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HdBe-SOEPVerslag

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	Concept	Status
HdBe-SOAPReport	Een SOEP verslag is een tekstueel verslag van (een deel van het consult) volgens de SOEP-structuur. SOEP (acroniem voor subjectief, objectief, evaluatie, plan) is een methode die gebruikt wordt door zorgverleners om informatie die bij een contact tussen de patiënt en een zorgverlener aan de orde komt, gestructureerd vast te leggen in het dossier van de patiënt. Bij de verslaglegging wordt de volgende gestandaardiseerde indeling aangehouden: Subjectief: de klacht en hulpvraag van de patiënt en de anamnestische gegevens Objectief: de bevindingen uit het lichamelijk en aanvullend onderzoek. Evaluatie: de werkhypothese en het denkproces, bijvoorbeeld een differentiaaldiagnose van de zorgverlener. Plan: het diagnostisch plan of behandelplan en wat met de patiënt is besproken of afgesproken. Het SOEP verslag wordt met name in de huisartsenzorg gebruikt. Purpose Een contactverslag volgens de SOEP structuur biedt een zorgverlener mogelijkheid op gestructureerde wijze in vrije tekst informatie rond een contact met een patiënt vast te leggen. Door de gestandaardiseerde wijze van vastleggen maakt een SOEP verslag het tevens mogelijk om de aandoening van de patiënt en de behandeling daarvan te volgen in de tijd. Traceability to other Standards Deze zorginformatie bouwsteen is gebaseerd op de bouwsteen blauwdruk ZorgNotitie-v1.0.	draft

CBB

Concept

Status

HdBe-SOAPReport

Een SOEP verslag is een tekstueel verslag van (een deel van het consult) volgens de SOEP-structuur. SOEP (acroniem voor subjectief, objectief, evaluatie, plan) is een methode die gebruikt wordt door zorgverleners om informatie die bij een contact tussen de patiënt en een zorgverlener aan de orde komt, gestructureerd vast te leggen in het dossier van de patiënt. Bij de verslaglegging wordt de volgende gestandaardiseerde indeling aangehouden:

Subjectief: de klacht en hulpvraag van de patiënt en de anamnestische gegevens
Objectief: de bevindingen uit het lichamelijk en aanvullend onderzoek.
Evaluatie: de werkhypothese en het denkproces, bijvoorbeeld een differentiaaldiagnose van de zorgverlener.
Plan: het diagnostisch plan of behandelplan en wat met de patiënt is besproken of afgesproken.

Het SOEP verslag wordt met name in de huisartsenzorg gebruikt.

Purpose

Een contactverslag volgens de SOEP structuur biedt een zorgverlener mogelijkheid op gestructureerde wijze in vrije tekst informatie rond een contact met een patiënt vast te leggen. Door de gestandaardiseerde wijze van vastleggen maakt een SOEP verslag het tevens mogelijk om de aandoening van de patiënt en de behandeling daarvan te volgen in de tijd.

Traceability to other Standards

Deze zorginformatie bouwsteen is gebaseerd op de bouwsteen blauwdruk ZorgNotitie-v1.0.

draft

SOAPReport			SOAPReport	Element id SOAPReport Short description SOEPVerslag Definition Rootconcept van de bouwsteen SOEPVerslag. Dit rootconcept bevat alle gegevenselementen van de bouwsteen SOEPVerslag. Data type SOAPReport Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id SOAPReport.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id SOAPReport.extension Short description Additional content defined by implementations Alternate names extensions, user content 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. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
SoapreportDateTime		0..1	dateTime	Element id SOAPReport.SoapreportDateTime Short description SOEPVerslagDatumTijd Definition Datum en tijd waarop het verslag vastgelegd is Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Author	I	0..1	Reference(HdBe-HealthProfessional)	Element id SOAPReport.Author Short description Auteur Definition De zorgverlener die het verslag heeft opgesteld en verantwoordelijk is voor de inhoud. 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. Data type Reference(HdBe-HealthProfessional) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
Soapline		1..4	BackboneElement	Element id SOAPReport.Soapline Short description SOEPRegel Definition Container van het concept SOEPRegel. Deze container bevat alle gegevenselementen van het concept SOEPRegel. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id SOAPReport.Soapline.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id SOAPReport.Soapline.extension Short description Additional content defined by implementations Alternate names extensions, user content 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. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id SOAPReport.Soapline.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers 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). 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
SoaplineCode		0..1	CodeableConceptBinding	Element id SOAPReport.Soapline.SoaplineCode Short description SOEPRegelCode Definition Aan een regel kunnen eventueel gecodeerde waarden toegevoegd worden die essentiële aspecten van de regel beschrijven. Bij een SOEP verslag worden alleen aan de S en E regel eventueel een ICPC code toegekend. 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. Data type CodeableConcept Binding SOAPLineCode codes SOAPLineCode (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
SoaplineHeader		1..1	CodeableConceptBinding	Element id SOAPReport.Soapline.SoaplineHeader Short description SOEPRegelNaam Definition De naam van de SOEP regel als gecodeerde omschrijving. Voor een SOEP verslag kan dit één van de volgende waarden zijn: subjectief, objectief, evaluatie of plan. 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. Data type CodeableConcept Binding SOAPLineHeader codes SOAPLineHeader (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
SoaplineText		1..1	string	Element id SOAPReport.Soapline.SoaplineText Short description SOEPRegelTekst Definition De feitelijke inhoud van de sectie als vrije tekst. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a

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	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
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	rim: n/a
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	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
SOAPReport.SoapreportDateTime
Definition	Date and time when the report was recorded
Cardinality	0...1
Type	dateTime
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
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	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))`
Mappings	rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
SOAPReport.Soapline
Definition	Container of the SOAPLine concept.This container contains all data elements of the SOAPLine concept.
Cardinality	1...4
Type	BackboneElement
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
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	rim: n/a
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	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
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	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
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 SOAPLineCode (required)
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	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
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 SOAPLineHeader (required)
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	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
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	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a

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