FHIR © HL7.org  |  Server Home  |  FHIR Server FHIR Server 3.4.11  |  FHIR Version n/a  User: [n/a]

Resource StructureDefinition/FHIR Server from package nictiz.fhir.nl.r4.zib2020#0.11.0-beta.1 (63 ms)

Package nictiz.fhir.nl.r4.zib2020
Type StructureDefinition
Id Id
FHIR Version R4
Source https://simplifier.net/resolve?scope=nictiz.fhir.nl.r4.zib2020@0.11.0-beta.1&canonical=http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport.SOAPLine
Url http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport.SOAPLine
Status draft
Name ZibSOAPReportSOAPLine
Title zib SOAPReport.SOAPLine
Experimental False
Realm nl
Authority hl7
Description A SOAP report is a textual report of a (partial) consult with relation to a single problem 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. Note: the zib doesn't state explicitly if zib SOAPReport pertains a consult or a partial consult, but it has become clear that the zib, and thus this profile, should be interpreted as a partial consult with relation to a single problem (see ). The text above has been adjusted according to this insight.
Purpose This Observation resource represents the SOAPLine concept of the Dutch [zib ('Zorginformatiebouwsteen', i.e. Health and Care Information Model) SOAPReport v1.0 (2020)](https://zibs.nl/wiki/SOAPReport-v1.0(2020EN)).
Copyright Copyright and related rights waived via CC0, https://creativecommons.org/publicdomain/zero/1.0/. This does not apply to information from third parties, for example a medical terminology system. The implementer alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize third party IP in connection with the specification or otherwise.
Type Observation
Kind resource

Resources that use this resource

StructureDefinition
http://nictiz.nl/fhir/StructureDefinition/nl-core-SOAPReport.SOAPLine nl core SOAPReport.SOAPLine
http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport zib SOAPReport

Resources that this resource uses

StructureDefinition
http://nictiz.nl/fhir/StructureDefinition/ext-SOAPReport.SOAPLineCode ext SOAPReport.SOAPLineCode
http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 SOEPRegelNaamCodelijst


Narrative

Note: links and images are rebased to the (stated) source

No narrative is provided for definitional resources. A human-readable rendering can be found in the implementation guide(s) where this resource is used.

