SOAPReport-v1.1(2021EN)
General information
Name: nl.zorg.SOAPReport 
Version: 1.1
HCIM Status:Final
Release: 2021
Release status: Prepublished
Release date: 01-12-2021
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 | 01-12-2021 |
| DCM::PublicationStatus | Prepublished |
| DCM::ReviewerList | |
| DCM::RevisionDate | 20-08-2021 |
| DCM::Supersedes | nl.zorg.SOEPVerslag-v1.0 |
| DCM::Version | 1.1 |
| 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 |
Concept
A SOAP report is a textual report of (part of the consult) according to the SOAP structure. 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:
- 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
| Type | Id | Concept | Card. | Definition | DefinitionCode | Reference | ||||||||
|
NL-CM:13.6.1 |  SOAPReport
|
Root concept of the SOAPReport information model.This root concept contains all data elements of the SOAPReport information model. | |||||||||||
|
NL-CM:13.6.2 |  SOAPReportDateTime
|
0..1 | Date and time when the report was recorded | ||||||||||
|
NL-CM:13.6.3 | Author::HealthProfessional
|
0..1 | The healthcare provider who prepared the report and who is responsible for its content. |
| |||||||||
|
NL-CM:13.6.4 | SOAPLine
|
1..4 | Container of the SOAPLine concept.This container contains all data elements of the SOAPLine concept. | ||||||||||
|
NL-CM:13.6.5 | SOAPLineCode
|
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. |
|
| ||||||||
|
|
NL-CM:13.6.6 | SOAPLineHeader
|
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. |
| |||||||||
|
NL-CM:13.6.7 | SOAPLineText
|
1 | The actual content of the section as free formatted text. |
|
|||||||||
Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page 
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
- Release 2020, (Version 1.0)
- Prerelease 2022-1, (Version 1.2)
- Prerelease 2023-1, (Version 1.3)
- Prerelease 2024-1, (Version 1.3)
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
- HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR
Downloads
This information model is also available as pdf file 
or as spreadsheet 
About this information
The information in this wikipage is based on Pre-release 2021-2
SNOMED CT and LOINC codes are based on:
- SNOMED Clinical Terms version: 20210731 [R] (July 2021 Release)
- LOINC version 2.67
Conditions for use are located on the mainpage
This page is generated on 30/11/2021 09:45:38 with ZibExtraction v. 6.4.8004.1652