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
Resources that this resource uses
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.