diff --git a/schemas/med_dossier/Correspondence.yaml b/schemas/med_dossier/Correspondence.yaml index 28d3912..0f9602e 100644 --- a/schemas/med_dossier/Correspondence.yaml +++ b/schemas/med_dossier/Correspondence.yaml @@ -22,7 +22,7 @@ properties: type: string format: date example: "2023-03-31" - specialty_code: + speciality_code: description: |- A short memocode representing the speciality of `other`. For example, `"OOG"` (eye specialist), `"CHI"` (Surgery), etc. Often blank. @@ -50,8 +50,8 @@ properties: example: "Naar: Plastische chirurgie HMC, Den Haag" practicioner: $ref: 'Practicioner.yaml' - zd: + zorgdomein: description: |- - If known and provided, The ZorgDomein message ID. ZD IDs are often used when referring a patient. Not all source systems provide these. + If known and provided, The ZorgDomein message ID. ZorgDomein IDs are often used when referring a patient. Not all source systems provide these. type: string example: "ZD1234" diff --git a/schemas/med_dossier/Journal.yaml b/schemas/med_dossier/Journal.yaml index d1ea775..946a78a 100644 --- a/schemas/med_dossier/Journal.yaml +++ b/schemas/med_dossier/Journal.yaml @@ -30,31 +30,46 @@ properties: type: string format: date example: "2015-05-01" - text: + s: description: |- - The journal text as typed by the practicioner. Can, obviously, be quite long, and can contain newlines. + The journal text as typed by the practicioner for the 'S' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _S_ / _Subjectief_). + + A (transcription of the) description of the medical issue by the patient themselves. + + Can contain newlines, and can be quite long. For teleconsulting often contains everything the patient typed. + type: string + o: + description: |- + The journal text as typed by the practicioner for the 'O' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _O_ / _Objectief_). + + The description of the medical issue as observed by a trained medical practicioner. + + Can contain newlines, and can be quite long. For teleconsulting in particular, might be empty. + type: string + a: + description: |- + The journal text as typed by the practicioner for the 'A' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _E_ / _Evaluatie_). + + The diagnosis. + + Can contain newlines, and can be quite long. + type: string + p: + description: |- + The journal text as typed by the practicioner for the 'P' field of SOAP (Subjective / Objective / Analysis / Plan). (Dutch: _P_ / _Plan_). + + The course of action to take, or notes about next steps to deal with the issue raised in this journal entry. + + Can contain newlines, and can be quite long. type: string - soap: + x: description: |- - Most medical systems separate journal text using the SOAP system (dutch: _SOEP_): - * `S`: Subjective (dutch: _Subjectief_) - A (transcription of the) description of the medical issue by the patient themselves - * `O`: Objective (dutch: _Objectief_) - The description of the medical issue as observed by a trained medical practicioner - * `A`: Analysis (dutch: _Evaluatie_) - The diagnosis. - * `P`: Plan (dutch: _Plan_) - The course of action to take, or notes about next steps to deal with the issue raised in this journal entry. - * `X`: Unknown - this text does not fit any of the 4 SOAP categories, or this represents journal text not written using the SOAP system. + The journal text as typed by the practicioner for any non-SOAP field. - Any of these can be missing. For example, for tele-health various practices have internal policy to leave Objective blank, especially if - no video or pictures are made, because no medical professional is on hand to make an objective report about the stated issues. + Will be omitted if blank / not available. For source systems that do not work with the SOAP methodology, all journal text will be under this entry. - Often newlines appear in weird places, or newlines are not conveyed even if typed by the practicioner; these are limitations in the source system. + Can contain newlines, and can be quite long. type: string - enum: - - S - - O - - A - - P - - X - example: S practicioner: $ref: 'Practicioner.yaml' type: diff --git a/schemas/med_dossier/Measurement.yaml b/schemas/med_dossier/Measurement.yaml index a8fe6c1..1a6df1b 100644 --- a/schemas/med_dossier/Measurement.yaml +++ b/schemas/med_dossier/Measurement.yaml @@ -50,12 +50,6 @@ properties: of what the source has provided. type: string example: 48 - source_value: - description: |- - *OPTIONAL* The value of the measurement as reported by the source, verbatim (no normalization is applied in any way). - Only provided if meaningfully different from the normalized value. - type: string - example: HUISARTS comment: description: |- *OPTIONAL* Some source systems allow adding a comment to any measurement; if one is present, it is provided here.