>
This page is generated on 29/09/2020 21:24:24 with ZibExtraction v. 4.0.7577.31095<!--ftDate--> <BR>
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Versie van 29 sep 2020 21:19


Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.zorg.SOAPReport NL.png
Version: 1.0
HCIM Status:Final
Release: 2020
Release status: Published
Release date: 01-09-2020

Back 16.png Back to HCIM list

Metadata

DCM::CoderList
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList
DCM::CreationDate 25-5-2020
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.13.6
DCM::KeywordList Notitie, Verslag, SOEP
DCM::LifecycleStatus Final
DCM::ModelerList Zib centrum
DCM::Name nl.zorg.SOEPVerslag
DCM::PublicationDate 01-09-2020
DCM::PublicationStatus Published
DCM::ReviewerList
DCM::RevisionDate
DCM::Supersedes
DCM::Version 1.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-09-2020) .

Concept

A SOUP report is a textual report of (part of the consult) according to the SOUP structure. SOUP (acronym for subjective, objective, evaluation, 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:

  • Subjective: the patient's complaint and request for help and the amnesic data
  • Objective: the findings from the physical and supplementary examination.
  • Assessment: the working hypothesis and the thinking process, for example a differential diagnosis of the healthcare professional.
  • Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient.

The SOAP report is mainly used in general practice care.

Purpose

A contact note using the SOAP format offers a healthcare professional the possibility to record in a structured manner information of a contact with a patient in free text. Due to the standardized method of recording, an SOAP report also makes it possible to monitor the patient's condition and its treatment over time.

Information Model


#SOAPLineCodeCodelist#13870HealthProfessional-v3.5(2020EN)#SOAPLineHeaderCodelist#13866#13869#13868#13871#13867SOAPReport-v1.0Model(2020EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:13.6.1 Arrowdown.pngSOAPReport Root concept of the SOAPReport information model.This root concept contains all data elements of the SOAPReport information model.
TS.png NL-CM:13.6.2 Arrowright.pngSOAPReportDateTime 0..1 Date and time when the report was recorded
Verwijzing.png NL-CM:13.6.3 Arrowright.pngAuthor::HealthProfessional 0..1 The healthcare provider who prepared the report and who is responsible for its content.
Block.png HealthProfessional
Folder.png NL-CM:13.6.4 Arrowdown.pngSOAPLine 1..4 Container of the SOAPLine concept.This container contains all data elements of the SOAPLine concept.
CD.png NL-CM:13.6.5 Arrowright.pngSOAPLineCode 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 E line.

List2.png SOAPLineCodeCodelist
CD.png NL-CM:13.6.6 Arrowright.pngSOAPLineHeader 1 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.
List2.png SOAPLineHeaderCodelist
ST.png NL-CM:13.6.7 Arrowright.pngSOAPLineText 1 The actual content of the section as free formatted text.
422813005 Document section

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page List2.png

Example Instances

Only available in Dutch

SOEP Verslag
SOEPVerslagDatumTijd 21-07-2019
Auteur
Medewerkerscode 01299
AGBCode 01999999
Initialen H.A
Geslachtsnaam Janszens
ZorgverlenersRol Huisarts
SOEPRegel
SOEPRegelNaam S
SOEPRegelTekst Sinds 2 maanden hoesten. Begonnen na start enalapril. Een weekje gestopt, klachten toen weg. Na hervatten klachten weer terug gekomen.
SOEPRegelCode Hoesten, ICPC code R05
SOEPRegel
SOEPRegelNaam O
SOEPRegelTekst Keelinspectie geen bijzonderheden, pulmonaal vesiculair ademgeruis (VAG)
SOEPRegel
SOEPRegelNaam E
SOEPRegelTekst bijwerking ACE-remmer
SOEPRegelCode Geneesmiddelbijwerking, ICPC code A85
SOEPRegel
SOEPRegelNaam P
SOEPRegelTekst Overzetten van enalapril naar telmisartan. Evaluatie over 2 weken.

Traceability to other Standards

This health and care information model is based on the information model template ClinicalNote-v1.0.

Valuesets

SOAPLineCodeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.6.1 Binding: Required
Conceptname Codesystem name Codesystem OID
Alle waarden ICPC-1 NL 2.16.840.1.113883.2.4.4.31.1

SOAPLineHeaderCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Subjective 255362007 SNOMED CT 2.16.840.1.113883.6.96 Subjectief
Objective 260224007 SNOMED CT 2.16.840.1.113883.6.96 Objectief
Evaluation - action 129265001 SNOMED CT 2.16.840.1.113883.6.96 Evaluatie
Management - action 129271007 SNOMED CT 2.16.840.1.113883.6.96 Plan

This information model in other releases

Information model references

This information model refers to

This information model is used in

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Technical specifications in HL7v3 CDA and HL7 FHIR

To exchange information based on health and care information models, additional, more technical specifications are required.
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:

  • HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment Artdecor.jpg
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png

Downloads

This information model is also available as pdf file PDF.png or as spreadsheet Xlsx.png

About this information

The information in this wikipage is based on Release 2020
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms version: 20200731 [R] (July 2020 Release)
  • LOINC version 2.67

Conditions for use are located on the mainpage List2.png
This page is generated on 29/09/2020 21:24:24 with ZibExtraction v. 4.0.7577.31095

Back 16.png Back to HCIM list
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