SOAPReport-v1.3(2023EN)

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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: 1.3
HCIM Status:Final
Release: 2023
Release status: Prepublished
Release date: 15-10-2023

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 15-10-2023
DCM::PublicationStatus Prepublished
DCM::ReviewerList
DCM::RevisionDate 05-09-2023
DCM::Supersedes nl.zorg.SOEPVerslag-v1.2
DCM::Version 1.3
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-09-2020)

Publicatieversie 1.1 (01-12-2021)

ZIB-1418 Terminologiekoppeling SOAPReport
ZIB-1473 SOEP is SOAP in het Engels: vertaling klopt niet

Publicatieversie 1.2 (10-06-2022)

ZIB-1474 SOEPVerslag = Contactverslag of Deelcontactverslag

Publicatieversie 1.3 (15-10-2023)

ZIB-1841 Inconsistentie in zib SOEPVerslag
ZIB-1920 Tekstuele wijzigingen zib SOEPVerslag

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:

  • 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.

    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.
    The SOAP report is mainly used in general practice care.

    Information Model


    #SOAPLineCodeCodelist#1960HealthProfessional-v4.0(2023EN)#SOAPLineHeaderCodelist#1956#1959#1958#1961#1957SOAPReport-v1.3Model(2023EN).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 professional 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 A line.

    11591000146107 Patient encounter report
    List2.png SOAPLineCodeCodelist
    CD.png NL-CM:13.6.6 Arrowright.pngSOAPLineHeader 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.
    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
    All values 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, (S)
    Objective 260224007 SNOMED CT 2.16.840.1.113883.6.96 Objectief, (O)
    Evaluation - action 129265001 SNOMED CT 2.16.840.1.113883.6.96 Evaluatie, (E)
    Management - action 129271007 SNOMED CT 2.16.840.1.113883.6.96 Plan, (P)

    This information model in other releases

    Information model references

    This information model refers to

    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.
    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 Prerelease 2023-1
    SNOMED CT and LOINC codes are based on:

    • SNOMED Clinical Terms versie: 20230930 [R] (september 2023-editie)
    • LOINC version 2.76

    Conditions for use are located on the mainpage List2.png
    This page is generated on 31/10/2023 18:36:32 with ZibExtraction v. 9.3.8704.31782

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