|
|
|
|
@ -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:
|
|
|
|
|
|