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General information

Name: nl.zorg.SOAPReport NL.png
Version: 1.1
HCIM Status:Final
Release: 2021
Release status: Prepublished
Release date: 01-12-2021

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DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::CreationDate 25-5-2020
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Name PM
DCM::Id 2.16.840.1.113883.
DCM::KeywordList Notitie, Verslag, SOEP
DCM::LifecycleStatus Final
DCM::ModelerList Zib centrum
DCM::Name nl.zorg.SOEPVerslag
DCM::PublicationDate 01-12-2021
DCM::PublicationStatus Prepublished
DCM::RevisionDate 20-08-2021
DCM::Supersedes nl.zorg.SOEPVerslag-v1.0
DCM::Version 1.1
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-09-2020)

Publicatieversie 1.1 (01-12-2021)

ZIB-1418 Terminologiekoppeling SOAPReport
ZIB-1473 SOEP is SOAP in het Engels: vertaling klopt niet


A SOAP report is a textual report of (part of the consult) 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.


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
Block.png NL-CM:13.6.1 Arrowdown.pngSOAPReport Root concept of the SOAPReport information model.This root concept contains all data elements of the SOAPReport information model.
TS.png NL-CM:13.6.2 Arrowright.pngSOAPReportDateTime 0..1 Date and time when the report was recorded
Verwijzing.png NL-CM:13.6.3 Arrowright.pngAuthor::HealthProfessional 0..1 The healthcare provider who prepared the report and who is responsible for its content.
Block.png HealthProfessional
Folder.png NL-CM:13.6.4 Arrowdown.pngSOAPLine 1..4 Container of the SOAPLine concept.This container contains all data elements of the SOAPLine concept.
CD.png NL-CM:13.6.5 Arrowright.pngSOAPLineCode 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.

11591000146107 Patient encounter report
List2.png SOAPLineCodeCodelist
CD.png NL-CM:13.6.6 Arrowright.pngSOAPLineHeader 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.
List2.png SOAPLineHeaderCodelist
ST.png NL-CM:13.6.7 Arrowright.pngSOAPLineText 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 List2.png

Example Instances

Only available in Dutch

SOEP Verslag
SOEPVerslagDatumTijd 21-07-2019
Medewerkerscode 01299
AGBCode 01999999
Initialen H.A
Geslachtsnaam Janszens
ZorgverlenersRol Huisarts
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
SOEPRegelNaam O
SOEPRegelTekst Keelinspectie geen bijzonderheden, pulmonaal vesiculair ademgeruis (VAG)
SOEPRegelNaam E
SOEPRegelTekst bijwerking ACE-remmer
SOEPRegelCode Geneesmiddelbijwerking, ICPC code A85
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.



Valueset OID: 2.16.840.1.113883. Binding: Required
Conceptname Codesystem name Codesystem OID
Alle waarden ICPC-1 NL 2.16.840.1.113883.


Valueset OID: 2.16.840.1.113883. 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

Information model references

This information model refers to

This information model is used in


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 Artdecor.jpg
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png


This information model is also available as pdf file PDF.png or as spreadsheet Xlsx.png

About this information

The information in this wikipage is based on Pre-release 2021-2
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms version: 20210731 [R] (July 2021 Release)
  • LOINC version 2.67

Conditions for use are located on the mainpage List2.png
This page is generated on 30/11/2021 09:45:38 with ZibExtraction v. 6.4.8004.1652

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