SOAPReport-v1.0(2020EN)

Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.zorg.SOAPReport
Version: 1.0
HCIM Status:Final
Release: 2020
Release status: Published
Release date: 01-09-2020

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Metadata

DCM::CoderList
DCM::ContactInformation.Address	*
DCM::ContactInformation.Name	*
DCM::ContactInformation.Telecom	*
DCM::ContentAuthorList
DCM::CreationDate	25-5-2020
DCM::DescriptionLanguage	nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name	PM
DCM::EndorsingAuthority.Telecom
DCM::Id	2.16.840.1.113883.2.4.3.11.60.40.3.13.6
DCM::KeywordList	Notitie, Verslag, SOEP
DCM::LifecycleStatus	Final
DCM::ModelerList	Zib centrum
DCM::Name	nl.zorg.SOEPVerslag
DCM::PublicationDate	01-09-2020
DCM::PublicationStatus	Published
DCM::ReviewerList
DCM::RevisionDate
DCM::Supersedes
DCM::Version	1.0
HCIM::PublicationLanguage	EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-09-2020) .

Concept

A SOUP report is a textual report of (part of the consult) according to the SOUP structure. SOUP (acronym for subjective, objective, evaluation, 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.

Purpose

A contact note using the SOAP format offers a healthcare professional the possibility to record in a structured manner information of a contact with a patient in free text. Due to the standardized method of recording, an SOAP report also makes it possible to monitor the patient's condition and its treatment over time.

Information Model

Type	Id	Concept						Card.	Definition	DefinitionCode	Reference
	NL-CM:13.6.1	SOAPReport							Root concept of the SOAPReport information model.This root concept contains all data elements of the SOAPReport information model.
	NL-CM:13.6.2		SOAPReportDateTime					0..1	Date and time when the report was recorded
	NL-CM:13.6.3		Author::HealthProfessional					0..1	The healthcare provider who prepared the report and who is responsible for its content.		HealthProfessional
	NL-CM:13.6.4		SOAPLine					1..4	Container of the SOAPLine concept.This container contains all data elements of the SOAPLine concept.
	NL-CM:13.6.5			SOAPLineCode				0..1	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.		SOAPLineCodeCodelist
	NL-CM:13.6.6			SOAPLineHeader				1	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.		SOAPLineHeaderCodelist
	NL-CM:13.6.7			SOAPLineText				1	The actual content of the section as free formatted text.	422813005 Document section

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page

Example Instances

Only available in Dutch

SOEP Verslag
SOEPVerslagDatumTijd	21-07-2019
Auteur
Medewerkerscode	01299
AGBCode	01999999
Initialen	H.A
Geslachtsnaam	Janszens
ZorgverlenersRol	Huisarts
SOEPRegel
SOEPRegelNaam	S
SOEPRegelTekst	Sinds 2 maanden hoesten. Begonnen na start enalapril. Een weekje gestopt, klachten toen weg. Na hervatten klachten weer terug gekomen.
SOEPRegelCode	Hoesten, ICPC code R05
SOEPRegel
SOEPRegelNaam	O
SOEPRegelTekst	Keelinspectie geen bijzonderheden, pulmonaal vesiculair ademgeruis (VAG)
SOEPRegel
SOEPRegelNaam	E
SOEPRegelTekst	bijwerking ACE-remmer
SOEPRegelCode	Geneesmiddelbijwerking, ICPC code A85
SOEPRegel
SOEPRegelNaam	P
SOEPRegelTekst	Overzetten van enalapril naar telmisartan. Evaluatie over 2 weken.

Traceability to other Standards

This health and care information model is based on the information model template ClinicalNote-v1.0.

Valuesets

SOAPLineCodeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.6.1

Binding: Required

Conceptname	Codesystem name	Codesystem OID
Alle waarden	ICPC-1 NL	2.16.840.1.113883.2.4.4.31.1

SOAPLineHeaderCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2

Binding: Required

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Subjective	255362007	SNOMED CT	2.16.840.1.113883.6.96	Subjectief
Objective	260224007	SNOMED CT	2.16.840.1.113883.6.96	Objectief
Evaluation - action	129265001	SNOMED CT	2.16.840.1.113883.6.96	Evaluatie
Management - action	129271007	SNOMED CT	2.16.840.1.113883.6.96	Plan

This information model in other releases

• Prerelease 2021-2, (Version 1.1)
• Prerelease 2022-1, (Version 1.2)
• Prerelease 2023-1, (Version 1.3)
• Prerelease 2024-1, (Version 1.3)

Information model references

This information model refers to

• HealthProfessional-v3.5

This information model is used in

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Technical specifications in HL7v3 CDA and HL7 FHIR

To exchange information based on health and care information models, additional, more technical specifications are required.
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:

• HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment
• HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR

Downloads

This information model is also available as pdf file or as spreadsheet

About this information

The information in this wikipage is based on Release 2020
SNOMED CT and LOINC codes are based on:

• SNOMED Clinical Terms version: 20200731 [R] (July 2020 Release)
• LOINC version 2.67

Conditions for use are located on the mainpage
This page is generated on 14/10/2020 14:02:25 with ZibExtraction v. 4.0.7592.24969

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