HdBe-SOAPReport
WARNING This page contains a draft CBB, as raw output from the zib export and automatic conversion to CBB. It requires thorough review and adaption to the Belgian realm. This CBB is merely added for informative use.
CBB | Description | Status |
---|---|---|
HdBe-SOAPReport | 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:
The SOAP report is mainly used in general practice care. PurposeA 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. | draft |
SOAPReport | SOAPReport | ||
id | 0..1 | string | |
extension | I | 0..* | Extension |
SoapreportDateTime | 0..1 | dateTime | |
Author | I | 0..1 | Reference(HdBe-HealthProfessional) |
Soapline | 1..4 | BackboneElement | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
SoaplineCode | 0..1 | CodeableConceptBinding | |
SoaplineHeader | 1..1 | CodeableConceptBinding | |
SoaplineText | 1..1 | string |
SOAPReport | 0..* | |
SOAPReport.SoapreportDateTime | dateTime | 0..1 |
SOAPReport.Author | Reference(HdBe-HealthProfessional) | 0..1 |
SOAPReport.Soapline | BackboneElement | 1..4 |
SOAPReport.Soapline.SoaplineCode | CodeableConcept | 0..1 |
SOAPReport.Soapline.SoaplineHeader | CodeableConcept | 1..1 |
SOAPReport.Soapline.SoaplineText | string | 1..1 |
SOAPReport | |
Definition | Root concept of the SOAPReport information model.This root concept contains all data elements of the SOAPReport information model. |
Cardinality | 0...* |
Invariants |
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Mappings |
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SOAPReport.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Cardinality | 0...1 |
Type | string |
Mappings |
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SOAPReport.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Slicing | Unordered, Open, by url(Value) |
Invariants |
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Mappings |
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SOAPReport.SoapreportDateTime | |
Definition | Date and time when the report was recorded |
Cardinality | 0...1 |
Type | dateTime |
Invariants |
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Mappings |
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SOAPReport.Author | |
Definition | The healthcare professional who prepared the report and who is responsible for its content. |
Cardinality | 0...1 |
Type | Reference(HdBe-HealthProfessional) |
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. |
Invariants |
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Mappings |
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SOAPReport.Soapline | |
Definition | Container of the SOAPLine concept.This container contains all data elements of the SOAPLine concept. |
Cardinality | 1...4 |
Type | BackboneElement |
Invariants |
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Mappings |
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SOAPReport.Soapline.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Cardinality | 0...1 |
Type | string |
Mappings |
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SOAPReport.Soapline.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Slicing | Unordered, Open, by url(Value) |
Invariants |
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Mappings |
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SOAPReport.Soapline.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Cardinality | 0...* |
Type | Extension |
Modifier | True |
Summary | True |
Alias | extensions, user content, modifiers |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants |
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Mappings |
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SOAPReport.Soapline.SoaplineCode | |
Definition | 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. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | SOAPLineCode codes |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. |
Invariants |
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Mappings |
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SOAPReport.Soapline.SoaplineHeader | |
Definition | 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. |
Cardinality | 1...1 |
Type | CodeableConcept |
Binding | SOAPLineHeader codes |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. |
Invariants |
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Mappings |
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SOAPReport.Soapline.SoaplineText | |
Definition | The actual content of the section as free formatted text. |
Cardinality | 1...1 |
Type | string |
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size |
Invariants |
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Mappings |
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Example instances
[CBB name] | |
---|---|
[Concept name ] | [example value] |
// example of NameInformation
## Example instances
| NameInformation | |
|----------------------|-------------------|
| FirstNames | Johanna Petronella Maria
| Initials | J.P.M.
| GivenName | Jo
| NameUsage | Geslachtsnaam partner gevolgd door eigen geslachtsnaam
| LastName.Prefix | van
| LastName.LastName | Putten
| LastNamePartner.PartnerPrefix | van der
| LastNamePartner.PartnerLastName | Giessen
| Titles |
zib [zib name + version](https://zibs.nl/wiki/[zib name + version(release)]) difference
Concept | Category | Description |
---|---|---|
[element.path] |
[category of change] | [Description of change]([Reference to ticket/issue/zulip chat using MarkDown link]) |
Terminology Bindings
Path | Name | Strength | URL |
---|---|---|---|
Soapline.SoaplineCode | SOAPLineCode | required | https://fhir.healthdata.be/ValueSet/SOAPLineCode |
Soapline.SoaplineHeader | SOAPLineHeader | required | https://fhir.healthdata.be/ValueSet/SOAPLineHeader |