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FHIR IG Statistics: StructureDefinition/zib-SOAPReport.SOAPLine

Packagenictiz.fhir.nl.r4.zib2020
TypeStructureDefinition
Idzib-SOAPReport.SOAPLine
FHIR VersionR4
Sourcehttps://simplifier.net/resolve?scope=nictiz.fhir.nl.r4.zib2020@0.12.0-beta.1&canonical=http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport.SOAPLine
URLhttp://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport.SOAPLine
Statusdraft
NameZibSOAPReportSOAPLine
Titlezib SOAPReport.SOAPLine
Realmnl
Authorityhl7
DescriptionA 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 <https://bits.nictiz.nl/browse/ZIB-1474>). The text above has been adjusted according to this insight.
PurposeThis 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)).
CopyrightCopyright 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.
TypeObservation
Kindresource

Resources that use this resource

StructureDefinition
nl-core-SOAPReport.SOAPLinenl core SOAPReport.SOAPLine
zib-SOAPReportzib SOAPReport

Resources that this resource uses

StructureDefinition
ext-SOAPReport.SOAPLineCodeext SOAPReport.SOAPLineCode
ValueSet
2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000SOEPRegelNaamCodelijst

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": "<!-- snip (see above) -->"
  },
  "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"
          }
        ]
      }
    ]
  }
}