Source

{
  "resourceType" : "StructureDefinition",
  "id" : "zib-SOAPReport.SOAPLine",
  "text" : {
    "status" : "empty",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">No narrative is provided for definitional resources. A human-readable rendering can be found in the implementation guide(s) where this resource is used.</div>"
  },
  "url" : "http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport.SOAPLine",
  "name" : "ZibSOAPReportSOAPLine",
  "title" : "zib SOAPReport.SOAPLine",
  "status" : "draft",
  "publisher" : "Nictiz",
  "contact" : [
    {
      "name" : "Nictiz",
      "telecom" : [
        {
          "system" : "url",
          "value" : "https://www.nictiz.nl",
          "use" : "work"
        }
      ]
    }
  ],
  "description" : "A SOAP report is a textual report of a (partial) consult with relation to a single problem 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:\r\n\r\n* Subjective: the patient's complaint and request for help and the amnesic data\r\n* Objective: the findings from the physical and supplementary examination.\r\n* Assessment: the working hypothesis and the thinking process, for example a differential diagnosis of the healthcare professional.\r\n* Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient.\r\n\r\nThe SOAP report is mainly used in general practice care.\r\n\r\nNote: the zib doesn't state explicitly if zib SOAPReport pertains a consult or a partial consult, but it has become clear that the zib, and thus this profile, should be interpreted as a partial consult with relation to a single problem (see <https://bits.nictiz.nl/browse/ZIB-1474>). The text above has been adjusted according to this insight.",
  "purpose" : "This Observation resource represents the SOAPLine concept of the Dutch [zib ('Zorginformatiebouwsteen', i.e. Health and Care Information Model) SOAPReport v1.0 (2020)](https://zibs.nl/wiki/SOAPReport-v1.0(2020EN)).",
  "copyright" : "Copyright and related rights waived via CC0, https://creativecommons.org/publicdomain/zero/1.0/. This does not apply to information from third parties, for example a medical terminology system. The implementer alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize third party IP in connection with the specification or otherwise.",
  "fhirVersion" : "4.0.1",
  "mapping" : [
    {
      "identity" : "zib-soapreport-v1.0-2020EN",
      "uri" : "https://zibs.nl/wiki/SOAPReport-v1.0(2020EN)",
      "name" : "zib SOAPReport-v1.0(2020EN)"
    }
  ],
  "kind" : "resource",
  "abstract" : true,
  "type" : "Observation",
  "baseDefinition" : "http://hl7.org/fhir/StructureDefinition/Observation",
  "derivation" : "constraint",
  "differential" : {
    "element" : [
      {
        "id" : "Observation",
        "path" : "Observation",
        "short" : "SOAPLine",
        "comment" : "Zib SOAPReport is implemented using two profiles: this profile implements the SOAPLine concept of the zib, while <http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport> represents the SOAPReport concept of the zib.",
        "alias" : [
          "SOEPRegel"
        ],
        "constraint" : [
          {
            "key" : "zib-SOAPReport-1",
            "severity" : "error",
            "human" : "In a SOAP report an ICPC code may be assigned, but only to the S and A line.",
            "expression" : "extension('http://nictiz.nl/fhir/StructureDefinition/ext-SOAPReport.SOAPLineCode').exists() implies (code.coding.where(code = '255362007' and system = 'http://snomed.info/sct').exists() or code.coding.where(code = '129265001' and system = 'http://snomed.info/sct').exists())"
          }
        ],
        "mapping" : [
          {
            "identity" : "zib-soapreport-v1.0-2020EN",
            "map" : "NL-CM:13.6.4",
            "comment" : "SOAPLine"
          }
        ]
      },
      {
        "id" : "Observation.extension:soapLineCode",
        "path" : "Observation.extension",
        "sliceName" : "soapLineCode",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://nictiz.nl/fhir/StructureDefinition/ext-SOAPReport.SOAPLineCode"
            ]
          }
        ],
        "condition" : [
          "zib-SOAPReport-1"
        ]
      },
      {
        "id" : "Observation.extension:soapLineCode.value[x]",
        "path" : "Observation.extension.value[x]",
        "condition" : [
          "zib-SOAPReport-1"
        ]
      },
      {
        "id" : "Observation.status",
        "path" : "Observation.status",
        "comment" : "Unless explicitly recorded, a value of _final_ would be expected."
      },
      {
        "id" : "Observation.code",
        "path" : "Observation.code",
        "short" : "SOAPLineHeader",
        "definition" : "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.",
        "alias" : [
          "SOEPRegelNaam"
        ],
        "condition" : [
          "zib-SOAPReport-1"
        ],
        "binding" : {
          "strength" : "required",
          "valueSet" : "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000"
        },
        "mapping" : [
          {
            "identity" : "zib-soapreport-v1.0-2020EN",
            "map" : "NL-CM:13.6.6",
            "comment" : "SOAPLineHeader"
          }
        ]
      },
      {
        "id" : "Observation.code.coding",
        "path" : "Observation.code.coding",
        "condition" : [
          "zib-SOAPReport-1"
        ]
      },
      {
        "id" : "Observation.value[x]",
        "path" : "Observation.value[x]",
        "slicing" : {
          "discriminator" : [
            {
              "type" : "type",
              "path" : "$this"
            }
          ],
          "rules" : "open"
        }
      },
      {
        "id" : "Observation.value[x]:valueString",
        "path" : "Observation.value[x]",
        "sliceName" : "valueString",
        "short" : "SOAPLineText",
        "definition" : "The actual content of the section as free formatted text.",
        "alias" : [
          "SOEPRegelTekst"
        ],
        "type" : [
          {
            "code" : "string"
          }
        ],
        "mapping" : [
          {
            "identity" : "zib-soapreport-v1.0-2020EN",
            "map" : "NL-CM:13.6.7",
            "comment" : "SOAPLineText"
          }
        ]
      }
    ]
  }
}

XIG built as of ??metadata-date??. Found ??metadata-resources?? resources in ??metadata-packages?? packages.