<status value="active" /> <publisher value="Nictiz" /> <contact> <name value="Nictiz" /> <telecom> <system value="url" /> <value value="https://www.nictiz.nl" /> <use value="work" /> </telecom> </contact> <description value="JournalEntry S-O-A-P (Dutch S-O-E-P) as defined in the NHG HIS Referentiemodel." /> <fhirVersion value="3.0.2" /> <kind value="resource" /> <abstract value="false" /> <type value="Observation" /> <baseDefinition value="http://fhir.nl/fhir/StructureDefinition/nl-core-observation" /> <derivation value="constraint" /> <differential> <element id="Observation.extension:nl-core-episodeofcare"> <path value="Observation.extension" /> <sliceName value="nl-core-episodeofcare" /> <comment value="It is recommended to use the nl-core-episodeofcare extension to reference nl-core-episodeofcare (EpisodeOfCare) instances rather than the `context` element, as this approach will be enforced in FHIR R4." /> <type> <code value="Extension" /> <profile value="http://nictiz.nl/fhir/StructureDefinition/extension-context-nl-core-episodeofcare" /> </type> </element> <element id="Observation.identifier"> <path value="Observation.identifier" /> <max value="1" /> </element> <element id="Observation.basedOn"> <path value="Observation.basedOn" /> <max value="0" /> </element> <element id="Observation.status"> <path value="Observation.status" /> <short value="final" /> <definition value="The status of the journal entry" /> <fixedCode value="final" /> </element> <element id="Observation.code"> <path value="Observation.code" /> <short value="NHG SOAP Code" /> <definition value="Subjective, Objective, Evaluation, Plan" /> <binding> <strength value="required" /> <description value="NHG SOAP codes" /> <valueSetReference> <reference value="http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.103.11.2--20111012000000" /> <display value="JournaalregelType" /> </valueSetReference> </binding> </element> <element id="Observation.subject"> <path value="Observation.subject" /> <type> <code value="Reference" /> <targetProfile value="http://fhir.nl/fhir/StructureDefinition/nl-core-patient" /> </type> </element> <element id="Observation.context"> <path value="Observation.context" /> <short value="Encounter during which this observation is made" /> <definition value="The encounter during which this journal entry was made." /> <comment value="It is recommended to use the nl-core-episodeofcare extension to reference nl-core-episodeofcare (EpisodeOfCare) instances rather than the `context` element, as this approach will be enforced in FHIR R4." /> <min value="1" /> <type> <code value="Reference" /> <targetProfile value="http://nictiz.nl/fhir/StructureDefinition/gp-Encounter" /> </type> </element> <element id="Observation.effective[x]"> <path value="Observation.effective[x]" /> <definition value="Sending the effective date is recommended, but is otherwise understood to fall in the encounter date range." /> <mustSupport value="true" /> </element> <element id="Observation.issued"> <path value="Observation.issued" /> <max value="0" /> </element> <element id="Observation.value[x]"> <path value="Observation.value[x]" /> <short value="Journal Entry text" /> <definition value="The text as recorded or generated for this journal entry." /> <alias value="Journaalregel tekst" /> <min value="1" /> <type> <code value="string" /> </type> </element> <element id="Observation.dataAbsentReason"> <path value="Observation.dataAbsentReason" /> <max value="0" /> </element> <element id="Observation.interpretation"> <path value="Observation.interpretation" /> <max value="0" /> </element> <element id="Observation.comment"> <path value="Observation.comment" /> <max value="0" /> </element> <element id="Observation.bodySite"> <path value="Observation.bodySite" /> <max value="0" /> </element> <element id="Observation.method"> <path value="Observation.method" /> <max value="0" /> </element> <element id="Observation.specimen"> <path value="Observation.specimen" /> <max value="0" /> </element> <element id="Observation.device"> <path value="Observation.device" /> <max value="0" /> </element> <element id="Observation.referenceRange"> <path value="Observation.referenceRange" /> <max value="0" /> </element> <element id="Observation.related"> <path value="Observation.related" /> <max value="0" /> </element> <element id="Observation.component"> <path value="Observation.component" /> <slicing> <discriminator> <type value="pattern" /> <path value="code" /> </discriminator> <rules value="open" /> </slicing> <definition value="Journal entry Evaluation often has an ICPC code that qualifies it. Journal entry Subjective is sometimes qualified using an ICPC code too." /> <max value="2" /> </element> <element id="Observation.component:ICPC_S"> <path value="Observation.component" /> <sliceName value="ICPC_S" /> <max value="1" /> </element> <element id="Observation.component:ICPC_S.code"> <path value="Observation.component.code" /> <definition value="ICPC code qualifying journal entry Subjective" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/v3/ActCode" /> <code value="ADMDX" /> <display value="admitting diagnosis" /> </coding> </patternCodeableConcept> </element> <element id="Observation.component:ICPC_S.value[x]"> <path value="Observation.component.value[x]" /> <min value="1" /> <type> <code value="CodeableConcept" /> </type> </element> <element id="Observation.component:ICPC_S.value[x].coding"> <path value="Observation.component.value[x].coding" /> <min value="1" /> <max value="1" /> </element> <element id="Observation.component:ICPC_S.value[x].coding.system"> <path value="Observation.component.value[x].coding.system" /> <min value="1" /> <fixedUri value="http://hl7.org/fhir/sid/icpc-1-nl" /> </element> <element id="Observation.component:ICPC_S.value[x].coding.code"> <path value="Observation.component.value[x].coding.code" /> <min value="1" /> </element> <element id="Observation.component:ICPC_E"> <path value="Observation.component" /> <sliceName value="ICPC_E" /> <max value="1" /> </element> <element id="Observation.component:ICPC_E.code"> <path value="Observation.component.code" /> <definition value="ICPC code qualifying journal entry Evaluation" /> <patternCodeableConcept> <coding> <system value="http://hl7.org/fhir/v3/ActCode" /> <code value="DISDX" /> <display value="discharge diagnosis" /> </coding> </patternCodeableConcept> </element> <element id="Observation.component:ICPC_E.value[x]"> <path value="Observation.component.value[x]" /> <min value="1" /> <type> <code value="CodeableConcept" /> </type> </element> <element id="Observation.component:ICPC_E.value[x].coding"> <path value="Observation.component.value[x].coding" /> <min value="1" /> <max value="1" /> </element> <element id="Observation.component:ICPC_E.value[x].coding.system"> <path value="Observation.component.value[x].coding.system" /> <min value="1" /> <fixedUri value="http://hl7.org/fhir/sid/icpc-1-nl" /> </element> <element id="Observation.component:ICPC_E.value[x].coding.code"> <path value="Observation.component.value[x].coding.code" /> <min value="1" /> </element> </differential> </StructureDefinition>